Acute Cardiac Care, 2010; 12: 3–9

ORIGINAL ARTICLE

Predictors and in-hospital outcomes of cardiogenic shock on

admission in patients with acute coronary syndromes admitted
to hospitals without on-site invasive facilities

ARTUR DZIEWIERZ1, ZBIGNIEW SIUDAK1, TOMASZ RAKOWSKI1, JACEK S. DUBIEL1 &

DARIUSZ DUDEK2
12nd Department of Cardiology, 2Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow,
Poland
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10

Abstract
Background: The purpose was to identify predictors of cardiogenic shock (CS) on admission and to asses associations
between CS and real-life management patterns and outcomes in unselected cohort of acute coronary syndrome (ACS)
patients admitted to hospitals without onsite invasive facilities. Methods: Data concerning in-hospital management and
mortality of 56 (4.3%) patients with and 1257 (95.7%) without CS on hospital admission was assessed. Results: Prior
myocardial infarction, prior heart failure symptoms, age, and diabetes mellitus were independently associated with increased
risk of CS on admission. A total of 23.8% patients were transferred for invasive treatment during index hospital stay and
For personal use only.

the frequency of transfer was similar among patients with and without CS on admission (21.4% versus 23.9%; P  0.75),
but in the STEMI subgroup, patients with shock were transported less frequently (21.4% versus 43.8%; P  0.0027). CS
patients were less likely to receive guideline-recommended therapies including antiplatelet drugs, statins, and beta-blockers.
In-hospital mortality was lower in non-shock patients (6.2% versus 63.6%; P  0.001) and CS on admission was an
independent predictor of in-hospital death. Conclusions: CS on admission is an important determinant of treatment strat-
egy selection and is associated with unfavorable prognosis of ACS patients admitted to hospitals without on-site invasive
facilities.

Key Words: Cardiogenic shock, acute coronary syndrome, acute myocardial infarction, management, mortality

Cardiogenic shock is an important determinant of designed to examine current epidemiology, in-hospital

prognosis of patients with acute coronary syndromes
(ACS) (1–5). As patients with cardiogenic shock are
frequently excluded from randomized studies, data
concerning differences in management and out-
comes of such group of patients are still limited.
The purpose of the present study was to identify
predictors of presentation with cardiogenic shock on
admission and to asses associations between cardio-
genic shock on admission and real-life management
patterns and outcomes in an unselected cohort of
ACS patients admitted to hospitals without on-site
invasive facilities.
Methods
The Krakow Registry of Acute Coronary Syndromes
was a prospective, multicenter, observational registry
management and outcome of patients with acute
coronary syndromes in this region of Poland. Design
and main results of the Registry were published pre-
viously (6,7). Cardiogenic shock was defined as
reduced blood pressure (systolic blood pressure 90
mmHg or a drop of mean arterial pressure  30
mmHg) and/or low urine output (0.5 ml/kg/h),
with a pulse rate 60 beats per minute with or with-
out evidence of organ congestion (8). Patients were
classified as non-ST-segment elevation myocardial
infarction (NSTEMI) and ST-segment elevation
myocardial infarction (STEMI) based on their final
diagnosis. STEMI was diagnosed if ST-segment ele-
vation 1 mm occurred in 1 lead or new left bundle
branch block with biochemical evidence of myocar-
dial necrosis (1 positive biochemical cardiac necro-
sis markers measurement). NSTEMI was diagnosed
in patients with  1 positive biochemical cardiac

Correspondence: Dariusz Dudek, Department of Interventional Cardiology, Jagiellonian University Medical College, Kopernika 17 St, 31–501 Krakow,
Poland. Fax: 48 12 424 71 84. E-mail: mcdudek@cyf-kr.edu.pl

(Received 27 May 2009; accepted 18 January 2010)

