Survival Benefit from Early Revascularization in Elderly Patients with Cardiogenic Shock after Acute Myocardial Infarction: A Co

ABSTRACT: Objectives. To assess if early revascularization offers any survival benefit in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) who are ≥ 75 years of age. Background. CS after AMI continues to pose formidable therapeutic challenges in elderly patients. Methods. We conducted survival analyses of 310 consecutive subjects (including 80 patients ≥ 75 years of age) who developed cardiogenic shock after AMI at two study centers – Rush University Medical Center and the John H. Stroger Jr. Hospital of Cook County (both in Chicago, Illinois). The data were collected over a 6-year period. Where appropriate, we used Kaplan-Meier survival plots, multivariate Cox proportional hazards modeling, stepwise multivariate Poisson regression analyses and unconditional logistic regression analysis. Results. Early revascularization was associated with a statistically significant survival benefit both in patients Methods Study subjects. A total of 310 consecutive patients with AMI complicated by CS, admitted to Rush University Medical Center in Chicago, Illinois (n = 129) and the John H. Stroger, Jr. Hospital of Cook County (Cook County Hospital) in Chicago (n = 181) from January 1999 to June 2005, were identified via ICD-9 codes after protocol approval by the respective institutional review boards. Data were extracted through chart review and adjudicated. Cardiogenic shock, for the purpose of the current analyses, was defined as sustained hypotension with systolic blood pressure ≤ 90 mmHg or mean arterial pressure ≤ 60 mmHg with cyanosis, cold extremities, congestive heart failure, or persistent oliguria occurring at any time during hospitalization in patients admitted with MI. Patients developing shock after revascularization were not included in this analysis. Mortality and cardiac events were ascertained by review of inpatient and outpatient medical records, coronary angiograms, and query of the Social Security Death Index. Patients were studied as a retrospective cohort to determine predictors of mortality. Overall, this retrospective cohort represented a follow-up period of 352.38 person-years, with a median survival time of 8.31 months and 177 (57%) deaths. The median length of hospital stay was 8 days (interquartile range 4–15 days). Prediction of mortality. The influence of age on mortality after cardiogenic shock was the major focus of this study. We grouped the study subjects into four age categories: Results Baseline characteristics. Our cohort of 310 subjects with AMI complicated by CS consisted of 76 (24%) subjects 70% occlusion) was observed in a single vessel in 46 (15%) subjects, in two vessels in 52 (18%) subjects and in all three vessels in 94 (30%) subjects. A total of 135 (62%) patients were taken to the catheterization laboratory within 18 hours of development of their symptoms. However, irrespective of the time elapsed between symptom onset and the EIT, a total of 148 patients underwent revascularization, 100 patients underwent PCI only, 40 patients underwent CABG only, and 8 patients underwent both PCI and CABG. Association of age and early invasive therapy with survival. In our study cohort, we first determined whether the two major predictors being considered in the present report — age and EIT — were associated with a varying clinical course post MI. The Kaplan-Meier plots for the age categories (Figure 1A) were associated with statistically significant varying rates of progression to death (log rank p Discussion Overall implications of the study results. To revascularize or not to revascularize is a cardinal question in the management of elderly patients developing CS after AMI. Our results suggest that while the expected survival benefit after ERV is less in subjects 75+ years of age as compared to those 65 years of age. In light of these published reports, it can be safely argued that ERV needs to be the axis of the therapeutic approach in all patients, not just in those Conclusions CS complicating AMI continues to pose therapeutic challenges, especially in patients 75+ years of age. In light of the published literature and the current AHA/ACC guidelines, our results also point toward a need to strongly emphasize the AHA/ACC recommendations so that revascularization practices in this very high-risk population are not far behind the guidelines. From the *The John H. Stroger Jr. Hospital of Cook County (Cook County Hospital), Chicago, Illinois, §Rush University Medical Center, Chicago, Illinois, and £Lata Medical Research Foundation, Nagpur, India. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 30, 2008, provisional acceptance given January 16, 2009, final version accepted March 30, 2009. Address for correspondence: Amit P. Amin, MD, Division of Adult Cardiology, John H. Stroger Jr. Hospital of Cook County (Cook County Hospital), 1901 W. Harrison Street, Suite 3620, Chicago, IL 60612. E-mail: amit_p_amin@yahoo.com.

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