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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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Fraccaro C, Karam N, Möllmann H, Bleiziffer S, Bonaros N, Teles RC, Carrilho Ferreira P, Chieffo A, Czerny M, Donal E, Dudek D, Dumonteil N, Esposito G, Fournier S, Hassager C, Kim WK, Krychtiuk KA, Mehilli J, Pręgowski J, Stefanini GG, Ternacle J, Thiele H, Thielmann M, Vincent F, von Bardeleben RS, Tarantini G. Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:634-651. [PMID: 37624587 PMCID: PMC10587846 DOI: 10.4244/eij-d-23-00473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.
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Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicole Karam
- Heart Valves Unit, Georges Pompidou European Hospital, Université Paris Cité, INSERM, Paris, France
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | | | - Nikolaos Bonaros
- Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental (HSC), Carnaxide, Portugal and Comprehensive Health Research Center (CHRC), Nova Medical School, Lisbon, Portugal
| | - Pedro Carrilho Ferreira
- Cardiology Department, Santa Maria University Hospital, CHULN, CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre, Freiburg University, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erwan Donal
- Service de Cardiologie, CCP CHU de Rennes, University of Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Giovanni Esposito
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland and University of Lausanne, Lausanne, Switzerland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Won-Keun Kim
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Konstantin A Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, German Centre for Cardiovascular Research (DZHK), Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Jerzy Pręgowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warszawa, Poland
| | - Giulio G Stefanini
- Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada and Université Laval, Quebec, QC, Canada
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany and University of Leipzig, Leipzig, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Flavien Vincent
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS. Basic mechanisms in cardiogenic shock: part 1-definition and pathophysiology. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:356-365. [PMID: 35218350 DOI: 10.1093/ehjacc/zuac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/17/2022] [Accepted: 02/07/2022] [Indexed: 05/23/2023]
Abstract
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, the most widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Part 1 of this two-part educational review defines cardiogenic shock and discusses current treatment strategies. In addition, we summarize current knowledge on basic mechanisms in the pathophysiology of cardiogenic shock, focusing on inflammation and microvascular disturbances, which may ultimately be translated into diagnostic or therapeutic approaches to improve the outcome of our patients.
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Affiliation(s)
- Konstantin A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christiaan Vrints
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Core Facilities, Medical University of Vienna, Vienna, Austria
| | - Kurt Huber
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Unit, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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Awad K, Sayed A, Banach M. Coenzyme Q10 Reduces Infarct Size in Animal Models of Myocardial Ischemia-Reperfusion Injury: A Meta-Analysis and Summary of Underlying Mechanisms. Front Cardiovasc Med 2022; 9:857364. [PMID: 35498032 PMCID: PMC9053645 DOI: 10.3389/fcvm.2022.857364] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/15/2022] [Indexed: 01/14/2023] Open
Abstract
Objective Effective interventions that might limit myocardial ischemia-reperfusion (I/R) injury are still lacking. Coenzyme Q10 (CoQ10) may exert cardioprotective actions that reduce myocardial I/R injury. We conducted this meta-analysis to assess the potential cardioprotective effect of CoQ10 in animal models of myocardial I/R injury. Methods We searched PubMed and Embase databases from inception to February 2022 to identify animal studies that compared the effect of CoQ10 with vehicle treatment or no treatment on myocardial infarct size in models of myocardial I/R injury. Means and standard deviations of the infarct size measurements were pooled as the weighted mean difference with 95% confidence interval (CI) using the random-effects model. Subgroup analyses were also conducted according to animals' species, models' type, and reperfusion time. Results Six animal studies (4 in vivo and 2 ex vivo) with 116 animals were included. Pooled analysis suggested that CoQ10 significantly reduced myocardial infarct size by −11.36% (95% CI: −16.82, −5.90, p < 0.0001, I2 = 94%) compared with the control group. The significance of the pooled effect estimate was maintained in rats, Hartley guinea pigs, and Yorkshire pigs. However, it became insignificant in the subgroup of rabbits −5.29% (95% CI: −27.83, 17.26; I2 = 87%). Furthermore, CoQ10 significantly reduced the myocardial infarct size regardless of model type (either in vivo or ex vivo) and reperfusion time (either ≤ 4 h or >4 h). Conclusion Coenzyme Q10 significantly decreased myocardial infarct size by 11.36% compared with the control group in animal models of myocardial I/R injury. This beneficial action was retained regardless of model type and reperfusion time.