ISSN 1748-2941 print/ISSN 1748-295X online © 2010 Informa UK Ltd.
DOI: 10.3109/17482941003637106
 4 A. Dziewierz et al.
necrosis markers measurement without new ST-
segment elevation in electrocardiogram. Differences
in the baseline characteristics and rate of transfer for
invasive treatment during index hospital stay were
assessed in all patients. Differences in pharmaco-
logical treatment, in-hospital mortality, and other
in-hospital complications (ischemic stroke, hemor-
rhagic stroke, a need for blood transfusion, ventricular
tachycardia/ventricular fibrillation, atrial fibrillation,
second and third grade atrioventricular block, pulmo-
nary edema) were reported for patients not trans-
ferred for invasive treatment.
Statistical analysis
Data were analyzed according to the established
standards of descriptive statistics. Values were
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10
expressed as mean  standard deviation. Categorical
variables were presented as percentages. Statistical
comparisons between groups were performed using
chi-square test and Fisher’s exact test for categorical
variables and Mann–Whitney U test for continuous
variables, as appropriate. Logistic regression analysis
was performed to find independent predictors of
presentation with cardiogenic shock on admission.
For personal use only.
Forward selection in logistic regression with the
probability value for covariates to enter the model
was set at 0.05 level.
The following covariates were tested: gender, age,
body mass index, presence of diabetes mellitus, arte-
rial hypertension, hyperlipidemia, prior angina, prior
myocardial infarction, prior heart failure symptoms,
prior revascularization (percutaneous coronary inter-
vention or coronary artery bypass graft), prior stroke/
transient ischemic attack, history of smoking, periph-
eral arterial disease, chronic renal insufficiency,
chronic obstructive pulmonary disease, chest pain
presence on admission, time from chest pain onset
to admission, and final diagnosis. Additional models
were constructed for STEMI, NSTEMI, and unsta-
ble angina patients’ subsets. Multivariate Cox regres-
sion analysis was performed to find significant
predictors of in-hospital death. The same covariates
as used in logistic regression analysis were tested and
forward selection in Cox regression with the proba-
bility value for covariates to enter the model were set
at 0.05 level. Risk of in-hospital death was expressed
as hazard ratio with 95% confidence interval. All
tests were two-tailed, and a P value of 0.05 was
considered statistically significant. All statistical anal-
ysis was performed using SPSS 15.0 (SPSS Inc.,
Chicago, Illinois).
Results
1414 patients with suspicion of acute coronary syn-
drome admitted to hospitals without on-site invasive
facilities were enrolled into the Krakow Registry of
Acute Coronary Syndromes between February 2005
and March 2005, and between December 2005 and
January 2006. 101 patients with a final diagnosis
other than myocardial infarction (e.g. stable angina,
extracardiac cause of chest pain) were excluded from
the analysis. Cardiogenic shock on admission was
diagnosed in 56 (4.3%) of the remaining 1313
patients. Baseline demographic and clinical charac-
teristics of patients with and without cardiogenic
shock on admission are summarized in Table I.
Patients with cardiogenic shock at admission had
more high-risk clinical characteristics such as older
age, history of diabetes, chronic renal failure, and
prior heart failure symptoms. Cardiogenic shock was
more common in acute myocardial infarction patients
(STEMI, NSTEMI) than in unstable angina patients
(STEMI versus NSTEMI versus unstable angina:
8.4% versus 6.8% versus 0.3% respectively; P
0.001), but the frequency of cardiogenic shock on
admission did not differ between STEMI and
NSTEMI patients. As shown in Table II, both STEMI
and NSTEMI diagnoses, prior heart failure symp-
toms, age, diabetes mellitus, arterial hypertension,
and hyperlipidemia were independently associated
with presence of cardiogenic shock on admission.
Age was also the predictor of cardiogenic shock
occurrence either in STEMI and NSTEMI patients.
Low frequency of cardiogenic shock on admission in
unstable angina patients did not allow identification
of significant predictors of shock in that subgroup of
patients (Table II).
312 (23.8%) patients were transferred for inva-
sive treatment during index hospital stay. The fre-
quency of transfer was similar among patients with
and without cardiogenic shock on admission (21.4%
versus 23.9%; P  0.75), but it was significantly
lower in shock than non-shock STEMI patients subset
(non-shock versus shock: STEMI: 43.8% versus
21.4%; P  0.027, NSTEMI: 24.0% versus 23.1%;
P  0.99, unstable angina: 13.6% versus 0%; P 
0.99). Among patients with cardiogenic shock there
was significant difference in frequency of elderly
patients (65 years: non-transferred versus trans-
ferred 68.2% versus 25.0%; P  0.018), patients
with prior chronic heart failure symptoms (40.9%
versus 8.3%; P  0.043), and patients with chest
pain on admission (61.4% versus 100%; P  0.011)
between transferred and non-transferred patients.
Also, time from chest pain onset to admission was
significantly longer in non-transferred shock patients,
than in transferred ones (15.620.7 versus 4.77.0 h,
P  0.023) .
1001 patients were not transferred and, therefore,
they only received non-invasive therapy. Among them,
patients presenting with cardiogenic shock on admis-
sion were less likely to receive guideline-recommended
therapies including antiplatelet drugs (aspirin, clopi-
dogrel, ticlopidin, glycoprotein IIb/IIIa inhibitors),
statins, beta-blockers, and angiotensin-converting
 Cardiogenic shock and outcomes in ACS 5

