Current Spectrum of Cardiogenic Shock and Effect of Early Revascularization on Mortality
Results of an International Registry
Background Cardiogenic shock remains the leading cause of death of patients hospitalized with acute myocardial infarction (MI). This study was conducted to examine (1) the current spectrum of cardiogenic shock, (2) the proportion of patients who are potential candidates for a trial of early revascularization, and (3) the apparent impact of early revascularization on mortality.
Methods and Results Nineteen participating centers in the United States and Belgium prospectively registered all patients diagnosed with cardiogenic shock. Two hundred fifty-one patients were registered. The mean age was 67.5±11.7 years, and 43% were women. Acute mitral regurgitation or ventricular septal rupture was the cause of shock in 8%. Concurrent conditions contributing to the development of shock were noted in 5%, and 2% had isolated right ventricular shock. Among the remaining 214 patients, nonspecific findings on the ECG associated with “nontransmural” MI were seen in 14%. The median time to shock diagnosis after MI was 8 hours. The overall in-hospital mortality was 66%. Patients clinically selected to undergo cardiac catheterization were significantly younger and had a lower mortality than those not selected (51% versus 85%, P<.0001) even if they were not revascularized (58%). Mortality for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) was 60% (n=55) and 19% (n=16) for coronary artery bypass graft surgery (CABG). Sixty percent (n=150) of registered patients were judged eligible for a trial of early revascularization. Trial-eligible patients were significantly younger (65.4±11.0 versus 70.6±11.9 years, P<.001), had an earlier median time to shock onset after MI (6.5 versus 17.5 hours, P=.003), and had lower mortality (62% versus 73%, P=.077) than ineligible patients.
Conclusions Patients diagnosed with cardiogenic shock complicating acute MI are a heterogeneous group. Those eligible for a trial of early revascularization tended to have lower mortality. Patients selected to undergo cardiac catheterization had lower mortality whether or not they were revascularized. Emergent PTCA and CABG are promising treatment modalities for cardiogenic shock, but biased case selection for treatment may confound the data. Whether PTCA and CABG reduce mortality and which patient subgroups benefit most remain to be determined in a randomized clinical trial.
Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction (MI). The incidence (7.5%) and mortality (80%) were unchanged from 1975 to 1988 in a report on the Worcester, Mass, community.1 The incidence of shock in the Thrombolysis in Myocardial Infarction (TIMI) 2B Trial, where patients who were eligible to receive thrombolytic agents and were less than 75 years old were selected, was similar at 5.7%.2
Reports first appeared 20 years ago that patients with cardiogenic shock who underwent surgical revascularization had a lower mortality than those not revascularized.3 4 Recently, reports of nonrandomized series of patients selected for percutaneous transluminal coronary angioplasty (PTCA) also showed lower mortality rates for those undergoing successful PTCA for cardiogenic shock when compared with (1) those with failed PTCA,5 6 7 (2) those not selected for cardiac catheterization and PTCA,8 9 and (3) historic control subjects.10 11 12 13 14 15 16 17 18 19 20
Cardiogenic shock can develop by multiple mechanisms, including mechanical causes (ventricular septal defect [VSD] and mitral regurgitation [MR]), global subendocardial ischemia/infarction, and/or extensive transmural infarction. Many studies have not clearly evaluated these issues in relation to outcome. Accordingly, to assess prospectively the proportion of patients with “transmural” MI, who were seen early after shock diagnosis and who would be eligible for a randomized clinical trial of a direct invasive strategy of early revascularization, we compiled an international registry of patients with cardiogenic shock. The registry was initiated in January 1992 to examine (1) the current spectrum of cardiogenic shock, (2) the proportion of patients who are potential candidates for a trial of early revascularization, and (3) the apparent impact of early revascularization. The registry was completed in April 1993.
Nineteen participating centers in the United States and Belgium prospectively identified all patients diagnosed with cardiogenic shock complicating acute MI. The clinical diagnosis of cardiogenic shock was made if all the following criteria were present: (1) systolic blood pressure (BP) persistently ≤90 mm Hg or vasopressors required to maintain BP >90 mm Hg, (2) evidence of end organ hypoperfusion (eg, urine output <30 mL or cold/diaphoretic extremities or altered mental status), and (3) evidence of elevated filling pressures, for example, pulmonary congestion on examination or chest radiograph.
