Hochman J S, Sleeper L A, Webb J G, Sanborn T A, White H D, Talley J D, Buller C E, Jacobs A K, Slater J N, Col J, McKinlay S M, LeJemtel T H
St. Luke's-Roosevelt Hospital Center and Columbia University, New York, NY 10025, USA.
N Engl J Med. 1999 Aug 26;341(9):625-34. doi: 10.1056/NEJM199908263410901.
The leading cause of death in patients hospitalized for acute myocardial infarction is cardiogenic shock. We conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock.
Patients with shock due to left ventricular failure complicating myocardial infarction were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either coronary-artery bypass grafting or angioplasty. Intraaortic balloon counterpulsation was performed in 86 percent of the patients in both groups. The primary end point was mortality from all causes at 30 days. Six-month survival was a secondary end point.
The mean age of the patients was 66+/-10 years, 32 percent were women and 55 percent were transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87 percent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days did not differ significantly between the revascularization and medical-therapy groups (46.7 percent and 56.0 percent, respectively; difference, -9.3 percent; 95 percent confidence interval for the difference, -20.5 to 1.9 percent; P=0.11). Six-month mortality was lower in the revascularization group than in the medical-therapy group (50.3 percent vs. 63.1 percent, P=0.027).
In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock.
因急性心肌梗死住院患者的主要死因是心源性休克。我们进行了一项随机试验，以评估心源性休克患者的早期血运重建治疗。
因心肌梗死并发左心室衰竭而导致休克的患者被随机分为紧急血运重建组（152例患者）或初始药物稳定治疗组（150例患者）。血运重建通过冠状动脉旁路移植术或血管成形术完成。两组中86%的患者接受了主动脉内球囊反搏治疗。主要终点是30天时的全因死亡率。6个月生存率是次要终点。
患者的平均年龄为66±10岁，32%为女性，55%从其他医院转诊而来。休克发生的中位时间为梗死发生后5.6小时，大多数梗死位于前壁。分配到血运重建组的患者中，97%接受了早期冠状动脉造影，87%接受了血运重建；分配到药物治疗组的患者中，只有2.7%在无临床指征的情况下转而接受早期血运重建治疗。血运重建组和药物治疗组30天时的总体死亡率无显著差异（分别为46.7%和56.0%；差异为-9.3%；差异的95%置信区间为-20.5%至1.9%；P=0.11）。血运重建组6个月死亡率低于药物治疗组（50.3%对63.1%，P=0.027）。
在心源性休克患者中，紧急血运重建在30天时并未显著降低总体死亡率。然而，6个月后有显著的生存获益。对于并发心源性休克的急性心肌梗死患者，应强烈考虑早期血运重建治疗。