Table I. Baseline demographic and clinical characteristics.

Cardiogenic shock on admission

No Yes
Characteristics (n  1257) (n  56) P value

Male 56.7% 42.9% 0.041

Age (years) 67.4  11.9 75.6  10.2 0.001
Age  75 years 26.7% 58.9% 0.001
Body mass index (kg/m2) 27.3  6.9 26.4  3.8 0.20
Diabetes mellitus 20.6% 37.5% 0.004
Insulin 9.8% 28.6% 0.001
Arterial hypertension 78.2% 53.6% 0.001
Hyperlipidemia 56.0% 23.2% 0.001
Prior angina 67.9% 62.5% 0.39
Prior myocardial infarction 32.3% 30.4% 0.76
Prior heart failure symptoms 18.9% 33.9% 0.005
Prior PCI 9.1% 3.6% 0.23
Prior CABG 4.1% 1.8% 0.72
Prior revascularization (PCI or CABG) 12.2% 5.4% 0.08
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10

Prior stroke/transient ischemic attack 5.4% 7.1% 0.54

Current smoker 29.5% 16.1% 0.034
Chronic obstructive pulmonary disease 9.4% 8.9% 0.99
Family history of coronary artery disease 14.0% 10.7% 0.56
Peripheral arterial disease 10.2% 16.1% 0.18
Chronic renal insufficiency 4.5% 14.3% 0.005
Chest pain on admission 64.1% 69.6% 0.48
Time from chest pain onset to admission (h) 15.8  20.5 13.3  19.1 0.09
Time from chest pain onset to admission 12 h 33.9% 26.9% 0.37
Heart rate on admission (beat/min) 82.2  21.8 106.7  36.4 0.001
For personal use only.

Systolic blood pressure on admission (mmHg) 146.6  28.7 93.3  54.8 0.001
Diastolic blood pressure on admission (mmHg) 87.4  14.7 75.4  22.2 0.001
Left ventricular ejection fraction (%) 53.2  12.8 42.7  17.1 0.001
Discharge diagnosis of STEMI 24.3% 50.0% 0.001
Discharge diagnosis of NSTEMI 28.2% 46.4%
Discharge diagnosis of unstable angina 47.5% 3.6%

Values are presented as percentages or mean  standard deviation.

CABG, coronary artery bypass graft; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutanous coronary intervention;
STEMI, ST-segment elevation myocardial infarction.

enzyme inhibitor/angiotensin II antagonist during significantly shorter in patients without cardiogenic