If a right heart catheterization was performed, confirmation of the absence of hypovolemia with a pulmonary capillary wedge pressure (PCWP) of ≥15 mm Hg was recorded. The following information was recorded: age, sex, race, location of MI, presence of ST elevations or new Q waves or new (not known to be old) left bundle branch block (LBBB), thrombolytic therapy eligibility (defined as no absolute contraindication to thrombolytic therapy), thrombolytic agent administration, time from MI onset to shock onset, use of intra-aortic balloon counterpulsation (IABP), performance of cardiac catheterization, attempts at PTCA and their success, performance of coronary artery bypass graft surgery (CABG), time from shock onset to revascularization, length of hospital stay, and vital status at hospital discharge. The data were collected as a pilot study to assess the feasibility of a multicenter, randomized, controlled trial of early revascularization for cardiogenic shock. The following concomitant conditions would preclude emergent PTCA for cardiogenic shock and were recorded: active bleeding or other contraindication to heparin, severe valvular disease, and/or prior diagnosis of dilated cardiomyopathy.
Causes of cardiogenic shock other than severe left ventricular dysfunction were recorded, including isolated right ventricular (RV) shock, severe MR, papillary muscle/chordal or ventricular septal rupture, tamponade, and shock complicated by hemorrhage or sepsis.
Fisher’s exact test was used to examine the association between categorical variables. Analyses stratified by age or cardiac catheterization status were conducted using the Mantel-Haenszel method, with age dichotomized as <65 years versus ≥65 years. Multivariate analyses of mortality were conducted using logistic regression. Comparisons of the mean of normally distributed variables, such as age, were made using the Student’s t test. The distributions of skewed variables, such as the time interval between MI and shock diagnosis and time between shock and revascularization, were compared using the Wilcoxon rank sum test. Descriptive statistics are expressed as mean±1 SD for age and the median and interquartile (Q1,Q3) range for skewed variables. All P values are two sided, and they are considered significant when P<.05. It should be noted that these registry data are from an observational study and not a study designed to detect specified group differences. Comparisons within patient subgroups are presented here for descriptive purposes and may aid in the development of research hypotheses for future randomized studies.
Two hundred thirty-one patients were prospectively registered from 19 centers. In addition, 20 patients were included from retrospective review of the last few months of 1991 by two of the centers. The mean age of the total sample (N=251) was 67.5±11.7 years. Eighty-four percent of patients were white, and 43% were women. Women were significantly older than men (69.5±11.2 versus 65.9±11.8 years) (P=.014). Forty-two percent of the patients had been transferred to the participating tertiary care medical centers.
Shock was of mechanical origin, that is, ventricular septal rupture (VSD) or acute severe MR in 19 patients (8%) and was due to isolated RV shock in 6 patients (2%). Twelve patients (5%) had concurrent conditions contributing to the development of shock, including prior severe valvular heart disease, concomitant hemorrhage, or sepsis. These patients are excluded from all subsequent analyses, resulting in 214 evaluable patients with primary left ventricular (LV) failure. The patients with VSD and MR are analyzed separately.
Thrombolytic agents were administered to 42% of all 214 patients and to 47% of patients presenting with ST elevations/Q-wave/new LBBB MI. The median interval between MI onset and shock diagnosis was 8 hours (Q1 to Q3, 3 to 24 hours) (n=198). A PCWP ≥15 mm Hg was confirmed in 95% of the 68% of patients with PCWP recorded. Fifty-eight percent underwent left heart catheterization and angiography, 26% PTCA, and 8% CABG. The overall in-hospital mortality was 66%. Patients who received thrombolytic agents had mortality similar to thrombolytic agent–eligible patients not receiving therapy (61% versus 71%, P=.334). Age was highly associated with mortality: Patients discharged alive had a mean age of 63.8±11.2 years, while nonsurvivors were on average 68.4±11.5 years old (P=.006).
Characteristics and Outcome by ECG Abnormality
Patients were divided into two groups according to their ECG findings on presentation. Patients in group 1 had ECG finding suggestive of a transmural MI, that is, ST elevation, new Q wave, or new LBBB. Patients in group 2 had ECG findings compatible with subendocardial infarction/ischemia, ie, ST-T depression and/or T-wave inversion or old LBBB. They comprised 14% of the 214 patients with primary LV failure.
Half (51%) of all infarcts in group 1 patients were categorized as anterior, 38% as inferior, 11% as posterior, and 24% as lateral. (All infarct sites were recorded, and multiple locations were present.) Within group 1, 53% of patients with inferior MI died, and 67% of those with anterior MI died (P=.097).
