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[Treatment of cardiogenic shock with thrombolysis and coronary angioplasty].

The incidence of cardiogenic shock in patients with acute myocardial infarction can be estimated between 2 and 12%, with a mortality close to 75%. Most pathologic studies demonstrate that myocardial necrosis involves more than 40% of left ventricular mass in these patients. Severe coronary disease is the rule, with three vessel disease in nearly 70% of cases. The efficacity of fibrinolytic treatment in reducing mortality is less evident in patient with shock. In the GISSI-1 study, Killip class IV patients had 69% mortality with streptokinase and 70% without; In the GISSI-2 trial, mortality was 65% with streptokinase and 78% with tPA. The thrombolytic drug used does not seem, thus, to influence the results. In a small series of 44 patients, intracoronary streptokinase achieved recanalization in 43% of cases, less than the average for the general population of patients with acute myocardial infarction receiving conventional treatment. Mortality was 42% in successfully treated patients, less than in those not reperfused. Coronary angioplasty seems superior to conventional fibrinolytic treatment. Results are promising, with survival between 56% and 61% in successfully reperfused patients. Recanalization rate may reach 75%. Surgery offers the only alternative when shock is due to any types of cardiac rupture; in the absence of this complication, its role is not well defined yet. Survival may be estimated in 50%.