index hospital stay (Table III). Observed difference
in the rate of thrombolytics use was associated with
difference in frequency of STEMI presentation
between the shock and non-shock patients. Among
STEMI patients thrombolysis was administered in
similar frequency in patients presenting with and
without shock on admission (18.2% versus 12.8%;
P  0.51).
Among patients treated conservatively during
index hospital stay in-hospital mortality was lower in
non-shock than in shock patients (6.2% versus
63.6%; P  0.001). This difference in mortality rate
was observed in all patients subsets stratified by diag-
nosis (non-shock versus shock: STEMI: 16.3% ver-
sus 72.7%; NSTEMI: 9.3% versus 50.0%; unstable
angina: 1.2% versus 100%; P  0.001 for all). In
multivariate Cox regression analysis cardiogenic
shock on admission was an independent predictor of
in-hospital death in the total population, as well as
in STEMI, NSTEMI, and unstable angina patients’
subsets (Table IV). Frequency of other in-hospital
complications is shown in Figure 1. Among
non-transferred survivors, mean hospital stay was
shock on admission (9.1  5.0 versus 12.8  4.5 days;
P  0.001).
Discussion
In our study cardiogenic shock on admission was an
important determinant of treatment strategy selec-
tion and outcomes in an unselected cohort of ACS
patients admitted to hospitals without on-site inva-
sive facilities.
In previous studies cardiogenic shock on admis-
sion was observed in approximately 2 to 4% of
patients with acute myocardial infarction (1–4). In
line with previous reports, prior heart failure symp-
toms, age, diabetes mellitus were identified as inde-
pendent predictors of increased risk of development
of cardiogenic shock on admission (2,5). Presence of
arterial hypertension and hyperlipidemia were asso-
ciated with decreased risk of cardiogenic shock on
admission. These observations were not confirmed
by data from the Acute Myocardial Infarction in
Switzerland (AMIS) Plus Registry, where higher
 6 A. Dziewierz et al.

Table II. Predictors of presentation with cardiogenic shock on admission.

Variable Odds ratio 95% Confidence interval P value

All patients (n  1313)

Diagnosis of STEMI (versus unstable angina) 17.21 3.96–74.77 0.001
Diagnosis of NSTEMI (versus unstable angina) 15.14 3.52–65.16 0.001
Prior heart failure symptoms 2.11 1.06–4.20 0.033
Diabetes mellitus 1.95 1.03–3.70 0.041
Age (per one year) 1.05 1.02–1.09 0.001
Hyperlipidemia 0.44 0.23–0.86 0.016
Arterial hypertension 0.33 0.17–0.64 0.001
STEMI patients (n  334)
Female (versus male) 2.51 1.01–6.26 0.048
Age (per one year) 1.06 1.01–1.10 0.010
NSTEMI patients (n  380)
Age (per one year) 1.07 1.03–1.12 0.002
Arterial hypertension 0.32 0.13–0.79 0.013
Hyperlipidemia 0.27 0.10–0.75 0.012
Unstable angina (n  599)
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10

None identified – – –

NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.

rates of these risk factors were noted in shock patients
compared to non-shock patients (2). Patients with
hyperlipidemia and arterial hypertension are at
higher chance of receiving chronic treatment with
statins, beta-blockers, and angiotensin-converting
For personal use only.
cardiogenic shock on admission was significantly
higher in patients with myocardial infarction than
unstable angina (10), and in STEMI than NSTEMI
patients (2,11,12).
Importantly, less than one quarter of patients

enzyme inhibitor before admission. However, the
same is truth for prior chronic heart failure symp-
toms or diabetes mellitus, that where more frequent
in patients with cardiogenic shock on admission.
These drugs, especially statins can modulate early
pathophysiological processes in patients presenting
with acute myocardial infarction. This hypothesis is
supported by findings from the Global Registry of
Acute Coronary Events (GRACE) (9), where patients
receiving long-term therapy with statins before
admission were less likely to have ST-segment eleva-
tion or myocardial infarction, and to present with
cardiogenic shock on admission. In addition, observed
rates of in-hospital death and other complications
were lower in patients with previous statins use (9).
Additionally, in-line with previous reports the risk of
with cardiogenic shock on admission were trans-
ferred for invasive diagnostics and treatment during
index hospital stay as recommended by current
guidelines (13–16). NSTEMI patients with clinical
symptoms of heart failure or hemodynamic instabil-
ity, including cardiogenic shock should be qualified
for urgent invasive strategy (14). As reported by Jeger
et al. in patients with cardiogenic shock emergency
revascularization is associated with significant mor-
tality reduction, either in patients with cardiogenic
shock on admission and in patients with delayed car-
diogenic shock (3). Also, other studies have reported
improved outcomes in patients with cardiogenic
shock associated with higher utilization of invasive
treatment (2,4). Therefore, invasive strategies were
sub-optimally used in our registry. Moreover, we have

Table III. Pharmacological treatment during index hospital stay in non-transferred patients. Values are presented as percentages.

