Table 2.
Summary of Studies of Therapeutic Interventions for Patients With Cardiogenic Shock (CS) Associated With Acute Myocardial Infarctiona
| Source | Intervention | Study design | No. of participants |
Primary outcome | Adverse effects |
|---|---|---|---|---|---|
| Coronary artery revascularization | |||||
| SHOCK,9 1999 | Emergency revascularization vs initial medical stabilization with delayed revascularization at least 54 h after randomization | RCT | 302 | 30-d all-cause mortality: 46.7% vs 56.0%; RR, 0.83 (95% CI, 0.67-1.04); P = .11 | Acute kidney failure (defined as serum creatinine >3.0 mg/dL): 13% vs 24%; P = .03 |
| SMASH,49 1999 | Emergency revascularization vs initial medical stabilization | RCT | 55 | 30-d all-cause mortality: 22/32 (69%) vs 18/23 (78%)b | Recurrent myocardial infarction: 1/32 (3.1%) vs 1/23 (4.3%) |
| CULPRIT-SHOCK,7 2017 | Culprit lesion-only PCI, with option of staged PCI of nonculprit lesions vs immediate multivessel PCI | RCT | 706 | All-cause death or kidney replacement therapy at 30-d follow up: 158 (45.9%) vs 189 (55.4%); RR, 0.83 (95% CI, 0.71-0.96); P = .01 | Recurrent myocardial infarction: 4 (1.2%) vs 3 (0.9%); RR, 1.32 (95% CI, 0.30-5.86); P = 1.00 Stroke: 12 (3.5%) vs 10 (2.9%); RR, 1.19 (95% CI, 0.52-2.72); P = .68 |
| Percutaneous mechanical circulatory support | |||||
| IABP-SHOCK I,50 2010 | IABP compared with no IABP | RCT | 45 | Change in APACHE II score at 4 d: 2.4 vs 2.8 pointsc; difference not significant | |
| IABP-SHOCK II,8 2012 | IABP compared with no IABP | RCT | 600 | 30-d mortality: 39.7% vs 41.3%; RR, 0.96 (95% CI, 0.79-1.17); P = .69 | Life-threatening bleeding: 4.3% vs 3.4%; RR, 1.29 (95% CI, 0.58-2.90); P = .53 Stroke in hospital |
| IMPRESS,44 2017 | Microaxial LVAD vs IABP | RCT | 48 | 30-d mortality: 11/24 (45.8%) vs 12/24 (50%); HR with microaxial LVAD, 0.96 (95% CI, 0.42-2.18); P = .92 | Ischemic stroke: 1/24 (4.2%) vs 1/24 (4.2%) Major vascular complication: 1/24 (4%) vs 0/24 Life threatening bleeding: 8/24 (33.3%) vs 2/24 (8.3%) |
| National Cardiogenic Shock Initiative,19 2019 | Standardized implantation of microaxial LVAD before PCI compared with no receipt of microaxial LVAD | Observational | 171 | Survival to hospital discharge: 123/171 (71.9%) | Life-threatening bleeding: 17/171 (9.9%) Ischemic limb requiring intervention: 7/171 (4.1%) Thrombus formation on device: 2/171 (1.2%) Refractory CS requiring escalation of hemodynamic support: 15/171 (8.8%) |
| Catheter-based Ventricular Assist Device Registry,45 2017 | Comparison of receipt of standardized implantation of microaxial LVAD before PCI with no receipt of microaxial LVAD | Observational | 287 | Survival to hospital discharge: 127/287 (44.2%) | Not reported |
| Dhruva et al,46 2020 | Propensity-matched microaxial LVAD compared with IABP using US National Registry Data | Observational | 1680 matched pairs | In-hospital mortality: 756/1680 (45%) vs 573/1680 (34.1%); absolute risk difference, 10.9% (95% CI, 7.6%-14.2%); P <.001 | Life-threatening bleeding: 526/1680 (31.3%) vs 268/1680 (16.0%); absolute risk difference, 15.4% (95% CI, 12.5%-18.2%); P <.001 |
| Schrage et al,48 2019 | Propensity-matched microaxial LVAD (from US National Registry Data) compared with IABP (from IABP-SHOCK II) | Observational | 237 matched pairs | 30-d mortality: 115/237 (48.5%) vs 110/237 (46.4%); P = .64 | In-hospital recurrent MI: 7/237 (3.5%) vs 6/237 (2.5%); P = .56 Stroke in hospital: 6/237 (2.5%) vs 5/237 (2.5%); P = .76 Peripheral ischemic complications requiring intervention: 23/237 (9.8%) vs 40/237 (16.9%); P = .05 Life-threatening bleeding: 20/237 (8.5%) vs 7/237 (3.0%); P <.01 |
| Medications | |||||
| TRIUMPH,51 2007 | Ilarginine (L-NG-monomethylarginine), 1-mg/kg bolus and 1-mg/kg per hour 5-h infusion vs matching placebo | RCT | 398 | 30-d mortality: 97/201 (48%) vs placebo 76/180 (42%); HR, 1.14 (95% CI, 0.92-1.41); P = .24 | Recurrent MI: 8/198 (4.0) vs 7/179 (3.9); HR, 1.02 (95% CI, 0.59-1.77); P = .95 |
| PRAGUE-7,52 2011 | Abciximab prior to PCI vs periprocedural PCI in patients with CS associated with AMI | RCT | 80 | 30-d death, recurrent MI, stroke, new kidney failure: 17/40 (42.5%) vs 11/40 (27.5%); P = .24 | Life-threatening bleeding: 7/40 (17.5%) vs 3/40 (7.5%); P = .31 |
| Levy et al,34 2018 | Norepinephrine compared with dopamine for CS following AMI | RCT | 57 | Change in cardiac index at 72-h: no significant difference | Refractory cardiogenic shock: 10/27 (37.0%) norepinephrine vs 2/30 (6.7%) dopamine; P = .01 |
Abbreviations: AMI, acute myocardial infarction; HR, hazard ratio; IABP, intra-aortic balloon pump; LVAD, left ventricular assist device; PCI, percutaneous coronary intervention; RCT, randomized clinical trial; RR, relative risk.
a
Studies included are limited to those that specifically included patients with CS associated with AMI.
b
P value reported as nonsignificant.
c
Acute Physiology and Chronic Health Evaluation (APACHE) II score provides an estimate of intensive care unit mortality; range, 0-74; higher scores are associated with increased mortality.53