Interhospital transfer for early revascularization in patients with ST-elevation myocardial infarction complicated by cardiogenic shock—a report from the SHould we revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) trial and registry

Background Early revascularization (ERV) in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) reduces mortality rates. Patients admitted to hospitals without revascularization capability have high mortality rates and are not often transferred for ERV. Methods Transfer and direct-admit patients with STEMI from the SHOCK Trial and Registry with left ventricular failure (N = 969) were analyzed to determine benefit of ERV in transfer patients. Results Transfer patients (46%) were younger and less likely to have prior hypertension, myocardial infarction, and heart failure. They received more aggressive treatment, were revascularized later after CS (median 7.3 vs 3.9 hours, P = .0002), and had similar adjusted inhospital mortality compared with direct-admit patients (55% vs 56%). Inhospital mortality was lower in ERV than no/late revascularization (41% vs 53%, P = .017 for transfer patients; 55% vs 71%, P = .0003 for direct-admit patients). Multiple logistic regression showed that inhospital mortality was associated with age (odds ratio [OR] 1.50 per decade increase, 95% CI 1.31-1.73, P < .0001), mean arterial pressure (OR 0.98 per 1 mm Hg increase, 95% CI 0.97-0.99, P < .0001), fibrinolysis before CS (OR 0.65, 95% CI 0.52-0.96, P = .040), and ERV (OR 0.70, 95% CI 0.52-0.96, P = .028), but not transfer admission (OR 1.23, 95% CI 0.86-1.74, P = .26). Conclusions Despite longer time to treatment, transfer patients are a selected population with similar adjusted inhospital mortality and ERV benefit as direct-admit patients. Selected patients with STEMI and CS admitted to hospitals without revascularization capability should be transferred to centers with revascularization capability for immediate angiography.