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Aetiology of shock

Figure 6.1 Aetiology of suspected cardiogenic shock in the combined SHOCK trial registry and trial (total n = 1422, only first 232 trial patients are included). "Other" includes shock caused by prior severe valvar disease, dilated cardiomyopathy, excess P blockade/calcium channel blockade, haemorrhage, and procedural complications. Aortic dissection, pulmonary embolism, and dynamic subaortic outflow obstruction should also be considered. LVF, left ventricular function; MR, mitral regurgitation; RVF, right ventricular failure; VSR, ventricular septal rupture.

Aetiology of shock

Figure 6.1 Aetiology of suspected cardiogenic shock in the combined SHOCK trial registry and trial (total n = 1422, only first 232 trial patients are included). "Other" includes shock caused by prior severe valvar disease, dilated cardiomyopathy, excess P blockade/calcium channel blockade, haemorrhage, and procedural complications. Aortic dissection, pulmonary embolism, and dynamic subaortic outflow obstruction should also be considered. LVF, left ventricular function; MR, mitral regurgitation; RVF, right ventricular failure; VSR, ventricular septal rupture.

Table 6.1 Usefulness of echocardiography in cardiogenic shock

► Evaluate left ventricular function and myocardium at risk

► Evaluate remote myocardial segments

► Screen for ventricular septal rupture

► Screen for severe mitral regurgitation and proceed to transoesophageal echocardiography as needed

► Look for tamponade/rupture

► Assess right ventricular function

► Look for aortic dissection revascularisation strategy were clearly warranted and the National Heart, Lung, and Blood Institute funded the SHOCK trial in the USA, while the SMASH trial in Switzerland evaluated the same issue.19 20 While SMASH failed to recruit an adequate number of patients, SHOCK reported an increase in 30 day survival from 46.7% to 56.0% by the adoption of an early revascularisation strategy, but this absolute 9% difference did not reach significance (p = 0.11). On follow up, the survival difference in favour of the early revascularisation strategy became larger and significant at six months (36.9% v 49.7%, p = 0.027) and one year (33.6% v 46.7%) for an absolute reduction of 13.2% (95% CI 2.2% to 24.1%, p < 0.03). The Kaplan-Meier survival curves for the early revascularisation and initial medical stabilisation arms are illustrated in fig 6.2. There were 10 prespecified subgroup variables examined, including sex, age, prior MI, hypertension, diabetes, anterior MI, early or late shock, and transfer or direct admission status. A benefit of early revascularisation was demonstrated for all subgroups except for the elderly. Age > 75 versus < 75 years interacted significantly with treatment effect at 30 days, six months, and one year. The benefit of early revascularisation was large for those < 75 years at 30 days (41.4% v 56.8%, 95% CI -27.8% to -3.0%), and six months (44.9% v 65.0%, 95% CI

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