Interhospital transfer for early revascularization in patients with ST-elevation myocardial infarction complicated by cardiogenic shock--a report from the SHould we revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) trial and registry

Am Heart J. 2006 Oct;152(4):686-92. doi: 10.1016/j.ahj.2006.06.010.


Background: Early revascularization (ERV) in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) reduces mortality rates. Patients admitted to hospitals without revascularization capability have high mortality rates and are not often transferred for ERV.

Methods: Transfer and direct-admit patients with STEMI from the SHOCK Trial and Registry with left ventricular failure (N = 969) were analyzed to determine benefit of ERV in transfer patients.

Results: Transfer patients (46%) were younger and less likely to have prior hypertension, myocardial infarction, and heart failure. They received more aggressive treatment, were revascularized later after CS (median 7.3 vs 3.9 hours, P = .0002), and had similar adjusted inhospital mortality compared with direct-admit patients (55% vs 56%). Inhospital mortality was lower in ERV than no/late revascularization (41% vs 53%, P = .017 for transfer patients; 55% vs 71%, P = .0003 for direct-admit patients). Multiple logistic regression showed that inhospital mortality was associated with age (odds ratio [OR] 1.50 per decade increase, 95% CI 1.31-1.73, P < .0001), mean arterial pressure (OR 0.98 per 1 mm Hg increase, 95% CI 0.97-0.99, P < .0001), fibrinolysis before CS (OR 0.65, 95% CI 0.52-0.96, P = .040), and ERV (OR 0.70, 95% CI 0.52-0.96, P = .028), but not transfer admission (OR 1.23, 95% CI 0.86-1.74, P = .26).

Conclusions: Despite longer time to treatment, transfer patients are a selected population with similar adjusted inhospital mortality and ERV benefit as direct-admit patients. Selected patients with STEMI and CS admitted to hospitals without revascularization capability should be transferred to centers with revascularization capability for immediate angiography.

MeSH terms

  • Aged
  • Cohort Studies
  • Coronary Disease / surgery
  • Counterpulsation
  • Female
  • Hospital Mortality
  • Hospitalization*
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / complications
  • Myocardial Infarction / diagnosis*
  • Myocardial Revascularization*
  • Patient Admission
  • Patient Transfer*
  • Randomized Controlled Trials as Topic
  • Registries
  • Shock, Cardiogenic / etiology*
  • Shock, Cardiogenic / surgery*
  • Shock, Cardiogenic / therapy
  • Thrombolytic Therapy
  • Time Factors