Cardiogenic Shock

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Cardiogenic shock complicates acute myocardial infarction in 5-15% of patients (145) and is recognized clinically as systemic hypotension resulting in end-organ hypoperfusion in the presence of elevated cardiac filling pressures. The subset of patients who present with or develop cardiogenic shock are more likely to be women, tend to be older, have more coronary artery disease risk factors, and are more likely to have had a prior myocardial infarction or surgical revascularization (146).

To evaluate the role of coronary revascularization strategies in the treatment of car-diogenic shock, the SHOCK (Should we emergently revascularize Occluded Coronary arteries for cardiogenic shocK) trial was conducted (147,148). This multicenter trial randomized 302 patients who presented with acute myocardial infarction and cardiogenic shock due to left ventricular dysfunction confirmed by both clinical and hemodynamic criteria. Approximately 37% of women were assigned to undergo revascularization and 27% to medical therapy. While there was no significant difference in 30-d mortality between treatment groups (46.7 vs 56.0%), by 6 mo, there was a survival benefit for patients who underwent percutaneous or surgical revascularization procedures. Interestingly, age >75 yr was found to be an independent predictor of increased morbidity and mortality for patients that underwent angioplasty or coronary artery bypass grafting at both 30 d and 6 mo (148). As women who present with acute myocardial infarction and cardiogenic shock are often older, these observations suggest that coronary revascular-

ization procedures may not improve mortality, and in fact, may predict a worse outcome in this cohort.

Importantly, a total of 1492 patients were screened for the SHOCK trial, and 1107 were deemed ineligible and entered into a registry. Women accounted for approx 40% of Registry patients and were more likely to be in cardiogenic shock due to isolated right ventricular shock (149), acute severe mitral regurgitation (150), or ventricular septal rupture (151), than from predominant left ventricular failure. Women entered in the Registry had a higher incidence of diabetes and 2- or 3-vessel disease, yet the combined percutaneous and surgical revascularization rate for these women was lower than that for nondiabetic patients with single vessel disease (152).

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