Patients with ST depression, nonspecific changes, or old LBBB (group 2) were significantly older than patients with ST elevation and new Q wave or new LBBB (group 1) patients (70.7±10.5 years versus 66.1±11.7 years, P=.041) (Table 1⇓). The gender distribution was similar. Cardiac catheterization and PTCA were performed more frequently in group 1 than in group 2 patients (62% versus 29%, P=.002, and 29% versus 7%, P=.012, respectively). The proportion of patients in each group who underwent CABG was similar (7% versus 10%, P=.476). Mortality was similar for group 1 and group 2 patients (64% versus 77%, P=.215).
Cardiac Catheterization and Revascularization
Patients who were not selected for cardiac catheterization were significantly older (70.2±11.7 versus 64.0±11.2 years, P=.0011) and more often had evidence of subendocardial infarction than patients not undergoing cardiac catheterization (Table 2⇓). In-hospital mortality for all patients selected to undergo cardiac catheterization was 51% (61 of 119) versus 85% (75 of 88) for those who did not undergo cardiac catheterization (P<.0001) (Figure⇓). A significant difference in mortality remained after adjustment for age, thrombolytic therapy, ECG changes, and MI location (crude and adjusted odds ratios for mortality of no cardiac catheterization group versus cardiac catheterization group, 5.49 and 4.76, respectively, both P<.0001). The median length of hospital stay of patients not undergoing cardiac catheterization was 2 days (Q1 to Q3, 1 to 7 days), in contrast to 12 days (Q1 to Q3, 3 to 20 days) for those undergoing cardiac catheterization. The short hospital stay for those not undergoing cardiac catheterization largely reflects their early death, as 85% died.
Characteristics and outcome of patients undergoing PTCA and CABG for shock as well as of the 5 patients who underwent very late revascularization after resolution of shock are shown in Table 2⇑. The characteristics of patients who underwent cardiac catheterization but no revascularization are also summarized in Table 2⇑.
The mortality rate for the 51 patients who underwent early revascularization (≤24 hours after shock diagnosis) was 51% (55% for PTCA, 29% for CABG) (Figure⇑). However, the mortality of 43 patients who underwent cardiac catheterization without revascularization was similar (58%) (Table 2⇑). In 5 patients, reasons for not attempting revascularization were unspecified. Of the remaining 38 patients, 29 (76%) had diffuse and severe coronary artery disease that was not amenable to PTCA or CABG surgery, while 9 (24%) had mild to moderate coronary disease that did not require intervention. Twelve patients underwent late PTCA or CABG for shock (median time after shock, 48 hours); three died (25%). Of note, 4 patients underwent very late CABG (median time after shock, 8 days) and 1 patient very late PTCA (32 days after shock) once cardiogenic shock had resolved, and none died.
There was no characteristic that was associated with survival among patients undergoing early revascularization in this relatively small sample (Table 3⇓). Age, sex, MI location, time from MI onset to shock diagnosis, and time to revascularization after shock diagnosis were similar for survivors (n=25) and nonsurvivors (n=26). In contrast, nonsurvivors who did not undergo early revascularization were significantly older than survivors (70.3±10.8 years versus 64.4±11.1 years, P=.007). Seventy-three percent of nonsurvivors were at least 65 years old. Other characteristics were similar.
The success rate of PTCA in patients with cardiogenic shock was 69% (33 of 48 patients with available information). The mortality rate was 61% in patients with successful PTCA and 73% in patients with unsuccessful PTCA.
Mortality was significantly lower with the use of IABP (72% without IABP versus 57% with IABP, P=.039, n=173). However, patients with IABP were significantly younger (64.5±10.7 versus 68.2±12.4 years, P=.039) and more often underwent cardiac catheterization (88% with IABP versus 30% without IABP, P<.0001). After adjusting for cardiac catheterization status, there was no significant association between mortality and IABP (P=.660). Among 47 patients who underwent PTCA, mortality rates did not differ by IABP use (62% with IABP versus 54% without IABP, P=.743). The success rates of PTCA were also similar for patients with and without IABP (69% versus 60%, P=.707).
Overall mortality was significantly greater in patients aged 65 years or over when compared with that of patients under 65 years (72% versus 56%, P=.017). The mortality of patients age 65 or over who underwent PTCA was not significantly different from that observed in PTCA patients under 65 years (64% versus 56%, P=.587).
