Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction
Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction
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DOI：
10.1001/jama.295.21.2511
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发表时间：
2006-06-07
影响因子：
120.7
通讯作者：
White, Harvey D.
中科院分区：
文献类型：
--
作者：
Hochman, Judith S.;Sleeper, Lynn A.;White, Harvey D.
背景心源性休克仍然是急性心肌梗死（MI）住院患者死亡的主要原因。尽管已证明接受早期血运重建的心源性休克并发急性心肌梗死患者的 1 年生存率明显高于初始医疗稳定患者，但缺乏证明长期生存的数据。 目的 确定早期血运重建是否影响心源性休克并发急性心肌梗死患者的长期生存。设计、环境和患者 休克（SHOCK）试验，一项国际随机临床试验，招募了1993年4月至1998年11月期间的302名急性心肌梗死并发心源性休克患者（随机分组时的平均年龄[SD]为66[11]岁）；直到 2005 年，每年进行一次生命状态长期随访，随访时间为 1 至 11 年（幸存者中位数为 6 年）。主要结果指标长期随访期间的全因死亡率。结果 1 年生存率组间差异有 13 个绝对百分点，有利于接受早期血运重建的患者，在 3 年和 6 年保持稳定（分别为 13.1% 和 13.2%；风险比） [人力资源], 0.74； 95% 置信区间 [CI]，0.57-0.97；对数秩 P=. 03）。 6 年时，早期血运重建组和初始医疗稳定组的总生存率分别为 32.8% 和 19.6%。在 143 名医院幸存者中，还观察到生存率存在组间差异（HR，0.59；95% CI，0.36-0.95；P=.03）。早期血运重建组和初始医疗稳定组的医院幸存者 6 年生存率分别为 62.4% 和 44.4%，年死亡率分别为 8.3% 和 14.3%，1 年幸存者分别为 8.0% 和 10.7%。任何亚组与治疗效果之间均不存在显着的交互作用。 结论 在这项随机试验中，接受早期血运重建治疗的心源性休克医院幸存者中近三分之二在 6 年后仍存活。与最初的医疗稳定相比，早期血运重建策略使 6 年生存率绝对提高了 13.2%，相对提高了 67%。对于急性心肌梗死并发左心室衰竭导致心源性休克的患者，应尽早进行血运重建。
Context Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking.Objective To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI.Design, Setting, and Patients The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock ( SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock ( mean [SD] age at randomization, 66 [ 11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years ( median for survivors, 6 years).Main Outcome Measures All-cause mortality during long-term follow-up.Results The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P=. 03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed ( HR, 0.59; 95% CI, 0.36-0.95; P=. 03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect.Conclusions In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.