Some patients with heart
attack shock survive years after aggressive treatment
Newswise — Despite advances in
treatment, people with a heart attack who survive the first hit and
get to a hospital remain in danger. Almost one out of 10 of these
patients will develop cardiogenic shock in which the heart
malfunctions, causing an inadequate amount of blood to be pumped to
the vital organs. As blood pressure plummets, the skin becomes cool
and the body’s organs shut down. Some 60% of these patients will not
survive, which is why cardiogenic shock is the leading cause of
death for heart attack patients once they reach the hospital.
However, an important study
published in 1999 by a group led by Judith S. Hochman, M.D., showed
aggressive invasive treatment of heart attack patients who develop
cardiogenic shock could save lives and as a result, the American
Heart Association and the American College of Cardiology recommend
aggressively treating heart attack shock patients.
Although aggressive therapy is
increasingly used in tertiary care hospitals, which have
sophisticated invasive care facilities, not all eligible patients
receive it. And most patients who reach a hospital without such
facilities are not transferred to a hospital where they can be
Now, a new study by Dr. Hochman’s
group demonstrates that some patients who quickly received invasive
treatment with angioplasty or open-heart surgery to bypass clogged
coronary arteries survive long-term, and the superiority of this
treatment is sustained over time.
They report in the June 7 issue of
the Journal of the American Medical Association that with
invasive treatment 33% of hospitalized heart attack patients with
cardiac shock were alive six years later. By comparison, only 20% of
shock patients who were treated initially with medications and a
device to support the circulation called an intra-aortic balloon
pump (IABP) survived long-term.
“This well conducted study clearly
shows that treating the sickest heart attack patients early and
aggressively provides a survival benefit that is sustained years
after treatment,” says Elizabeth G. Nabel, M.D., Director of the
National Heart, Lung, and Blood Institute. “These results should
guide physicians to consider emergency revascularization for patents
with cardiogenic shock complicating heart attack,” says Dr. Nabel.
“Our study shows a significant
survival benefit that is sustained up to 11 years. This benefit
extends even to selected patients over the age of 75,” says Dr.
Hochman, Clinical Chief of the Leon H. Charney Division of
Cardiology and Director of Cardiovascular Clinical Research at New
York University School of Medicine. “Patients can do very well and
clearly benefit from this therapy, but many doctors are reluctant to
treat shock patients aggressively because they are the sickest of
the sick and the death rate is so high,” says Dr. Hochman, who is
also the Harold Snyder Family Professor of Cardiology at NYU School
Another problem is that many shock
patients need to be put into an ambulance and transferred to
tertiary care centers where they can receive appropriate care.
Doctors usually have to accompany these patients to another
hospital, and Dr. Hochman says “there is a lot of legitimate fear
about putting very sick patients in an ambulance.” Tertiary care
hospitals provide specialized services such as catheterization labs
where angioplasty, which involves threading a catheter-tipped
balloon to the site of a blockage in a coronary artery, is
Only about 60 percent of shock
patients younger than 75 received the more aggressive treatment in
tertiary care centers in 2004, according to a previous study by Dr
Hochman and colleagues. And only 38 percent of patients with shock
were transferred to such centers from 1998 to 2001.
The latest report from Dr.
Hochman’s group stems from an international trial funded by the
National Heart, Lung, and Blood Institute called SHOCK, which
enrolled 302 patients between 1993 and 1998 at 29 tertiary care
centers. All patients were initially treated with medications and
IABP to support the circulation and half received immediate
angioplasty or bypass surgery. Patients in the medications arm of
the trial could undergo angioplasty or bypass surgery at least two
days later. One year after treatment, 47 percent of the patients who
received the invasive treatments immediately were alive compared to
34 percent of those in the medications group.
Dr. Hochman hopes that more
patients with cardiogenic shock will be treated aggressively and she
sees some progress. In January the New York State Department of
Health began a two-year experiment in which heart attack patients
with severe shock would be analyzed separately from the public
Already Dr. Hochman says that she
has heard from colleagues that more cardiogenic shock patients are
undergoing angioplasty and surgery in New York because physicians
aren’t worried about raising their publicly reported surgical and
angioplasty mortality rates due to treating many shock patients.
The change was in response to a
number of publications that suggested bias by New York physicians
against doing invasive procedures in these highest risk patients.
One study by Dr. Hochman and colleagues from Albert Einstein College
of Medicine and New England Research Institutes showed that shock
patients in New York were less likely than patients in other states
to be treated aggressively, presumably because of public reporting
requirements. The study’s findings were reported at a meeting last
year of the American Heart Association.
Research is underway to find new
treatments for cardiogenic shock. Dr. Hochman is leading a trial to
determine whether a compound called nitric oxide synthase inhibitor
can help shock patients by targeting excess nitric oxide production.