Mechanical Causes of Shock
Characteristics of the 19 patients with mechanical complications (VSD and acute MR) are summarized in Table 4⇓. The rate of mechanical complications among female patients (3 of 109, 11.9%) was almost three times that among male patients (6 of 142, 4.2%) (P=.029). Infarcts were located anteriorly in 47% of the 19 patients and inferiorly in 53%. Three patients received thrombolytic therapy. The median time from myocardial infarct onset to shock diagnosis (n=17) was 24 hours. This was a significantly longer time to shock onset than to that of 198 patients with primary LV failure (8 hours) (P=.004). Four patients underwent cardiac surgery at a median time of 24 hours after shock diagnosis, and all died.
Eligibility for Randomized Trial
One hundred one patients were believed to be ineligible for a trial of revascularization for cardiogenic shock (Table 5⇓). Forty patients were excluded for a concomitant condition that included active bleeding or other contraindication to heparin, preexisting severe valvular heart disease, and prior diagnosis of dilated cardiomyopathy. In addition, as noted earlier, 8% had a mechanical cause of cardiogenic shock, 2% were found to have isolated RV shock, and 5% had shock complicated by hemorrhage, sepsis, or other causes of shock. Patients with ST depressions, old LBBB, or nonspecific changes (12.4%) were also deemed to be trial ineligible, as they lacked evidence for new regional myocardial damage. Several patients were found to be ineligible by more than one criterion.
Sixty percent (n=150) of patients were considered trial eligible (Table 5⇑). Among the 71% of eligible patients with PCWP recorded, a PCWP ≥15 mm Hg was confirmed in 97%. Trial-eligible patients were younger than trial-ineligible patients, and they had a shorter time interval from infarct onset to shock diagnosis. Their in-hospital mortality was lower at 62% compared with 73% for trial-ineligible patients (P=.077).
Trial-eligible patients selected for early revascularization (≤24 hours from shock) are compared with patients with late (>24 hours) or no revascularization after shock diagnosis. Patients undergoing early revascularization were significantly younger by 6.1 years (P=.002) (Table 6⇓). Eighty-five percent underwent PTCA and 15% underwent CABG in the early revascularization group, compared with 2% PTCA and 6% CABG in the late/no revascularization group. The in-hospital mortality was significantly lower for those selected to undergo early revascularization (50%) compared with those with late/no revascularization (67%) (P=.048; RR=0.74; 95% CI, 0.54 to 1.02). A benefit associated with early revascularization remained after adjusting for differences in age (P=.042).
This international registry is, to our knowledge, the largest and only multicenter, prospective series of patients diagnosed with cardiogenic shock complicating acute MI. The data show that cardiogenic shock due to acute MI includes an extremely heterogeneous group of patients. This heterogeneity is important to consider when examining the outcome of patients selected for various therapies compared with other patients with cardiogenic shock and with historic control subjects.
Patients who were eligible for early interventional therapy with revascularization had a lower mortality than ineligible patients. Specifically, patients with subendocardial infarction by ECG criteria and patients with mechanical complications (VSD, MR) causing shock had a higher mortality. These patients are included in prior series used as historic control subjects.1 8 21 This is a consistent finding in clinical trials research. Patients who are not study eligible have a worse outcome than randomized patients. Previously, in large trials that included patients with all types of ECG findings, those with ST depression MIs have been shown to be different from ST elevation MI patients, including a worse prognosis.22 23 In this series, they were older, they developed shock slightly later, and they were less likely to be selected for cardiac catheterization and early revascularization.
Interestingly, there was a large proportion of inferior MIs in our patient population. This is consistent with the Duke report and other series24 25 but is contrary to a prior series that demonstrated a marked anterior predominance.11 Most of the inferior MIs in this study involved the posterior and lateral walls as well. Patients with inferior MIs in the general MI population22 23 have a lower mortality than patients with anterior MIs, and one prior study reported the same finding for shock patients.25 Our study showed no significant difference in these two mortality rates, but a trend was noted (P=.097).
Shock developed sooner after infarction than in several older reports, but the timing was similar to the findings in one recent report.1 24 25 However, shock was not present in the early hours after infarction, ie, on presentation in the majority of patients who were ultimately diagnosed with shock. Whether the shorter median time to shock observed in this study is a real change or due to more accurate identification and timing in a prospective registry is unclear.