Cardiogenic shock on admission

Characteristics No (n  957) Yes (n  44) P value

Aspirin 95.4% 88.6% 0.06

Clopidogrel 9.6% 0.0% 0.028
Ticlopidine 19.1% 9.1% 0.11
Glycoprotein IIb/IIIa inhibitor 3.3% 0.0% 0.39
Thrombolysis 2.5% 9.1% 0.031
Low-molecular-weight heparin 73.8% 72.7% 0.88
Beta-blocker 82.7% 38.9% 0.001
Angiotensin-converting enzyme inhibitor/ 77.1% 40.9% 0.001
angiotensin II antagonist
Calcium antagonist 11.3% 2.3% 0.08
Nitrates 71.0% 40.9% 0.001
Statins 86.0% 54.5% 0.001
 Cardiogenic shock and outcomes in ACS 7

Table IV. Multivariate Cox regression analysis for in-hospital death in non-transferred patients.

Variable Hazard ratio 95% Confidence interval P value

All patients (n  1001)
Cardiogenic shock on admission 7.39 4.50–12.11 0.001
Diagnosis of STEMI (versus unstable angina) 8.37 3.67–19.10 0.001
Diagnosis of NSTEMI (versus unstable angina) 3.73 1.59–8.72 0.002
Chronic obstructive pulmonary disease 2.17 1.28–3.65 0.004
STEMI patients (n  194)
Cardiogenic shock on admission 5.43 2.80–10.54 0.001
NSTEMI patients (n  289)
Cardiogenic shock on admission 4.75 2.09–10.81 0.001
Current smoker 0.11 0.02–0.81 0.030
Chronic obstructive pulmonary disease 2.51 1.11–5.67 0.026
Hyperlipidemia 0.29 0.09–0.87 0.027
Unstable angina (n  518)
Cardiogenic shock on admission 287.20 33.75–2443.82 0.001
Female (versus male) 0.03 0.01–0.45 0.012
Diabetes mellitus 9.50 1.64–55.19 0.012
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10

NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.

shown that patients with cardiogenic shock on admis-
sion were less likely to receive guideline-recommended
therapies, including acute aspirin, clopidogrel, beta-
blockers, and statins. Importantly, the Can Rapid
Risk Stratification of Unstable Angina Patients Sup-
For personal use only.
introduced during index hospital stay and prescribed
at discharge in all patients without contraindications
and who tolerate these medications, regardless of blood
pressure and left ventricular function (13). Low trans-
fer rate of patients in cardiogenic shock, and differ-

press Adverse Outcomes with Early Implementation
of the ACC/AHA Guidelines (CRUSADE) registry
data (17,18), as well as our previous paper (6) demon-
strated that patients who present with acute coronary
syndrome and do not receive guideline-recommended
therapies (including aspirin, clopidogrel, and beta-
blocker) have a higher mortality rate. Association bet-
ween aggressiveness of pharmacotherapy and in-hospital
mortality was confirmed either for shock and non-
shock patients (6). Alternatively, use of beta-blockers
in the acute phase is strictly contraindicated by current
guidelines in patients with clinical signs of hypoten-
sion (including shock patients) or congestive heart
failure. It is prudent to wait for the patient to stabilize
before starting an oral beta-blocker, and it should be
ence in pharmacotherapy between shock and non-shock
patients may be partially driven by observed differ-
ence in age, and other age related diseases.
Mortality rates in cardiogenic shock complicating
acute myocardial infarction are greater than 60%,
even in revascularized patients (2–4,11,12) and the
risk of death is higher in patients with cardiogenic
shock on admission than in patients with delayed
cardiogenic shock (2,3). In our study, cardiogenic
shock on admission was independently associated
with in-hospital mortality in the overall population,
as well as in STEMI, NSTEMI, and unstable angina
patients’ subsets. Observed mortality was also higher
in acute myocardial infarction (STEMI, NSTEMI)
than unstable angina patients (10). Additionally,