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Affiliation(s)
- Kamal Awad
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Zagazig University Hospitals, Zagazig, Egypt
- *Correspondence: Kamal Awad
| | - Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
- Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
- Maciej Banach
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Zhang T, Wang J, Li X. Association Between Anion Gap and Mortality in Critically Ill Patients with Cardiogenic Shock. Int J Gen Med 2021; 14:4765-4773. [PMID: 34466021 PMCID: PMC8403005 DOI: 10.2147/ijgm.s329150] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background No epidemiological study has determined the association between the anion gap (AG) and all-cause mortality in critically ill patients with cardiogenic shock (CS). This study was conducted to clarify the relationship between the AG and mortality in CS. Methods We extracted clinical data from the public database, MIMIC-III V1.4, by using a generalized additive model to identify the nonlinear relationship between the AG and the 30-day mortality in 1248 intensive care unit patients. Cox proportional hazard models were used to assess the association between the AG and the 30-day, 90-day, and 365-day mortality in CS. Results The AG and 30-day all-cause mortality showed a nonlinear relationship, indicated by a J-shaped curve. In the multivariate analysis, after adjusting for potential confounders, a high AG was associated with an increased risk of 30-day, 90-day, and 365-day all-cause mortality in patients with CS compared with patients who had low AG (hazard ratio [95% confidence interval] 1.62 [1.14-2.30]; 1.35 [1.04-1.84]; and 1.38 [1.03-1.84], respectively). Similar results were shown in Model I (adjusted for age, sex and ethnicity) and in Model II (fully adjusting for age, ethnicity, sex, acute kidney injury stage, CHF, renal disease, stroke, malignancy, respiratory failure, pneumonia, sodium, potassium, chloride, BUN, PT, WBC, pH, creatinine, albumin, glucose, bicarbonate, vasopressor use, diastolic blood pressure, respiration rate, temperature, the Elixhauser Comorbidity Index, SOFA score and SAPSII score). Conclusion The relationship between the AG and 30-day all-cause mortality followed a J-shaped curve. Higher AG was associated with an increased risk of 30-day, 90-day, and 365-day all-cause mortality in critically ill patients with CS.
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Affiliation(s)
- Tingting Zhang
- Department of Clinical Laboratory, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Jie Wang
- Department of Cardiology, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Xiangyang Li
- Department of Clinical Laboratory, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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[Cardiogenic shock]. Wien Klin Wochenschr 2020; 132:333-348. [PMID: 32095880 DOI: 10.1007/s00508-020-01612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cardiogenic shock (CS) is defined as end-organ hypoperfusion as the consequence of primary myocardial dysfunction. Among the diagnostic criteria are a systolic blood pressure < 90 mmHg, acute renal failure (oligoanuria), ischemic hepatitis, cyanosis and cold, clammy skin. Accepted hemodynamic cutoffs are a cardiac index < 2,2 (l/min)/m2 and a pulmonary capillary wedge pressure > 15 mmHg. It should be acknowledged, that a normal blood pressure does not rule out CS; there is a nonhypotensive variant of CS demonstrating all the signs mentioned above (including elevated lactate levels) while the blood pressure is compensated due to vasoconstriction.The single most frequent cause of CS is pump failure in the setting of an acute myocardial infarction and its mortality rate has been lowered to 40-50%, owing to the widespread availability of primary PCI. Regarding PCI, it has been demonstrated recently that a "culprit-lesion only strategy" should be followed in the setting of CS. Other important causes of CS to take into account are mechanical complications of myocardial infarction (papillary and ventricular septal rupture as well as rupture of the myocardial free wall leading to tamponade), valvular heart disease (mostly decompensated aortic stenosis) as well as myocarditis and end stage cardiomyopathy.The diagnosis of CS is made by patient history, physical examination, ECG, echocardiography and coronary angiography. Echocardiography should always be performed before coronary angiography because, in the case of mechanical complications, it significantly alters the management of the patients. Patients with clinical signs of CS but paradoxically preserved ejection fraction must be thoroughly evaluated for the presence of a papillary muscle rupture, particularly in the setting of a lateral wall infarction.Noradrenaline and dobutamine are the first-line agents for medical stabilization. When such conventional measures fail, extracorporeal support devices such as ECMO or Impella© may be used. Currently, trials are underway to assess wheter these devices confer a survival benefit in this high-risk population.
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Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2608318. [PMID: 33150168 PMCID: PMC7603544 DOI: 10.1155/2020/2608318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 12/16/2022]
Abstract
Blood lactate concentration predicts mortality in critically ill patients and is clinically used in the diagnosis, grading of severity, and monitoring response to therapy of septic shock. This paper summarizes available quantitative data to provide the first comprehensive description and critique of the accepted concepts of the physiology of lactate in health and shock, with particular emphasis on the controversy of whether lactate release is simply a manifestation of tissue hypoxia versus a purposeful transfer ("shuttle") of lactate between tissues. Basic issues discussed include (1) effect of nonproductive lactate-pyruvate exchange that artifactually enhances flux measurements obtained with labeled lactate, (2) heterogeneous tissue oxygen partial pressure (Krogh model) and potential for unrecognized hypoxia that exists in all tissues, and (3) pathophysiology that distinguishes septic from other forms of shock. Our analysis suggests that due to exchange artifacts, the turnover rate of lactate and the lactate clearance are only about 60% of the values of 1.05 mmol/min/70 kg and 1.5 L/min/70 kg, respectively, determined from the standard tracer kinetics. Lactate turnover reflects lactate release primarily from muscle, gut, adipose, and erythrocytes and uptake by the liver and kidney, primarily for the purpose of energy production (TCA cycle) while the remainder is used for gluconeogenesis (Cori cycle). The well-studied physiology of exercise-induced hyperlactatemia demonstrates massive release from the contracting muscle accompanied by an increased lactate clearance that may occur in recovering nonexercising muscle as well as the liver. The very limited data on lactate kinetics in shock patients suggests that hyperlactatemia reflects both decreased clearance and increased production, possibly primarily in the gut. Our analysis of available data in health and shock suggests that the conventional concept of tissue hypoxia can account for most blood lactate findings and there is no need to implicate a purposeful production of lactate for export to other organs.
