Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial: An observational study

Peter B. Berger, David Holmes, Amanda L. Stebbins, Eric R. Bates, Robert M. Califf, Eric J. Topol

Research output: Contribution to journalArticle

184 Citations (Scopus)

Abstract

Background: Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear. Methods and Results: We studied 2200 patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial with acute myocardial infarction complicated by cardiogenic shock (systolic blood pressure <90 mm Hg for ≤1 hour) who survived ≤1 hour after the onset of shock to determine the influence of an aggressive strategy of early angiography (within 24 hours of shock onset) and coronary angioplasty or bypass surgery, if appropriate, on survival. Revascularization was not protocol mandated but was selected by the attending physicians. Shock was present on admission in 11% and developed after admission in 89% of shock patients. The 30-day mortality was 38% in the 406 patients who underwent early angiography and were referred within 24 hours for angioplasty (n=175), bypass surgery (n=36), angioplasty and bypass surgery (n=22), or neither (late or no revascularization, n= 173) compared with 62% in the 1794 patients who did not (P=.0001). However, there were important differences in the baseline characteristics of the two groups, including younger age (63 versus 68 years, P=.0001), less prior infarction (19% versus 27%, P-.001), and a shorter time to thrombolytic therapy (2.9 versus 3.2 hours, P=.0001) in patients treated with an aggressive strategy. Using multivariate logistic regression analysis to adjust for differences in baseline characteristics, an aggressive strategy was independently associated with reduced 30-day mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54], P=.0001). Conclusions: An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.

Original languageEnglish (US)
Pages (from-to)122-127
Number of pages6
JournalCirculation
Volume96
Issue number1
DOIs
StatePublished - Jul 1 1997

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Streptokinase
Cardiogenic Shock
Tissue Plasminogen Activator
Catheterization
Observational Studies
Coronary Vessels
Mortality
Angioplasty
Shock
Angiography
Thrombolytic Therapy
Myocardial Infarction
Blood Pressure
Survival
Selection Bias
Coronary Angiography
Infarction
Patient Selection
Logistic Models
Odds Ratio

Keywords

  • Angiography
  • Angioplasty
  • Infarction
  • Reperfusion
  • Shock

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

@article{8eb29e330a7f48ddbb73a33a114a9865,
title = "Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial: An observational study",
abstract = "Background: Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear. Methods and Results: We studied 2200 patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial with acute myocardial infarction complicated by cardiogenic shock (systolic blood pressure <90 mm Hg for ≤1 hour) who survived ≤1 hour after the onset of shock to determine the influence of an aggressive strategy of early angiography (within 24 hours of shock onset) and coronary angioplasty or bypass surgery, if appropriate, on survival. Revascularization was not protocol mandated but was selected by the attending physicians. Shock was present on admission in 11{\%} and developed after admission in 89{\%} of shock patients. The 30-day mortality was 38{\%} in the 406 patients who underwent early angiography and were referred within 24 hours for angioplasty (n=175), bypass surgery (n=36), angioplasty and bypass surgery (n=22), or neither (late or no revascularization, n= 173) compared with 62{\%} in the 1794 patients who did not (P=.0001). However, there were important differences in the baseline characteristics of the two groups, including younger age (63 versus 68 years, P=.0001), less prior infarction (19{\%} versus 27{\%}, P-.001), and a shorter time to thrombolytic therapy (2.9 versus 3.2 hours, P=.0001) in patients treated with an aggressive strategy. Using multivariate logistic regression analysis to adjust for differences in baseline characteristics, an aggressive strategy was independently associated with reduced 30-day mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54], P=.0001). Conclusions: An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.",
keywords = "Angiography, Angioplasty, Infarction, Reperfusion, Shock",
author = "Berger, {Peter B.} and David Holmes and Stebbins, {Amanda L.} and Bates, {Eric R.} and Califf, {Robert M.} and Topol, {Eric J.}",
year = "1997",
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TY - JOUR

T1 - Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial

T2 - An observational study

AU - Berger, Peter B.

AU - Holmes, David

AU - Stebbins, Amanda L.

AU - Bates, Eric R.

AU - Califf, Robert M.

AU - Topol, Eric J.

PY - 1997/7/1

Y1 - 1997/7/1

N2 - Background: Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear. Methods and Results: We studied 2200 patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial with acute myocardial infarction complicated by cardiogenic shock (systolic blood pressure <90 mm Hg for ≤1 hour) who survived ≤1 hour after the onset of shock to determine the influence of an aggressive strategy of early angiography (within 24 hours of shock onset) and coronary angioplasty or bypass surgery, if appropriate, on survival. Revascularization was not protocol mandated but was selected by the attending physicians. Shock was present on admission in 11% and developed after admission in 89% of shock patients. The 30-day mortality was 38% in the 406 patients who underwent early angiography and were referred within 24 hours for angioplasty (n=175), bypass surgery (n=36), angioplasty and bypass surgery (n=22), or neither (late or no revascularization, n= 173) compared with 62% in the 1794 patients who did not (P=.0001). However, there were important differences in the baseline characteristics of the two groups, including younger age (63 versus 68 years, P=.0001), less prior infarction (19% versus 27%, P-.001), and a shorter time to thrombolytic therapy (2.9 versus 3.2 hours, P=.0001) in patients treated with an aggressive strategy. Using multivariate logistic regression analysis to adjust for differences in baseline characteristics, an aggressive strategy was independently associated with reduced 30-day mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54], P=.0001). Conclusions: An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.

AB - Background: Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear. Methods and Results: We studied 2200 patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial with acute myocardial infarction complicated by cardiogenic shock (systolic blood pressure <90 mm Hg for ≤1 hour) who survived ≤1 hour after the onset of shock to determine the influence of an aggressive strategy of early angiography (within 24 hours of shock onset) and coronary angioplasty or bypass surgery, if appropriate, on survival. Revascularization was not protocol mandated but was selected by the attending physicians. Shock was present on admission in 11% and developed after admission in 89% of shock patients. The 30-day mortality was 38% in the 406 patients who underwent early angiography and were referred within 24 hours for angioplasty (n=175), bypass surgery (n=36), angioplasty and bypass surgery (n=22), or neither (late or no revascularization, n= 173) compared with 62% in the 1794 patients who did not (P=.0001). However, there were important differences in the baseline characteristics of the two groups, including younger age (63 versus 68 years, P=.0001), less prior infarction (19% versus 27%, P-.001), and a shorter time to thrombolytic therapy (2.9 versus 3.2 hours, P=.0001) in patients treated with an aggressive strategy. Using multivariate logistic regression analysis to adjust for differences in baseline characteristics, an aggressive strategy was independently associated with reduced 30-day mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54], P=.0001). Conclusions: An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.

KW - Angiography

KW - Angioplasty

KW - Infarction

KW - Reperfusion

KW - Shock

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