Management of cardiogenic shock complicating acute myocardial infarction: towards evidence based medical practice

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Abstract
The largest prospectively identified registry of patients with cardiogenic shock so far analysed is from the GUSTO-I (global utilisation of streptokinase and tissue plasminogen activator for occluded coronary arteries) trial.4 , 8 , 10 Of the 41 021 patients recruited into that study, 7.2% (2972) developed cardiogenic shock, with an overall 30 day mortality of 55%.8 For those undergoing coronary artery bypass grafting (CABG) the 30 day mortality was 29%, and for those having percutaneous transluminal coronary angioplasty (PTCA) it was 22%. On single factor comparison of one year mortality, the hazard ratio (after adjustments for baseline characteristics) for PTCA versus no PTCA was 0.81 (95% confidence interval (CI), 0.71 to 0.94; p < 0.005), suggesting that there may be medium term benefit with the PTCA management strategy. However, patients were not randomly allocated to revascularisation or conservative treatment in that study, and the better PTCA outcome could reflect selection bias. The hazard ratio for CABG versus no CABG was 1.08 (95% CI, 0.89 to 1.30; p = 0.445). It is unclear why the 30 day mortality advantage of CABG was not mirrored at one year.