Читать книгу Interventional Cardiology - Группа авторов - Страница 337

Since the SHOCK trial, early revascularization has been recognized as the primary treatment modality for cardiogenic shock. Current ACC/AHA guidelines state a class I, level of evidence B indication for emergency revascularization with either PCI or CABG in suitable patients with cardiogenic shock due to pump failure after STEMI irrespective of the time delay from MI onset.[14]

The landmark SHOCK trial randomized 302 patients with cardiogenic shock complicating MI in a 1:1 fashion to treatment with emergency revascularization (n = 152) or initial medical stabilization (n = 150). Revascularization incorporated emergency coronary angiography followed by either coronary artery bypass graft surgery (CABG) or PCI. In the SHOCK trial, 30–day mortality rates were numerically lower in the early revascularization arm (46.7% vs. 56.0%, p‐0.11). However, at 6 months mortality rates were significantly lower with early revascularization (50.3% vs. 63.1%, p = 0.027) [1]. Furthermore, emergency revascularization was not only associated with improved survival, but also with improved quality of life, assessed by the multidimensional index of life quality and New York heart association heart failure class (NYHA class) [15].

An important substudy investigated the clinical outcome in patients assigned to emergency revascularization in the SHOCK trial undergoing PCI compared with CABG [16]. Out of 128 patients undergoing emergency revascularization 81 underwent PCI (63.3%), and 47 underwent CABG (36.7%). Patients undergoing CABG were at higher risk at baseline with a greater extent of coronary artery disease and a greater prevalence of diabetes mellitus. In the CABG group, 87.2% of patients were considered completely revascularized whereas only 23.1% of patients in the PCI group were considered completely revascularized. Despite the higher baseline risk profile of patients undergoing CABG one‐year survival was similar in both treatment arms, suggesting a potential benefit of complete revascularization. This hypothesis was tested in the CULPRIT‐SHOCK trial which randomized 706 CS patients with multivessel disease to PCI of the culprit lesion only or immediate multivessel PCI [4]. At 30–days there were higher rates of death or renal‐replacement therapy in the multivessel PCI group compared with the culprit‐lesion‐only PCI group (55.4% vs 45.9%, p = 0.01). At one‐year follow‐up, mortality was similar in both groups (50.0% culprit‐only vs. 56.9% multivessel PCI, p = ns) [17]. This led the European Society of Cardiology to include a Class III recommendation (harm) for routine revascularization of non‐IRA lesions in MI complicated by CS [18].