BRIEF REPORTS Limits of Reperfusion Therapy for Immediate Cardiogenic Shock Complicating Acute Myocardial Infarction Dominiaue Himbert. MD. Jean-Michel Juliard, MD, P. Gabriel Steg, MD, Gaetan J. Karrillon, MD, Marie-Claude Aumok, hiD, and Ren6 Gourgbn, ilD S everal investigators have demonstrated that aggres- sive reperfusion therapy, particularly emergency coronary angioplasty, effectively improves the poor prog- nosis of primary cardiogenic shock complicating acute myocardial infarction (AMI) by reducing in-hospital mortality from 80% to 90% to <50%.14 However, few studies have focused on the current outcome of nonse- lected patients in whom the onset of AM1 is immedi- ately complicated by cardiogenic shock. Since 1989, 25 of the 339 patients (7.4%) consecu- tively admitted to our department within 6 hours of the onset of Q-wave AMI presented in cardiogenic shock on admission. All 25 were screened for emergency coronary angiography and reperfusion therapy and their in-hos- pital and postdischarge outcome was studied. AM was defined by prolonged chest pain consistent with ongoing myocardial ischemia and 21 mm of ST-segment eleva- tion in 22 contiguous leads on the admission electro- cardiogram. The diagnosis of cardiogenic shock was based on the combination of systolic blood pressure of 180 mm Hg unresponsive to volume expansion, signs of acute circu- latory failure (cyanosis, cold extremities, restlessness, mental confusion, or coma), and congestive heart fail- ure. When necessary, the cardiogenic etiology of shock was confirmed by hemodynamic assessment of the car- diac index (~2 literslminlm2) and the pulmonary artery wedge pressure (>15 mm Hg) using a Swan-Ganz cath- eter. In all cases, a mechanical complication was exclud- ed by emergency echocardiography. The baseline clinical and angiographic characteris- tics of the patients are listed in Table I. Twelve patients (48%) were aged 270 years, 7 (28%) had prior AM, and 15 (60%) required prolonged cardiopulmonary re- suscitation for >I5 minutes before or on admission. The location of AM was anterior in 16 patients (64%). In 3 patients, the infarct-related artery (diagnosed on the basis of total or subtotal occlusion and of the presence of intraluminal thrombus) was the left main trunk, and multiple acute coronary occlusions were observed in 2 others. Multivessel disease was present in 20 patients (80%). The emergency therapeutic interventions used are specified in Table II. Successful thrombolysis was defined as reperfusion of the infarct-related artery (grade 3 flow of the Thrombolysis in Myocardial Infarction trial) on From the Service de Cardiologie A, Hepita Bichat, 46 me Henri Huchard, 75018 Paris; and the Service de Cardiologie, H6pital Beaujon, Clichy, France. Manuscript received December 6, 1993; revised manu- script received and accepted March 11, 1994. 492 THE AMERICAN JOURNAL OF CARDIOLOGY@’ VOLUME 74 the 60- to 90-minute angiogram. Successful angioplas- ty was defined as reper-sion of the infarct-related artery with residual stenosis 140%. “Conventional” therapy was only applied to 2 octogenarians who had absolute contraindications to both thrombolysis and catheteriza- tion by way of the femoral approach. The other 23 pa- tients were all given reper@sion therapy: 18 (72%) underwent primary angioplasty, and 5 (20%) underwent intravenous thrombolysis (2 before entering the hospi- tal) with emergency coronary angiography; rescue angioplasty was pegormed in the 3 patients in whom thrombolysis failed. Successful reperfusion was achieved in 20 patients within a mean period of 58 f 19 minutes after admission. Adjunctive intraaortic balloon counter- pulsation was used in 17 patients (68%). Emergency coronary bypass surgery was per$ormed in 5 patients with severe persistent hemodynamic failure despite suc- cessful reperfusion. Inotropic agents were administered to all patients, as well as vasopressors when the hemo- dynamic condition made this imperative. Eighteen patients (72%) died while in the hospital, 11 within 2 days of admission (3 in the catheterization laboratory). The deaths included 14 of the 20 patients with successfil repelfusion, and 4 of the 5 with unsuc- cessful reperfiision or conventional therapy. Death was due to rej?actory pump failure in 15 patients (83%) intractable ventricularfibrillation in 2, and cardiac rup- ture in 1. After a mean follow-up of 17 months, 3 of the 7 hos- pital survivors died (2 of them several months after suc- cessful cardiac transplantation). Among the 4 midterm survivors, 2 are in New York Heart Association func- tional class I or II, and 2 are in class III or IV. These results suggest that the occurrence of primary cardiogenic shock during the tirst few hours of AM1 still carries a grim immediate prognosis, despite the vigor- ous use of interventional reperfusion therapy and intra- aortic counter-pulsation. The outcome appears particu- larly poor in patients aged 270 years, with previous AM1 or prolonged prehospital cardiopulmonary resuscitation. These results may appear to conflict with the more opti- mistic conclusions drawn from numerous studies demon- strating the effectiveness of emergency angioplasty in changing the outcome of cardiogenic shock due to AMI.t4 However, these discrepancies may be explained by the worst clinical characteristics of the patients stud- ied in the present report: our investigation focused on cardiogenic shock occurring very early during AMI, a condition that was common to all our patients and was indicative of the particular and immediate severity of hemodynamic consequences induced by myocardial lesions. The rapid evolution of pump failure, leading to SEPTEMBER 1, 1994