American Journal of Emergency Medicine 33 (2015) 10721075

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Modied Shock Index is a Predictor for 7-Day Outcomes in Patients

With STEMI,
Qing Shangguan, MD 1, Jing-song Xu, MD 1, Hai Su, MD, PhD , Ju-xiang Li, MD, PhD, Wen-ying Wang,
Kui Hong, MD, PhD, Xiao-shu Cheng, MD, PhD
Department of Cardiology, Second Afliated Hospital of Nanchang University

a r t i c l e i n f o a b s t r a c t

Article history: Subject: The aim of this study was to compare the predictive values of modied shock index (MSI) and shock
Received 26 March 2015 index (SI) for 7-day outcome in patients with ST-segment elevation myocardial infarction (STEMI).
Received in revised form 27 April 2015 Methods: This retrospective study included 160 consecutive patients with STEMI and emergency percutaneous
Accepted 27 April 2015 coronary intervention. The blood pressure (BP) and heart rate (HR) measured at emergency department
were used to calculate SI (HR/systolic BP) and MSI (HR/mean artery pressure). The major adverse cardiac
events (MACE) included all-cause mortality, life-threatening arrhythmias, cardiogenic shock, and Killip class
within 7 days.
Results: Forty-nine patients had increased MSI (1.4), whereas 72 had increased SI (0.7). Except the parame-
ters on BP and HR, other parameters were similar between the normal and increased SI groups. However, the in-
creased MSI group had signicantly higher age (69.0 13.0 years vs 63.9 12.9 years, P = .025) than the normal
MSI group. The 7-day all-cause mortality was 8.8%, and MACE rate was 24.4% in this study. Both increased SI and
increased MSI predicted higher MACE rates. However, the odds ratios of increased MSI for all-cause mortality (6.8
vs 3.4), cardiogenic shock (3.0 vs 1.6), life-threatening arrhythmias (9.1 vs 4.6), and MACE (6.8 vs 3.4) were
higher than those of increased SI. Modied shock index and SI were independent factor for MACE, but the
odds ratio of MSI was higher than of SI (3.05 vs 1.07).
Conclusions: Both SI and MSI in emergency department could predict the all-cause mortality and MACE rates
within 7 days in patients with STEMI, but MSI may be more accurate than SI.
2015 Elsevier Inc. All rights reserved.

1. Introduction
Shock index (SI) is a simple index, dened as the ratio of heart rate
(HR) and systolic blood pressure (SBP). It has been demonstrated as
a useful predictor for hospital mortality among adult patients with
trauma [1-3]. Shock index is better not only than SBP, diastolic
blood pressure (DBP), and HR alone but also than some risk strati-
cation systems, for example, SI is more useful than the Triage Sort
(TSO) for secondary triage in a mass-casualty situation [4].
Competing interests: The authors declare no competing interests.
This work was supported by a grant from the National High Technology Research and
Development Program of China (863 Program, No. 2012AA02A516) and the Ministry of
Chinese Education Innovation Team Development Plan (IRT1141).
Corresponding author. No 1 Minded Road, Nanchang, Jiangxi, China 330006
Tel./fax: +86 791 86262262.
E-mail addresses: shangguan8910@163.com (Q. Shangguan), xujinsong636@sohu.com
(J. Xu), suyihappy@sohu.com (H. Su), ljx912@126.com (J. Li), wwy20080601@163.com
(W. Wang), hongkui88@163.com (K. Hong), xiaoshumenfan@126.com (X. Cheng).
1
Contributed equally.
In addition to trauma, SI could predict the risk of short- and long-term
mortality for other nontrauma diseases, such as pulmonary embolism
and aortic dissection. In patients with pulmonary embolism, SI could
provide information to stratify the risk of short- and long-term mortal-
ity [5]. In patients with acute pulmonary embolism, Toosi et al [6] found
that an elevated SI was associated with increased inhospital mortality,
independent of echocardiographic ndings. Meanwhile, in the patients
with aortic dissection, a signicant linear correlation was found
between the ratio of false/true lumen and the SI [7]. Therefore, the use-
fulness of SI is beyond to trauma and hemorrhagic diseases.
In clinical, the risk stratication for the patients with ST-segment
elevation myocardial infarction (STEMI) is very important to identify
those patients who are relatively more serious. Risk assessment pro-
vides an opportunity to integrate various patient characteristics into a
semiquantitative score that can convey an overall estimate of a patients
prognosis; can dictate the acuity, intensity, and location of care; and can
provide the patient and family with a more informed sense of potential
outcome [8]. At present, several systems of risk stratication such as
Thrombolysis In Myocardial Infarction (TIMI) and Globle Register
Acute Coronary Events (GRACE) are used, but the sophisticated calcula-
tion usually makes them inconvenient to operate at bedside in daily

