Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

ABSTRACT

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital mortality.