Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the global utilization of Streptokinase and tissue plasminogen activator for Occluded Coronary Arteries (GUSTO-I) trial : An observational study

Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear. We studied 2200 patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial with acute myocardial infarction complicated by cardiogenic shock (systolic blood pressure < 90 mm Hg for > or = 1 hour) who survived > or = 1 hour after the onset of shock to determine the influence of an aggressive strategy of early angiography (within 24 hours of shock onset) and coronary angioplasty or bypass surgery, if appropriate, on survival. Revascularization was not protocol mandated but was selected by the attending physicians. Shock was present on admission in 11% and developed after admission in 89% of shock patients. The 30-day mortality was 38% in the 406 patients who underwent early angiography and were referred within 24 hours for angioplasty (n = 175), bypass surgery (n = 36), angioplasty and bypass surgery (n = 22), or neither (late or no revascularization, n = 173) compared with 62% in the 1794 patients who did not (P = .0001). However, there were important differences in the baseline characteristics of the two groups, including younger age (63 versus 68 years, P = .0001), less prior infarction (19% versus 27%, P = .001), and a shorter time to thrombolytic therapy (2.9 versus 3.2 hours, P = .0001) in patients treated with an aggressive strategy. Using multivariate logistic regression analysis to adjust for differences in baseline characteristics, an aggressive strategy was independently associated with reduced 30-day mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54], P = .0001). An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.