Figure 1. In-hospital complications in non-transferred patients stratified by cardiogenic shock on admission presence. Abbreviations: AV,
atrioventricular; VT/VF, ventricular tachycardia/ventricular fibrillation.
 8 A. Dziewierz et al.
patients presenting with STEMI were at higher risk
of death during hospital stay than patients presenting
with NSTEMI, either among shock and non-shock
patients. However, in the previous studies assessing
cardiogenic shock patients observed mortality was
similar (12) and even higher (2,11) in NSTEMI than
STEMI patients. In addition, chronic obstructive pul-
monary disease was identified as the independent
predictor of in-hospital mortality. Salisbury et al. have
shown previously that patients with chronic obstruc-
tive pulmonary disease are at higher risk of death and
re-hospitalization during long-term follow-up after
a myocardial infarction (19). Observed lower in-
hospital mortality among patients with NSTEMI and
hyperlipidemia or current smoking status was con-
firmed also by the GRACE Registry data (1). Impor-
tantly, patients with cardiogenic shock on admission
were also at higher risk of other complications (isch-
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10
emic stroke, ventricular tachycardia/ventricular fib-
rillation, atrial fibrillation, pulmonary edema) and
prolongation of hospital stay. Similar increased risk of
cerebrovascular events in shock patients was reported
by AMIS Plus Registry investigators (2).
Limitations
For personal use only.
Several important limitations of the present report
should be acknowledged. First, the study is limited
by relatively small sample size and registry-based
study design. Second, according to the purpose of
analysis, the study focused only on in-hospital clini-
cal outcomes of patients treated conservatively in
centers without on-site invasive facilities. Data con-
cerning mortality in the group of patients transferred
for invasive treatment during index hospital stay, as
well as long-term clinical follow-up data for all
patients were not available. There is possible selec-
tion bias associated with lack of transfer criteria and
less frequent transfer of very severe patients. In addi-
tion, the frequency of developing cardiogenic shock
during hospital stay, as well as time relationship
between cardiogenic shock on admission and other
in-hospital complications were not assessed. How-
ever, observed associations between cardiogenic
shock on admissions and in-hospital management
and outcomes are clinically important and unlikely
to be influenced by study limitations.
Conclusions
Cardiogenic shock on admission is an important
determinant of treatment strategy selection and is
associated with unfavorable prognosis of acute coro-
nary syndrome patients admitted to hospitals with-
out on-site invasive facilities.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
References
1. Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle
KA, Cannon CP, et al. Predictors of hospital mortality in the
global registry of acute coronary events. Arch Intern Med.
2003;163:2345–53.
2. Jeger RV, Radovanovic D, Hunziker PR, Pfisterer ME,
Stauffer JC, Erne P, et al. Ten-year trends in the incidence
and treatment of cardiogenic shock. Ann Intern Med.
2008;149:618–26.
3. Jeger RV, Harkness SM, Ramanathan K, Buller CE, Pfisterer
ME, Sleeper LA, et al. Emergency revascularization in patients
with cardiogenic shock on admission: A report from the
SHOCK trial and registry. Eur Heart J. 2006;27:664–70.
4. Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T,
Hochman JS. Trends in management and outcomes of
patients with acute myocardial infarction complicated by
cardiogenic shock. JAMA 2005;294:448–54.
5. Conde-Vela C, Moreno R, Hernandez R, Perez-Vizcayno
MJ, Alfonso F, Escaned J, et al. Cardiogenic shock at
admission in patients with multivessel disease and acute
myocardial infarction treated with percutaneous coronary
intervention: related factors. Int J Cardiol. 2007;123:29–33.
6. Dziewierz A, Siudak Z, Rakowski T, Mielecki W,
Giszterowicz D, Dubiel JS, et al. More aggressive pharma-
cological treatment may improve clinical outcome in patients
with non-ST-elevation acute coronary syndromes treated
conservatively. Coron Artery Dis. 2007;18:299–303.
7. Dudek D, Siudak Z, Dziewierz A, Rakowski T, Mielecki W,
Brzeziński M, et al. Creating local hospital networks for
STEMI treatment for a population of 0.5 million increases
invasive treatment of acute coronary syndromes to the
European recommended level. The Malopolska Registry of
Acute Coronary Syndromes 2005–2006. Kardiol Pol. 2008;
66:489–97.
8. Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos
GS, Jondeau G, et al. Executive summary of the guidelines
on the diagnosis and treatment of acute heart failure: The
Task Force on Acute Heart Failure of the European Society
of Cardiology. Eur Heart J. 2005;26:384–416.
9. Spencer FA, Allegrone J, Goldberg RJ, Gore JM, Fox KA,
Granger CB, et al. Association of statin therapy with out-
comes of acute coronary syndromes: The GRACE study.
Ann Intern Med. 2004;140:857–66.
10. Steg PG, Goldberg RJ, Gore JM, Fox KA, Eagle KA, Flather
MD, et al. Baseline characteristics, management practices,
and in-hospital outcomes of patients hospitalized with acute
coronary syndromes in the Global Registry of Acute Coro-
nary Events (GRACE). Am J Cardiol. 2002;90:358–63.
11. Holmes DR Jr, Berger PB, Hochman JS, Granger CB,
Thompson TD, Califf RM, et al. Cardiogenic shock in
patients with acute ischemic syndromes with and without
ST-segment elevation. Circulation 1999;100:2067–73.
12. Jacobs AK, French JK, Col J, Sleeper LA, Slater JN,
Carnendran L, et al. Cardiogenic shock with non-
ST-segment elevation myocardial infarction: A report from
the SHOCK Trial Registry. Should we emergently revascu-
larize occluded coronaries for cardiogenic shock? J Am Coll
Cardiol. 2000;36:1091–6.
13. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C,
Crea F, Falk V, et al. Management of acute myocardial inf-
arction in patients presenting with persistent ST-segment
elevation: The Task Force on the Management of ST-Segment
Elevation Acute Myocardial Infarction of the European Soci-
ety of Cardiology. Eur Heart J. 2008;29:2909–45.
14. Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A,
Fernandez-Aviles F, et al. Guidelines for the diagnosis and
treatment of non-ST-segment elevation acute coronary syn-
dromes. Eur Heart J. 2007;28:1598–660.
15. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA,
Halasyamani LK, et al. 2007 focused update of the ACC/
AHA 2004 guidelines for the management of patients with

