Does current treatment of cardiogenic shock complicating the acute coronary syndromes comply with guidelines?

BACKGROUND

The purpose of our study was to evaluate the implementation of guidelines for the treatment of cardiogenic shock (CS) complicating the acute coronary syndromes (ACS).

METHODS AND RESULTS

Of the 10 136 patients in the Euro-Heart-Survey-ACS with complete data, CS occurred in 549 (5.4%), of whom 28.6% had CS upon presentation. We examined the use of coronary angiography (CA), percutaneous (PCI) and surgical (CABG) revascularization, and intra-aortic balloon counterpulsation (IABP) among ACS patients with and without CS. During the hospital course, there were no significant differences between patients with and without CS in referral to CA (52.4% vs 53.3%, respectively) or CABG (4.4% vs 4.5%), but CS patients were more likely to undergo IABP (17.7% vs 0.8%, P < .001) and PCI (40.8% vs 31.8%, P < .001), especially younger (<75 years) patients (52.2% vs 31.8%, P < .001). A similar trend was observed when comparing ST-elevation-ACS patients with (368 [8.5%]) and without CS (3945): CA (58.1% vs 56.2%), CABG (3.6% vs 3.3%), IABP (20.0% vs 0.9%, P < .01), and PCI (47.3% vs 40.6%, P < .01; 54.4% vs. 44.6% for patients <75 years, P < .003). Of the 94 ST-elevation-ACS patients presenting with CS, only 39 (41.4%) received any reperfusion treatment, more often fibrinolysis (64.1%). The in-hospital mortality was 52.1% for all CS pts vs 2.0% for all others ( P < .001).

CONCLUSIONS

Our contemporary survey demonstrates prohibitively-high mortality rates among ACS patients complicated by CS and poor implementation of recent guidelines advocating an aggressive invasive approach, including low rates of revascularization and IABP. Improved adherence to the guidelines pertaining to ACS patients developing CS may hopefully improve outcomes.