http://dx.doi.org/10.1016/j.ajem.2015.04.066
0735-6757/ 2015 Elsevier Inc. All rights reserved.
 Q. Shangguan et al. / American Journal of Emergency Medicine 33 (2015) 10721075 1073

clinical practice [9,10]. Recently, Huang et al [11] suggested that admis-
sion SI of 0.7 or greater is a useful predictor for short-term outcomes in
the patients with STEMI. Other studies also indicated that an SI of 0.8 of
greater is a novel predictor for inhospital and long-term mortality in the
patients with STEMI [12,13]. These results provided a simple index for
risk stratication in the patients with STEMI.
In last year, a new index, modied shock index (MSI), is created as
the ratio of HR and mean artery pressure (MAP) [12] because DBP is
an undeniable parameter when determining clinical severity. Some
studies have found that MSI is a better predictor than SI for the outcome
in adult patients with trauma [14,15]. However, the predictive value of
MSI has not been evaluated in the patients with STEMI. This study was
to identify whether MSI is better than SI for predicting the short-term
outcomes in the patients with STEMI.
2. Patients and methods
This retrospective study included 160 consecutive patients with
acute STEMI attended to the emergency department (ED) in our hospital
from September 2013 to October 2014. The including criteria are arriving
in the ED within 12 hours after symptom onset, diagnosis of STEMI,
and received emergency percutaneous coronary intervention (PCI)
later. ST-segment elevation myocardial infarction was dened as
follows: chest pain or equivalent symptoms in combination with
dynamic electrocardiographic changes consistent with STEMI (in the
presence of ST elevation N0.1 mV in 2 extremity leads, N 0.2 mV in
2 precordial leads, or accompanying with left bundle branch block
morphology) and increased serum biochemical markers of cardiac ne-
crosis, including creatine kinaseMB and troponin I. The excluding
criteria were atrial brillation and obvious arrhythmia at blood pressure
(BP) measurement.
Age, sex, and histories of myocardial infarction, hypertension,
diabetes, and heart failure were obtained. Fasting blood glucose, results
of coronary angiography, and Killip classes were also recorded [16].
All patients received standard medication therapy according to the
detection of physicians under the guidelines for the management of
STEMI, including antiplatelet and anticoagulation, statins, angiotensin-
converting enzyme inhibitor or angiotensin receptor antagonists, nitrates,
-blockers, calcium channel blockers [8,17,18]. The use of vascular active
drugs including dopamine, adrenaline, noradrenaline, metaraminat, and
isoprenaline was recorded.
2.1. SI and MSI
The BP and HR measured (Comen C50 Multi-parameter Patient
Monitor, Shenzhen COMEN Medical Instruments CO, Shenzhen, China) at
ED were used to calculate SI and MSI. Blood pressure and HR were measured
twice with 1-minute interval, and their average was used as nal value.
Shock index is the ratio of HR to SBP.
Modied shock index is the ratio of HR to mean blood pressure
(MAP). Here, MAP = [(DBP 2) + SBP]/3.
The cutoff value of SI was referred as 0.7 in the study by Huang et al
[11], whereas the cutoff value of MSI was determined as 1.4 on the
receiver operating characteristic curve. The C-statistic of MSI of 1.4
was 0.690.
2.2. Major adverse cardiac events
In this study, major adverse cardiac events (MACE) include all-cause
mortality, life-threatening arrhythmias (LTA), cardiogenic shock, and
heart failure within 7 days. The all-cause mortality was dened death
caused by any reason; cardiogenic shock was dened as persistent hypo-
tension (SBP b90 mm Hg) that did not respond to uid titration and re-
quirement of an intra-aortic balloon pump or intravenous inotropic
therapy. Heart failure was diagnosed on the Killip class of II or more.
Life-threatening arrhythmias included sustained ventricular tachycardia
and ventricular brillation in hospitalization [8,18].
3. Statistical analysis
All statistical analyses were carried out using the SPSS statistical soft-
ware, version 19.0 (SPSS Inc, Chicago, IL).The data were presented with
mean SD or median and interquartile range for continuous variables
and were compared by analysis of variance and Bonferroni correction if
the data had normal distribution, otherwise by Wilcoxon signed rank
test. Categorical variables presented as percentage were compared by
the Pearson 2 test.
Multiple logistic regression analysis was performed for 7-day MACE
[12]. The dependent variables were SI of 0.7 or greater (or MSI 1.4),
age, sex (male, 1; female, 2), the history of old myocardial infarction
(yes, 1; no, 2), diabetes (yes, 1; no, 2), hypertension (yes, 1; no, 2),
stroke (yes, 1; no, 2), and the levels of blood blood glucose. P values
were statistically signicant at b.05.

