Improved Survival After Acute Myocardial Infarction Complicated by Cardiogenic Shock With Circulatory Support and Transplantation: Comparing Aggressive Intervention With Conservative Treatment
Received 26 July 2005; received in revised form 27 July 2005; accepted 11 October 2005.
Background
The prognosis for patients with myocardial infarction has steadily improved, but remains poor for those developing cardiogenic shock. Utilization of re-vascularization, mechanical circulatory support and transplantation in these patients may improve survival.
Methods
We retrospectively analyzed the clinical outcome of 138 consecutive patients at the Cleveland Clinic from 1992 to 1998 who met the criteria for cardiogenic shock after acute myocardial infarction. All patients received intensive medical therapy and intra-aortic balloon pump support. Forty-three patients received intensive medical therapy (conservative group) and 95 patients were treated aggressively (aggressive group). The aggressive group comprised patients who were treated with percutaneous intervention/coronary artery bypass grafting (n = 77, re-vascularization group), and patients who received circulatory support/cardiac transplantation (n = 18).
Results
The baseline demographics and angiographic and hemodynamic features were comparable for the two groups. The in-hospital mortality rate was significantly reduced in the aggressive group compared with the conservative group (54% vs 81%, p = 0.002). The in-hospital mortality rate of the circulatory support/transplant group was markedly reduced compared with the conservative group (33% vs 81%, p < 0.001), and was also significantly lower than that of the re-vascularization group (33% vs 63%, p= 0.03). The aggressive group had a markedly improved 5-year survival compared with the conservative group (30% vs 6.2%, p = 0.003).
Conclusions
These data suggest that an aggressive strategy, particularly left ventricular assist device support as a bridge to heart transplantation, may improve survival in post-myocardial infarction patients with cardiogenic shock.
aDepartment of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
bDepartment of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
cDepartment of Cardiothoracic Surgery, Cleveland Clinic Foundation, Kaufman Center for Heart Failure, Cleveland, Ohio
Reprint requests: Mohamad H. Yamani, MD, Department of Cardiology, Cleveland Clinic Foundation, F25, 9500 Euclid Avenue, Cleveland, OH 44195. Telephone: 216-444-2755. Fax: 216-444-3407
ABSTRACT