Acute Coronary Syndrome: SHOCK (SHould we emergently revascularize Occluded Coronaries for Cardiogenic shocK)

Question 1

SHOCK Clinical Question

Answer 1

Among patients who developed cardiogenic shock during acute MI, what are the benefits of early revascularization compared to initial medical stabilization on mortality?

Question 2

SHOCK Bottom Line

Answer 2

• Compared to initial medical stabilization, early revascularization was associated with a nonsignificant trend towards improved survival at 30 days among patients who developed cardiogenic shock during acute MI. However, early revascularization did confer a significant benefit by 6 months.
• SHOCK trial cohort demonstrated the benefit or revascularization at 1 and 6 years, suggesting that the benefit of revascularization persisted for years.

Question 3

SHOCK Primary outcome

Answer 3

30-day mortality

Question 4

SHOCK Interventions

Answer 4

Patients randomly assigned within 12 hours after diagnosis of shock to:

• Emergency revascularization (PCI in 60% and CABG in 40%) within 6 hours of randomization. IABP recommended.
• Initial medical stabilization. Thrombolytic therapy and IABP recommended. If clinically appropriate, delayed revascularization allowed at minimum of 54 hours after randomization

Question 5

SHOCK Inclusion Criteria

Answer 5

• Suspected cardiogenic shock within 36 hours of acute MI
• EKG criteria for acute MI:
• –ST-segment elevation
• –Q-wave infarction
• –New LBBB
• Posterior infarction with anterior ST-segment depression
• Cardiogenic shock by both clinical and hemodynamic criteria
• Clinical criteria:
• –Hypotension (SBP <90mmHg ≥30 mins) or need for supportive measures to maintain SBP ≥90mmHg
• –Evidence of end-organ hypoperfusion
• Hemodynamic criteria:
• –CI ≤2.2 L/min/m2BSA
• –PCWP ≥15 mmHg