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Evevident
Original paper
1999NEJMCardiology

SHOCK

Early revascularization in acute myocardial infarction complicated by cardiogenic shock

RCTCardiogenic shock

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Overview

Early revascularization improved longer-term survival in MI complicated by cardiogenic shock.

Clinical takeaway

SHOCK established urgent revascularization as the default strategy for suitable patients with AMI-related cardiogenic shock.

Key result

Thirty-day mortality was not significantly lower, but 6-month survival favored early revascularization.

Practice impact

Transfer and activate cath/surgical pathways for AMI cardiogenic shock when feasible.

Evidence

Study design

Randomized controlled trial.

Enrollment

302

Follow-up

Primary outcome at 30 days; important survival follow-up at 6 months and beyond.

Geography

Multinational

Clinical question

Does early revascularization improve survival in acute MI complicated by cardiogenic shock?

Population

  • Patients with acute myocardial infarction complicated by cardiogenic shock.

Intervention

Emergency early revascularization with PCI or CABG.

Comparator

Initial medical stabilization, including thrombolysis and delayed/selective revascularization.

Primary outcome

30-day all-cause mortality.

Early revascularization did not significantly reduce 30-day mortality but improved longer-term survival.

Absolute comparison / p=0.11

Key results

  • 30-day mortality reduction did not reach statistical significance.
  • Six-month mortality was significantly lower with early revascularization.
  • Long-term follow-up supported durable survival benefit.

Harms

  • Invasive revascularization carries bleeding, vascular, renal, and procedural risks in unstable patients.

Clinical Use

When to cite

  • When urgently transferring AMI cardiogenic shock patients for revascularization.

Practice impact

  • Established emergent revascularization as standard care for AMI-related cardiogenic shock.

Applicability

  • AMI patients with cardiogenic shock who are candidates for PCI or CABG.

Limitations

  • Small trial by modern standards and pre-dates contemporary stents, antiplatelets, and shock support strategies.

Common misinterpretations

  • Do not stop at the nonsignificant 30-day primary endpoint; the practice-changing signal came from survival over time.

Related evidence

ISIS-2 - Earlier TrialCULPRIT-SHOCK - Later Trial

Citation

Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999;341(9):625-634. doi:10.1056/NEJM199908263410901