Table 1
The general information of the studies patients and the comparison between 2 groups divided on SI of 0.7 or more or MSI of 1.4 or more

Variable All (n = 160) SI b0.7 (n = 88) SI 0.7 (n = 72) P MSI b1.4 (n = 111) MSI 1.4 (n = 49) P

Age (y) 65.5 13.1 64.5 13.0 66.6 13.4 N.05 63.9 12.9 69.0 13.0 b.01
Male 132 (82.5%) 73 (83.0%) 59 (81.9%) N.05 92 (82.9%) 40 (81.6%) N.05
History of MI 3 (1.9%) 1 (1.81%) 2 (2.8%) N.05 2 (1.8%) 1 (2.0%) N.05
Diabetes mellitus 32 (20%) 17 (19.3%) 15 (20.8%) N.05 22 (19.8%) 10 (20.4%) N.05
Hypertension 92 (57.5%) 54 (61.4%) 38 (52.8%) N.05 68 (61.3%) 24 (49.0%) N.05
History of stroke 10 (6.3%) 5 (5.7%) 5 (6.9%) N.05 7 (6.3%) 3 (6.1%) N.05
Onset to admission intervals (h)a 5.0 (4.0, 8.0) 5.0 (4.0, 7.5) 5.0 (4.0, 8.0) N.05 5.0 (4.0, 7.5) 5.25 (4.0, 8.0) N.05
SBP (mm Hg) 119.1 24.9 130.6 23.5 105.1 18.7 b.01 126.7 23.4 101.9 18.9 b.01
DBP (mm Hg) 73.2 14.9 77.1 14.3 68.5 14.1 b.01 76.8 13.7 65.0 14.3 b.01
MAP (mm Hg) 64.1 12.2 69.2 11.6 57.8 9.9 b.01 67.8 11.3 55.6 9.8 b.01
Heart rate (beat/min)a 77 (68, 90) 71 (61, 78) 90 (79, 102) b.01 72 (64, 81) 93 (84, 107) b.01
Killip class N.05 N.05
I 139 (86.9%) 78 (88.6%) 61 (84.7%) 100 (90.1%) 39 (79.6%)
II 15 (9.4%) 8 (9.1%) 7 (9.7%) 9 (8.1%) 6 (12.2%)
III 2 (1.3%) 0 2 (2.8%) 0 2 (4.1%)
IV 4 (2.5%) 2 (2.3%) 2 (2.8%) 2 (1.8%) 2 (4.1%)
Blood sugar (mmol/L)a culprit vessel 6.2 (5.2, 7.7) 6.4 (5.2, 7.7) 5.9 (5.2, 7.4) N.05 6.1 (5.2, 7.3) 6.7 (5.3, 8.3) N.05
Anterior descending artery 81 (50.6%) 46 (52.3%) 35 (48.6%) N.05 60 (54.1%) 21 (42.9%) N.05
Left circumex branch 18 (10.6%) 7 (8.0%) 10 (13.9%) N.05 8 (7.2%) 9 (18.4%) .050
Right coronary artery 62 (38.8%) 35 (39.8%) 27 (37.5%) N.05 43 (37.8%) 19 (38.8%) N.05