The proportion of women in this registry of cardiogenic shock is high when compared with series of all MI patients (43% versus 20% to 25%).22 23 26 Women were only 3.6 years older than men. This is consistent with the previous finding that women have a higher mortality from acute MI than men27 28 and suggests that an increased incidence of shock among women1 contributes to this observation. Prior reports also document that when patients with acute MI and shock are compared with those without shock, women are disproportionately represented among those with shock.1 11 Most striking in the current study was the preponderance of women among those with mechanical complications. Rupture is the dominant mechanism in these cases, specifically rupture of the interventricular septum or chordae/papillary muscle. This finding is consistent with other reports of an increased incidence of rupture in women.29 30 31 Mechanical complications also developed earlier than previously reported.29
In this registry, patients receiving thrombolytic agents had a similar mortality to those not receiving them (61% versus 71%). Although it has been frequently stated that thrombolytic agents have not affected the mortality of patients in cardiogenic shock, this statement has been based, primarily, on a single study. The only placebo-controlled thrombolytic trial that examined the Killip IV subgroup was GISSI I,23 which used streptokinase without aspirin or heparin and found no benefit of streptokinase in patients with cardiogenic shock. The rate of adjunctive intra-aortic balloon pump (IABP) use was not reported. Other data suggest that intracoronary streptokinase, when successful at reperfusion, results in the same mortality as successful PTCA.32 The TIMI 2B Trial, which used recombinant tissue plasminogen activator (rTPA) and an aggressive antithrombotic regimen, had a 6-week mortality of 51% when cardiogenic shock was diagnosed.2 Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) recently reported a 55% 30-day mortality for their patients diagnosed with shock.33 That trial had no upper age limit, and all who participated received thrombolytic and antithrombotic agents. These mortality outcomes are similar to the PTCA pooled data.20 Unfortunately, hemodynamic data to confirm shock were not available for many of the patients in these reports. The comparative efficacy of PTCA and an aggressive lytic and antithrombotic regimen used in conjunction with augmentation of coronary perfusion pressure by IABP is unknown. It was recently demonstrated that intraaortic balloon counterpulsation enhances the rate of TPA-induced coronary thrombolysis in an experimental model of acute MI with hypotension.
This international registry of patients in cardiogenic shock confirms prior reports that patients selected for early revascularization with PTCA or CABG have a lower in-hospital mortality than those not selected. In fact, this mortality was the same as previously reported.20 Importantly, however, patients selected to undergo cardiac catheterization had a much lower mortality than those not selected to undergo cardiac catheterization, even when revascularization was not performed. The selection process by clinicians is such that the most critically ill and unstable patients with cardiogenic shock are often not taken to the cardiac catheterization laboratory. Probably this is due to (1) their rapid deterioration and death before such intervention can occur, (2) the very high risk of complications during cardiac catheterization and (3) the expected poor outcome for these patients with the most profound shock, and (4) presence of associated disease.
We were disappointed that survival after early revascularization could not be predicted in our registry by readily available clinical parameters. The age, sex, MI location, timing of shock onset, and timing of revascularization were the same in survivors and nonsurvivors after early revascularization. However, it should be noted that this series may be underpowered in this regard. The registry nature of this study limited the information collected; diabetes, prior hypertension, and prior MI were not assessed but may have influenced the selection process for early revascularization and subsequent patient outcome.
The small number of patients undergoing CABG for shock makes conclusions difficult regarding this group. However, the apparent lower mortality with CABG than with PTCA needs further examination as to whether it reflects selection bias or might indicate a real therapeutic difference of complete revascularization. Since the objective of this prospective registry was to better define the clinical course of patients in cardiogenic shock and no diagnostic or therapeutic intervention was mandated, coronary angiography and ventricular function data were not systematically collected.
Studies comparing primary PTCA with thrombolysis for acute MI have had varying results.35 36 37 Any beneficial findings of PTCA, however, cannot be extrapolated to either thrombolytic agent–ineligible patients or cardiogenic shock patients, as they were excluded35 36 or insufficiently represented.37 Furthermore, the success rate of PTCA for shock patients is much lower,20 and there is a suggestion from prior studies that failed PTCA in acute MI may be associated with a worse outcome.38 This may be especially true in patients with cardiogenic shock, who are less able to tolerate the negative inotropic effects of radiographic dye. The need for a randomized clinical trial of PTCA for cardiogenic shock has been stated repeatedly.20 39
Emergent PTCA and CABG are promising modalities for treatment of cardiogenic shock complicating acute MI. Whether they reduce mortality and which subgroups could potentially benefit most remain to be determined in a randomized clinical trial that is now ongoing.
