“我们是否应在心源性休克中紧急对闭塞冠状动脉进行血运重建（SHOCK）试验”中年龄≥75岁患者的结局：急性心肌梗死合并心源性休克的老年患者对紧急血运重建的反应是否不同？

Outcome of patients aged >or=75 years in the SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK (SHOCK) trial: do elderly patients with acute myocardial infarction complicated by cardiogenic shock respond differently to emergent revascularization?

作者信息

Dzavik Vladimir, Sleeper Lynn A, Picard Michael H, Sanborn Timothy A, Lowe April M, Gin Ken, Saucedo Jorge, Webb John G, Menon Venu, Slater James N, Hochman Judith S

机构信息

Interventional Cardiology Program, University Health Network, and University of Toronto, Toronto, Ontario, Canada.

出版信息

Am Heart J. 2005 Jun;149(6):1128-34. doi: 10.1016/j.ahj.2005.03.045.

DOI:10.1016/j.ahj.2005.03.045

PMID:15976798

Abstract

BACKGROUND

In the SHOCK trial, the group of patients aged >or=75 years did not appear to derive the mortality benefit from early revascularization (ERV) versus initial medical stabilization (IMS) that was seen in patients aged <75 years. We sought to determine the reason for this finding by examining the baseline characteristics and outcomes of the 2 treatment groups by age.

METHODS

Patients with cardiogenic shock (CS) secondary to left ventricular (LV) failure were randomized to ERV within 6 hours or to a period of IMS. We compared the characteristics by treatment group of patients aged >or=75 years and of their younger counterparts.

RESULTS

Of the 56 enrolled patients aged >or=75 years, those assigned to ERV had lower LV ejection fraction at baseline than IMS-assigned patients (27.5% +/- 12.7% vs 35.6% +/- 11.6%, P = .051). In the elderly ERV and IMS groups, 54.2% and 31.3%, respectively, were women ( P = .105) and 62.5% and 40.6%, respectively, had an anterior infarction (P = .177). The 30-day mortality rate in the ERV group was 75.0% in patients aged >or=75 years and 41.4% in those aged <75 years. In the IMS group, 30-day mortality was 53.1% for those aged >or=75 years, similar to the 56.8% for patients aged <75 years.

CONCLUSIONS

Overall, the elderly randomized to ERV did not have better survival than elderly IMS patients. Despite the strong association of age and death post-CS, elderly patients assigned to IMS had a 30-day mortality rate similar to that of IMS patients aged <75 years, suggesting that this was a lower-risk group with more favorable baseline characteristics. The lack of apparent benefit from ERV in elderly patients in the SHOCK trial may thus be due to differences in important baseline characteristics, specifically LV function, and play of chance arising from the small sample size. Therefore, the SHOCK trial overall finding of a 12-month survival benefit for ERV should be viewed as applicable to all patients, including those >or=75 years of age, with acute myocardial infarction complicated by CS.

摘要

背景

在休克（SHOCK）试验中，年龄≥75岁的患者组似乎未从早期血运重建（ERV）中获得相对于初始药物稳定治疗（IMS）的死亡率获益，而年龄＜75岁的患者则有此获益。我们试图通过按年龄检查两个治疗组的基线特征和结局来确定这一发现的原因。

方法

继发于左心室（LV）衰竭的心源性休克（CS）患者被随机分为在6小时内接受ERV或接受一段时间的IMS治疗。我们比较了年龄≥75岁的患者及其较年轻对应患者按治疗组划分的特征。

结果

在纳入的56例年龄≥75岁的患者中，分配接受ERV治疗的患者基线时左心室射血分数低于分配接受IMS治疗的患者（27.5%±12.7%对35.6%±11.6%，P = 0.051）。在老年ERV组和IMS组中，女性分别占54.2%和31.3%（P = 0.105），前壁梗死患者分别占62.5%和40.6%（P = 0.177）。年龄≥75岁的患者中ERV组的30天死亡率为75.0%，年龄＜75岁的患者中为41.4%。在IMS组中，年龄≥75岁的患者30天死亡率为53.1%，与年龄＜75岁的患者的56.8%相似。

结论

总体而言，随机接受ERV治疗的老年患者生存情况并不优于接受IMS治疗的老年患者。尽管年龄与CS后死亡密切相关，但分配接受IMS治疗的老年患者30天死亡率与年龄＜75岁的IMS患者相似，这表明这是一个基线特征更有利的低风险组。因此，SHOCK试验中老年患者未从ERV中获得明显获益可能是由于重要基线特征的差异，特别是左心室功能，以及小样本量导致的机遇因素。因此，SHOCK试验关于ERV使12个月生存率获益的总体发现应被视为适用于所有急性心肌梗死合并CS的患者，包括年龄≥75岁的患者。