Prevention of Cardiogenic Shock After Acute Myocardial Infarction Circulation

Abstract

C ardiogenic shock (CGS) after an ST-segment elevation acute myocardial in-farction has a poor prognosis. Apart from immediate revascularization, no other treatment has improved outcome. A recent large multicenter registry has convincingly shown that the benefit of primary percutaneous intervention (PPCI) is critically dependent on the elapsed time from first medical contact to balloon inflation. For every 10-minute treatment delay, 3.3 additional deaths per 100 PCI-treated patients occur. 1 These data strongly suggest that urgent recanali-zation of the culprit vessel resulting in reperfusion of the jeopardized myocardium is currently the key treatment to offer patients in CGS after ST-segment elevation acute myocardial infarction. Recent articles on CGS do not mention the option of immediate administration of a fibrinolytic agent as part of a pharmacoinvasive (PhI) strategy to prevent the development of CGS. We report here the results of a meta-analysis assessing the effect of a PhI strategy as compared to PPCI on the incidence of CGS in ST-segment elevation acute myocardial infarction. We searched the MEDLINE and EMBASE electronic databases for randomized controlled trials from January 2000 to January 2018, containing the MeSH terms fibrinolytic agent and myocardial infarction. In addition, bibliographies of articles were hand searched to identify additional studies without language restriction. Authors were contacted to obtain additional data. Two investigators assessed the eligibility for inclusion of the studies. We included trials comparing PPCI with a PhI strategy with early coronary angiography in ≥80% of the patients and reporting the incidence of CGS or congestive heart failure (CHF) within 30 days after ran-domization. Facilitated PCI studies were excluded because this reperfusion strategy has not shown benefit over PPCI. A random effect model was used based on the Mantel-Haenszel method using Review Manager 5.3 (Cochrane Collaboration). The search strategy resulted in 509 publications, of which 476 were excluded based on title and abstract. Including 2 hand-searched references, 35 studies were evaluated on full text, of which 31 were excluded (study design n=1, facilitated PCI n=10, thrombolysis only or absence of data on invasive management n=14, substudies n=3, no 30-day outcome n=1, no data on CHF or CGS after enquiry n=2). Four studies met the inclusion criteria. 2-5 Study design and baseline characteristics were similar, except for a longer symptom onset to reperfusion interval and an upper age limit of 75 years in EARLY-MYO (Early Routine Catheterization After Alteplase Fibrinolysis Versus Primary PCI in Acute ST-Segment-Elevation Myocardial Infarction). 5 Analytic methods and study materials are available on author request. Patients randomized to a PhI strategy were significantly more likely to have TIMI 2 to 3 flow before PCI (odds ratio [OR], 7.92; 95% CI, 5.67-11.07; P<0.001) without a difference in TIMI 2 to 3 flow after PCI (OR, 0.94; 95% CI, 0.21-4.23; P=0.93). Patients randomized to a PhI approach had a significantly lower risk of developing CGS (3.76% versus 5.67%; OR, 0.65; 95% CI, 0.46-0.92; P=0.02)