SHOCK Registry Investigators, in Order of Number of Patients Registered
CHR Citadelle, Liege, Belgium: Jean Boland, MD*; Pierre Materne, MD; Beatrice Koper, RN.
Baystate Medical Center, Springfield, Mass: Mark Porway, MD*; Deborah Warwick, RN.
Johns Hopkins University Hospital, Baltimore, Md: Jeffrey Brinker, MD*; Steven Schulman, MD; Vickie Coombs, RN.
Universite Catholique, Brussels, Belgium: Jacques Col, MD*; Jean Renkin, MD; Reine Lauwers, RN.
Boston University Hospital, Boston, Mass: Alice Jacobs, MD*; Jesse W. Currier, MD; Mary E. Mazur, RN.
St Luke’s/Roosevelt Hospital Center and Columbia University, New York, NY: James Slater, MD*; Anthony J. Pepe, MD; Gudrun Lang, RN.
New York Hospital/Cornell Medical Center, New York, NY: David H. Miller, MD*; Benjamin E. Zola, MD; Ellen Mellow, MD; Denise Silvasi, RN.
Columbia Presbyterian Medical Center, New York, NY: Hal Wasserman, MD*; Edith Escala, RN.
Montefiore Hospital Medical Center/Albert Einstein College of Medicine, Bronx, NY: Mark A. Menegus, MD*; Mark A. Greenberg, MD; Hiltrud S. Mueller, MD; Sheldon Breitbart, MD; Richard Charney, MD; Barbara Levine, PA.
University of Louisville, Louisville, Ky: J. David Talley, MD*; ZoeAnn Yussman, RN; Wendy Etka, RN.
Albert Einstein College of Medicine: Bronx Municipal and Jack D. Weiler Hospitals, Bronx, NY: Robert Forman, MD*; E. Scott Monrad, MD; Michele Nana, MD; Joel Strom, MD; Marie Galvao, RN.
University of Massachusetts, Worcester: Bonnie Weiner, MD*; Joel Gore, MD; Okike Okike, MD; Marie Borbone, RN.
Lenox Hill Hospital, New York, NY: Jeffrey W. Moses, MD*; Bruce Charash, MD; Nancy Cohen, RN.
Robert Wood Johnson Medical Center, New Brunswick, NJ: Abel E. Moreyra, MD*; Sebastian Palmeri, MD; Mary Helen Hosler, RN, BS.
Beth Israel Medical Center, New York, NY: Warren Sherman, MD*; Barbara Ventura, RN.
University of Texas Southwestern Medical Center, Dallas, Tex: John E. Willard, MD*; L. David Hillis, MD; Richard A. Lange, MD; Robert S. Meidell, MD; Kelly Heathman, RN.
Cardiovascular Center, Aalst, Belgium: Guy Heyndrickx, MD*; Bernard de Bruyne, MD; Peter Goemare, RN.
SUNY/Downstate University, Brooklyn, NY: Alan Feit, MD*; Michael Huber, MD.
St Vincent’s Hospital and Brooklyn/Caledonia Medical Center, New York: Peter Rentrop, MD*; Kenneth Ong, MD.
Clinical Coordinating Center: St Luke’s/Roosevelt Hospital Center and Columbia University
Judith Hochman, MD (Principal Investigator); Deborah Tormey, RN; Mary McAnulty, RN; and Albert Einstein College of Medicine: Thierry LeJemtel, MD (Co-Principal Investigator).
Data Coordinating Center: New England Research Institute
Sonja McKinlay, PhD (Principal Investigator); Lynn Sleeper, ScD; Judith Pierson, MSW.
We gratefully acknowledge unrestricted grants from Genentech, Inc, Philips Medical, Mansfield Division of Boston Scientific Co, and Medtronics to support this work. The authors wish to express their sincere appreciation to Linda Stevens, MT, ASCP, and Chris Rembert for their assistance in the preparation of the manuscript and to Karl Weimer for entry and editing of the SHOCK registry database.
Initial submission November 18, 1993; revision submitted June 27, 1994; revision accepted August 19, 1994.
↵1 For a complete list of investigators, see “Appendix.”
This study was presented in part at the 66th Scientific Session of the American Heart Association, Atlanta, Ga, November 1993.
- Copyright © 1995 by American Heart Association
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