Data are presented as mean SD, number (percentage), or median (25th, 75th percentiles).
a
Median (25th, 75th percentiles).
1074 Q. Shangguan et al. / American Journal of Emergency Medicine 33 (2015) 10721075

Table 2
The percentages of 7-day outcomes in the 4 groups stratied by SI and MSI

Outcome All patients (n = 160) MSI SI

b1.4 (n = 111) 1.4 (n = 49) P b0.7 (n = 88) 0.7 (n = 72) P

MACE 39 (24.4%) 17 (15.3%) 22 (44.9%) b.01 13 (14.8%) 26 (36.1%) b.01

Killip classes 20 (12.5%) 10 (9.0%) 10 (20.4%) b.05 6 (6.8%) 14 (19.4%) b.05
Cardiogenic shock 9 (5.6%) 4 (3.6%) 5 (10.2%) N.05 4 (4.5%) 5 (6.9%) N.05
LTA 9 (5.6%) 2 (1.8%) 7 (14.3%) b.01 2 (2.3%) 7 (9.7%) b.05
All-cause mortality 14 (8.8%) 4 (3.6%) 10 (20.4%) b.01 4 (4.5%) 10 (13.9%) b.05

4. Results At rst, the present study demonstrated that SI of 0.7 or greater is a

useful predictor for 7-day outcomes in the patients with STEMI. This re-
Based on optimizing the sum of sensitivity and specicity by receiver sult was concomitant with that from a study of 7187 patients with
operating characteristic curve analysis, the optimal cutoff value of MSI STEMI, in which SI of 0.7 or greater indicated greater 7- and 30-day
for predicting MACE was 1.4 in this study. all-cause mortality and MACE as the TIMI risk score (11). Other studies
The sensitivity of MSI of 1.4 or greater was lower (56.4% vs 66.7%) also showed that SI of 0.8 or more is strong independent predictor of
than that of SI of 0.7 or greater, but specicity was higher (77.7% vs short-term and/or long-term outcome in patients with STEMI [12,13].
62.0%) in this study. Second, the present study rstly demonstrated that MSI (1.4) is a
Table 1 shows the general information of 4 groups divided by SI less better predictor than SI (0.7) for 7-day all-cause mortality and MACE
than 0.7 or 0.7 or greater and MSI less than 1.4 or 1.4 or greater. On MSI, in the patients with STEMI, as increased MSI predicted higher rates for
111 patients had normal and 49 had increased MSI. Although on SI, 88 all-cause mortality (20.4% vs 13.9%) and MACE (44.9% vs 36.1%) as
patients had normal and 72 had increased SI. The median (25th, 75th compared with increased SI. Furthermore, the ORs of MSI of 1.4 or
percentiles) of SI was 0.9 (0.8, 1.0) in the increased MSI group. more for all-cause mortality (6.8 vs 3.4), cardiogenic shock (3.0 vs
Except the parameters on BP and HR, other parameters were similar 1.6), and LTA (9.1 vs 4.6) as well as MACE (6.8 vs 3.4) were higher
between the normal SI and increased SI groups. However, the increased than those of SI of 0.7 or more, except from for Killip classes. Meanwhile,
MSI group had signicantly higher age (69.0 13.0 years vs 63.9 the OR s of MSI was also higher than that of SI (3.05 vs 2.61 ).
12.9 years, P = .025) and percentage of left circumex branch (P = .05) As the calculation of MSI uses MAP from SBP and DBP, MSI could
as culprit vessel (Table 1). more correctly reect myocardial perfusion and systemic vascular resis-
Meanwhile, the increased MSI group had signicantly higher age tance [14]; its higher predicting power in the patients with STEMI is
than the increased SI group (69.0 13.0 years vs 66.6 13.4 years, easily to be understood
P = .334). Third, the present study demonstrated that increased MSI was an
The 7-day all-cause mortality was 8.8%, and MACE rate was 24.4% in independent factor for the 7-day MACE. Furthermore, the OR s of MSI
this study. Both increased SI and MSI groups had higher MACE rates. was higher than that of age (3.05 vs 1.07). These results indicated that
