Mortality rates in patients with acute myocardial infarction (MI) complicated by cardiogenic shock remain high. There are few randomised control trials which have looked at this. The role of primary percutaneous coronary intervention (PCI) in cardiogenic shock was evaluated in the 1999 ‘Should we emergently revascularize Occluded Coronaries for Cardiogenic shocK’ (SHOCK) trial, which showed that mortality at 30 days was not significantly reduced by early revascularization. We have considered the outcomes of patients presenting to a tertiary centre in a contemporary time period who underwent PCI.Methods
We reviewed PCI performed in the calendar year 2015 as coded on the Cardiovascular Imaging and Information System (CVIS) with cardiogenic shock and outcomes checked with the Northern Ireland Electronic Care Record (NIECR). Cardiogenic shock was coded by a cardiologist and defined as systolic blood pressure <80 mmHg despite hydration or requiring immediate inotropes, intra-aortic balloon pump (IABP) or autopulse support. The dataset included demographic characteristics: gender, age, diabetes mellitus (DM), smoking status, previous MI/ coronary artery bypass grafting (CABG)/PCI; procedural characteristics: access, coronary disease, thrombolysis in MI (TIMI) flow pre- and post-PCI, level of cardiac support; and mortality details: time from presentation, cardiac support, and extent of coronary artery disease.Results
There were 1833 PCI cases in 2015, of which 558 (30%) were elective and 1275 (70%) were emergency. Cardiogenic shock only occurred in the emergency cohort, of whom 73 (6%) were affected. The median age of patient affected by cardiogenic shock was 70 years (41–96 years), of whom 47 (64%) were male, 19 (26%) had previous MI, 7 (9.5%) had previous CABG, and 13 (27%) had previous PCI. DM affected 22 (30%), 31 (42.4%) were smokers, and 19 (26%) had known poor left ventricular (LV) function. Triple vessel disease was present in 21 (29%). Stent thrombosis occurred in two cases. Glycoprotein IIb/IIIa inhibitors were used in 33 (45%) cases, and 15 (21%) required admission to ICU.Implications
This audit has highlighted that 70% of the caseload at the Royal Victoria Hospital cardiac catheterisation laboratory is emergency. There was a 52% mortality rate in cardiogenic shock in the year 2015, which is comparable with the SHOCK trial. Patients who had previous MI, DM and poor LV function were more likely to have a poor outcome. These will have implications on the future suitability of intervention when multiple factors are present.