Frequency and clinical outcome of cardiogenic shock during acute myocardial infarction among patients receiving reteplase or alteplase Results from GUSTO-III

Results Shock occurred in 260 (5·3%) of 4921 patients randomized to alteplase and 560 (5·5%) of 10 138 patients randomized to reteplase. Of these patients, 28 (10·8%) and 55 (9·8%) randomized to alteplase and reteplase, respectively, presented with shock. In-hospital, 35% and 37% of shock patients assigned to alteplase or reteplase, respectively, underwent coronary angiography, with similar rates of percutaneous (211‐13%) or surgical (22‐3%) revascularization procedures subsequently performed. Death within 30 days occurred in 169 (65%) and 353 (63%) shock patients randomized to alteplase and reteplase, respectively (P=0·59). Of patients presenting with shock, 64% and 58% of patients randomized to alteplase or reteplase died within 30 days (P=0·59). Conclusion Compared with alteplase, reteplase did not improve outcome among patients who presented with shock or developed shock after receiving thrombolytics. The newer-generation thrombolytic agents remain of limited eYcacy in the treatment and prevention of shock. (Eur Heart J 1999; 20: 128‐135)

[1]  W. Weaver,et al.  Randomized comparison of coronary thrombolysis achieved with double-bolus reteplase (recombinant plasminogen activator) and front-loaded, accelerated alteplase (recombinant tissue plasminogen activator) in patients with acute myocardial infarction. The RAPID II Investigators. , 1996, Circulation.

[2]  J. Wittes,et al.  Analysis and interpretation of treatment effects in subgroups of patients in randomized clinical trials. , 1991, JAMA.

[3]  E R Bates,et al.  Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. , 1995, Journal of the American College of Cardiology.

[4]  M. Rubenfire,et al.  Intra-aortic balloon counterpulsation in cardiogenic shock. Report of a co-operative clinical trial. , 1973, The New England journal of medicine.

[5]  H. White,et al.  A Review of its Pharmacological Properties and Clinical Efficacy in the Management of Acute Myocardial Infarction , 1996 .

[6]  M. Simoons.  A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. , 1996, The New England journal of medicine.

[7]  K. Strein,et al.  Evaluation of thrombolytic and systemic effects of the novel recombinant plasminogen activator BM 06.022 compared with alteplase, anistreplase, streptokinase and urokinase in a canine model of coronary artery thrombosis. , 1992, Journal of the American College of Cardiology.

[8]  A. Jacobs,et al.  Current Spectrum of Cardiogenic Shock and Effect of Early Revascularization on Mortality Results of an International Registry , 1995 .

[9]  Gruppo Italiano per lo Studio della Soprawivenza nell'Inf Miocardico.,et al.  EFFECTIVENESS OF INTRAVENOUS THROMBOLYTIC TREATMENT IN ACUTE MYOCARDIAL INFARCTION , 1986, The Lancet.

[10]  R. Smalling.  Molecular biology of plasminogen activators: what are the clinical implications of drug design? , 1996, The American journal of cardiology.

[11]  W. O’Neill,et al.  Percutaneous transluminal coronary angioplasty improves survival in acute myocardial infarction complicated by cardiogenic shock. , 1988, Circulation.

[12]  Frans Van de Werf,et al.  An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. , 1993, The New England journal of medicine.

[13]  E. Topol,et al.  Cardiogenic shock: current understandings and future research directions. , 1994, The American journal of cardiology.

[14]  L. Hillis,et al.  Immediate angioplasty for acute myocardial infarction. , 1993, The New England journal of medicine.

[15]  E. Topol,et al.  Limitations of thrombolytic therapy for acute myocardial infarction complicated by congestive heart failure and cardiogenic shock. , 1991, Journal of the American College of Cardiology.

[16]  C. Bode,et al.  Patency trials with reteplase (r-PA): what do they tell us? , 1996, The American journal of cardiology.

[17]  J. Webb,et al.  Usefulness of coronary stenting for cardiogenic shock. , 1997, The American journal of cardiology.

[18]  R. Califf,et al.  Difference in countries' use of resources and clinical outcome for patients with cardiogenic shock after myocardial infarction: results from the GUSTO trial , 1997, The Lancet.

[19]  D. McTavish,et al.  Reteplase. A review of its pharmacological properties and clinical efficacy in the management of acute myocardial infarction. , 1996, Drugs.

[20]  C. Wilson,et al.  Efficacy of 100 mg of double-bolus alteplase in achieving complete perfusion in the treatment of acute myocardial infarction. , 1994, Journal of the American College of Cardiology.

[21]  J. Alpert,et al.  Frequency of inclusion of patients with cardiogenic shock in trials of thrombolytic therapy. , 1994, The American journal of cardiology.

[22]  P. Steg,et al.  Limits of reperfusion therapy for immediate cardiogenic shock complicating acute myocardial infarction. , 1994, The American journal of cardiology.

[23]  C. Simpfendorfer,et al.  Early and 1-year survival rates in acute myocardial infarction complicated by cardiogenic shock: a retrospective study comparing coronary angioplasty with medical treatment. , 1995, American heart journal.

[24]  J. Ducas,et al.  Marked systemic hypotension depresses coronary thrombolysis induced by intracoronary administration of recombinant tissue-type plasminogen activator. , 1992, Journal of the American College of Cardiology.

[25]  A. M. Skene,et al.  TRIAL OF TISSUE PLASMINOGEN ACTIVATOR FOR MORTALITY REDUCTION IN ACUTE MYOCARDIAL INFARCTION Anglo-Scandinavian Study of Early Thrombolysis (ASSET) , 1988, The Lancet.

[26]  J. Kalbfleisch,et al.  More rapid, complete, and stable coronary thrombolysis with bolus administration of reteplase compared with alteplase infusion in acute myocardial infarction. RAPID Investigators. , 1995, Circulation.

[27]  J. Ducas,et al.  Intraaortic balloon counterpulsation enhances coronary thrombolysis induced by intravenous administration of a thrombolytic agent. , 1994, Journal of the American College of Cardiology.

[28]  R. Califf,et al.  Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era. , 1992, Journal of the American College of Cardiology.

[29]  R. Califf,et al.  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. , 1997, Circulation.

[30]  G. Buckberg,et al.  Studies on prolonged acute regional ischemia. V. Metabolic support of remote myocardium during left ventricular power failure. , 1989, The Journal of thoracic and cardiovascular surgery.

[31]  J. Alpert,et al.  Cardiogenic shock after acute myocardial infarction: Incidence and Mortality from a Community-Wide Perspective, 1975 to 1988 , 1991 .