The increased SI group had signicantly higher all-cause mortality the poorer outcome in the increased MSI groups is not because of the
(13.9% vs 4.5%, P b .05) and MACE rate (36.1% vs 14.8%, P b .05) than older age, as the older patients may have higher SBP and lower DBP
the normal SI group. On MSI, these differences were more obvious and then had higher MSI. Thus, MSI per se is a useful predictor.
(all-cause mortality 20.4% vs 3.6%, P b .05; MACE rate 44.9% vs 15.3%, In addition, another independent actor was blood glucose level. This
P b .05) (Table 2). nding is concomitant with the wide-accepted concept that admission
The odds ratios (ORs) of MSI of 1.4 or more for all-cause mortality hyperglycemia is an independent predictor in patients with STEMI
(6.8 vs 3.4), cardiogenic shock (3.0 vs 1.6), and LTA (9.1 vs 4.6) as well undergoing primary PCI [8,19].
as MACE (6.8 vs 3.4) were higher than those for SI of 0.7 or more, except
Killip classes (Table 3). 5.1. Clinical implication
Multifactor analysis showed that, in addition to MSI or SI, age
and blood glucose level were the independent factors for the 7-day Although several systems have been used for risk stratication in the
MACE (Table 4). patients with STEMI, such as TIMI and GRACE, the sophisticated calcula-
tion usually makes them inconvenient to operate at bedside in daily
clinical practice [9,10]. Our results suggest that MSI of 1.4 or greater
5. Discussion could be used for risk stratication in the patients with STEMI, although
a large, more sufcient study is required to demonstrate these ndings
Shock index is known as hemodynamic stability predictor. Its in the future.
predicting value for the outcome has been fully demonstrated in the
patients with trauma [1-4]. Recently, some studies further showed 5.2. Limitations
that a new index, MSI, in the ED is a more valuable marker for predicting
the mortality rate than SI alone in adult patients with trauma [14]. The number of the studied patients in this study was small. Mean-
while, only 7-day outcomes were analyzed. Moreover, the SI and MSI
after PCI and treatment were not evaluated.
Table 3
The comparison of ORs for outcomes between MSI of 1.4 or more and SI of 0.7 or more
Table 4
MSI 1.4 (49/160) SI 0.7 (72/160) The independent factors for the 7-day MACE on MSI of 1.4 or more or SI of 0.7 or more
OR 95% CI OR 95% CI MSI SI
MACE 4.5 2.1-9.7 3.3 1.5-7.0 P OR 95% CI P OR 95% CI
Killip classes 2.6 1.0-6.7 3.3 1.2-9.1
Cardiogenic shock 3.0 0.8-11.9 1.6 0.4-6.0 Age b.01 1.07 1.03-1.12 b.01 1.08 1.03-1.13
LTA 9.1 1.8-45.5 4.6 0.9-23.0 SI or MSI b.05 3.05 1.19-7.82 b.05 2.61 1.03-6.65
All-cause mortality 6.8 2.0-23.1 3.4 1.0-11.3 Glucose b.05 1.18 1.03-1.36 b.05 1.18 1.02-1.36
 Q. Shangguan et al. / American Journal of Emergency Medicine 33 (2015) 10721075
Singh et al [15] pointed out that MSI of 0.7 or greater also predicts
poor outcome in patients with trauma. This study only divided the
patients into 2 groups by a cut point of MSI of 1.4 as the MSI less than
0.7 was only seen in 2 cases without 7-day MACE. Therefore, the value
of MSI less than 0.7 in the patients with STEMI is unclear now.
6. Conclusions
Both SI and MSI measured in ED could predict the all-cause mortality
and MACE within 7 days in patients with STEMI and received PCI, but
MSI may more accurately predict 7-day mortality and MACE than SI.
References
[1] Rady MY, Smithline HA, Blake H, Nowak R, Rivers E, et al. Comparison of shock index
and conventional vital signs to identify acute, critical illness in emergency depart-
