Clinical InvestigationInterventional CardiologyOutcome of patients aged ≥75 years in the SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) trial: Do elderly patients with acute myocardial infarction complicated by cardiogenic shock respond differently to emergent revascularization?☆
Section snippets
Trial design
The design of the SHOCK trial has been previously reported.8 Briefly, from 1993 to 1998, 302 patients with CS within 36 hours of MI and within 12 hours of shock diagnosis were randomly assigned to IMS or ERV in 36 participating centers. It was recommended that patients assigned to ERV who had 1- or 2-vessel disease undergo percutaneous coronary intervention (PCI) of the culprit lesion only, and that patients with severe 3-vessel or left main disease undergo emergency surgery, defined as within
Clinical characteristics
In patients aged ≥75 years, a trend was observed for a higher proportion of females, anterior wall MI location, and a lower rate of prior congestive heart failure in the group assigned to ERV (Table I). As expected per protocol, more patients randomized to IMS received thrombolytic therapy. In addition, IMS patients had undergone prior coronary artery bypass grafting more frequently than patients in the ERV group.
Left ventricular function and angiographic characteristics
Elderly patients assigned to ERV had a lower mean LVEF than the elderly in the IMS
Discussion
In the SHOCK trial, an international, multicenter randomized study of emergency revascularization in CS, we found that the response in the elderly to ERV appeared to differ from the younger cohort. The detailed analysis reported in this article identifies factors that may explain this apparent difference.
We observed that the elderly assigned to ERV in the SHOCK trial had a lower mean LVEF than those assigned to IMS. We have previously reported that LVEF measured early during shock presentation
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2019, Journal of the American College of CardiologyPercutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock
2019, Journal of the American College of CardiologyOutcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction
2015, American Journal of MedicineCitation Excerpt :While there was a significant benefit of revascularization for 30-day mortality when compared with initial medical stabilization in those aged <75 years (relative risk [RR] 0.73; 95% CI, 0.56-0.95), there was no such apparent benefit observed in the small cohort of patients who were age 75 years or older (RR 1.41; 95% CI, 0.95-2.11; Pinteraction = .01). The lack of benefit was likely due to differences in baseline characteristics (lower ejection fraction in the revascularization group) and the play of chance arising from the small sample size of the elderly subgroup (56 patients).16 However, in the SHOCK registry there was a significantly lower mortality rate in those receiving revascularization when compared with those treated conservatively, including in the elderly (RR 0.46; 95% CI, 0.28-0.75; P = .002).17
Treatment of acute coronary syndromes in the elderly and in patients with comorbidities
2014, Revista Espanola de Cardiologia
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This study was supported by grants R01 HL50020 and HL49970 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md.