ST-elevation myocardial infarction: A report of the American
College of Cardiology/American Heart Association Task
Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:
210–47.
16. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf
RM, Casey DE, Jr, et al. ACC/AHA 2007 guidelines for the
management of patients with unstable angina/non ST-
elevation myocardial infarction: A report of the American
College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Writing Committee to Revise
the 2002 Guidelines for the Management of Patients With
Unstable Angina/Non ST-Elevation Myocardial Infarction):
Developed in collaboration with the American College of
Emergency Physicians, the Society for Cardiovascular Angio-
graphy and Interventions, and the Society of Thoracic
Acute Card Care Downloaded from informahealthcare.com by HINARI on 12/21/10
For personal use only.
Cardiogenic shock and outcomes in ACS 9
Surgeons: endorsed by the American Association of Car-
diovascular and Pulmonary Rehabilitation and the Society
for Academic Emergency Medicine. Circulation 2007;116:e
148–e304.
17. Ohman EM, Roe MT, Smith SC, Jr, Brindis RG, Christenson
RH, Harrington RA, et al. Care of non-ST-segment elevation
patients: insights from the CRUSADE national quality
improvement initiative. Am Heart J. 2004;148:S34–9.
18. Roe MT, Peterson ED, Newby LK, Chen AY, Pollack CV,
Jr, Brindis RG, et al. The influence of risk status on guideline
adherence for patients with non-ST-segment elevation acute
coronary syndromes. Am Heart J. 2006;151:1205–13.
19. Salisbury AC, Reid KJ, Spertus JA. Impact of chronic
obstructive pulmonary disease on post-myocardial infarction
outcomes. Am J Cardiol. 2007;99:636–41.