ment. Ann Emerg Med 1994;24:68590.
[2] Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M, et al.
Utility of shock index in predicting mortality in traumatically injured patients.
J Trauma 2009;67:142630.
[3] Sloan EP, Koenigsberg M, Clark JM, et al. Shock Index and Prediction of Traumatic
Hemorrhagic Shock 28-Day Mortality: Data from the DCLHb Resuscitation Clinical
Trials. West J Emerg Med 2014;15:795802.
[4] Vassallo J, Horne S, Ball S, et al. Usefulness of the Shock Index as a secondary triage
tool. J R Army Med Corps 2014. http://dx.doi.org/10.1136/jramc-2013-000178.
[5] Kilic T, Ermis H, Glbas G, et al. Prognostic role of the Simplied Pulmonary Embo-
lism Severity Index and the Shock Index in pulmonary embolism. Pol Arch Med
Wewn 2014;124(12):67887.
[6] Toosi MS, Merlino JD, Leeper KV. Prognostic Value of the Shock Index Along With
Transthoracic Echocardiography in Risk Stratication of Patients With Acute Pulmo-
nary Embolism[J]. Am J Cardiol 2008;101(5):7005.
1075
[7] Guo ZJ, Lin Q, Zi XR, et al. Correlation of computed tomography angiography param-
eters and shock index to assess the ransportation risk in aortic dissection patients.
Radiol Med 2015;120(4):38692.
[8] O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the
Management of ST-Elevation Myocardial Infarction[J]. J Am Coll Cardiol 2013;
61(4):e78-140.
[9] Garca-Paredes T, Aguilar-Alonso E, Arboleda-Snchez JA, et al. Evaluation of
prognostic scale Thrombolysis In Myocardial Infarction and Killip. An ST-elevation
myocardial infarction new scale. Am J Emerg Med 2014;32:13649.
[10] Fujii T, Suzuki T, Torii S, et al. Diagnostic Accuracy of Global Registry of Acute
Coronary Events (GRACE) Risk Score in ST-Elevation Myocardial Infarction for
In-Hospital and 360-Day Mortality in Japanese Patients. Circ J 2014;78:29504.
[11] Huang B, Yang Y, Zhu J, et al. Usefulness of the admission shock index for predicting
short-term outcomes in patients with ST-segment elevation myocardial infarction.
Am J Cardiol 2014;114:131521.
[12] Spyridopoulos I, Noman A, Ahmed JM, et al. Shock-index as a novel predictor of
long-term outcome following primary percutaneous coronary intervention. Eur
Heart J Acute Cardiovasc Care 2014 [pii: 2048872614561480].
[13] Bilkova D, Motovska Z, Widimsky P, et al. Shock index: a simple clinical parameter
for quick mortality risk assessment in acute myocardial infarction. Can J Cardiol
2011;27:73942.
[14] Liu YC, Liu JH, Fang ZA, et al. Modied shock index and mortality rate of emergency
patients. World J Emerg Med 2012;3:1147.
[15] Singh A, Ali S, Agarwal A, et al. Correlation of Shock Index and Modied Shock Index
with the Outcome of Adult Trauma Patients: A Prospective Study of 9860 Patients.
N Am J Med Sci 2014;6:4502.
[16] Killip III T, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A
two year experience with 250 patients. Am J Cardiol 1967;20:45764.
[17] Thygesen K, Alpert JS, Jaffe AS, et al. Third universal denition of myocardial
infarction[J]. Eur Heart J 2012;33:255167.
[18] Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocar-
dial infarction in patients presenting with ST-segment elevation: The Task Force on
the management of ST-segment elevation acute myocardial infarction of the
European Society of Cardiology (ESC)[J]. Eur Heart J 2012;33:2569619.
[19] Pinto DS, Kirtane AJ, Pride YB, et al. Association of Blood Glucose With Angiographic
and Clinical Outcomes Among Patients With ST-Segment Elevation Myocardial
Infarction (from the CLARITY-TIMI-28 Study)[J]. Am J Cardiol 2008;101(3):3037.