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Positive association between systemic immune-inflammatory index and mortality of cardiogenic shock. Clin Chim Acta 2020; 511:97-103. [PMID: 33045194 DOI: 10.1016/j.cca.2020.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiogenic shock (CGS) is not only a state of hypoperfusion, but also related to inflammation. The prognostic value of systemic immune-inflammatory index (SII), an innovate biomarker of inflammation, in CGS patients has not been assessed. This study aims to explore the associations between SII and mortality in patients with CGS. METHODS Data on patients diagnosed with CGS were extracted from MIMIC-III database version 1.4. The follow-up started on the patients' first admission to ICU. The primary outcome was 30-day mortality. 90-day and 365-day mortality were the secondary outcomes. Cox proportional hazards models were used to investigate the associations between SII and mortality of CGS patients. RESULTS 707 patients with CGS were included in our study (59.8% male, 67.5% the white, 70.27 ± 14.56 years). For 30-day mortality, the HR (95% CI) value of high-SII group was 2.17 (1.60, 2.93) compared with the reference of low-SII group (P < 0.0001). The HR value of mid-SII group, however, showed none statistical significance (HR: 1.03, 95% CI: 0.74-1.43, P = 0.8516). When adjusted for age, gender and ethnicity in Model I, the adjusted HR (95% CI) value of high-SII group was 2.28 (1.69, 3.09). When further adjusted for heart rate, SBP, serum potassium, PTT, INR and ECI in Model II, the adjusted HR value of high-SII group was still statistically significant (HR: 2.08, 95% CI: 1.52-2.86, P < 0.0001). Similar results were also shown in the secondary outcomes of 90-day and 365-day mortality. CONCLUSIONS High level of SII is associated with increased short- and long-term mortality of patients with CGS. SII, a readily available biomarker, can independently predict the prognosis of CGS patients.
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Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by end-organ hypoperfusion and hypoxia primarily due to cardiac dysfunction and low cardiac output. Unfortunately, the mortality and morbidity associated with CS have remained high despite notable advances in heart failure management. Treatment should be carefully guided by hemodynamics assessment. Although inotropes, vasopressors, mechanical circulatory support, and catheter intervention for critical valve lesion are not always recommended, they are helpful in selected patients. Early diagnosis, accurate hemodynamic assessment, and prompt therapeutic intervention are crucial in the management of acute decompensated heart failure with CS.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan; Department of Clinical Research Support, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan.
| | - Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
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Shock Team Approaches in Managing Cardiogenic Shock—Intersection Between Critical Care and Advanced Heart Failure and Transplant Cardiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00820-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Jones TL, Tan MC, Nguyen V, Kearney KE, Maynard CC, Anderson E, Mahr C, McCabe JM. Outcome differences in acute vs. acute on chronic heart failure and cardiogenic shock. ESC Heart Fail 2020; 7:1118-1124. [PMID: 32160418 PMCID: PMC7261534 DOI: 10.1002/ehf2.12670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
Abstract
Aims Despite advances in coronary reperfusion and percutaneous mechanical circulatory support, mortality among patients presenting with cardiogenic shock (CS) remains unacceptably high. Clinical trials and risk stratification tools have largely focused on acute CS, particularly secondary to acute coronary syndrome. Considerably less is understood about CS in the setting of acute decompensation in patients with chronic heart failure (HF). We sought to compare outcomes between patients with acute CS and patients with acute on chronic decompensated HF presenting with laboratory and haemodynamic features consistent with CS. Methods and results Sequential patients admitted with CS at a single quaternary centre between January 2014 and August 2017 were identified. Acute on chronic CS was defined by having a prior diagnosis of HF. Initial haemodynamic and laboratory data were collected for analysis. The primary outcome was in‐hospital mortality. Secondary outcomes were use of temporary mechanical circulatory support, durable ventricular assist device implantation, total artificial heart implantation, or heart transplantation. Comparison of continuous variables was performed using Student's t‐test. For categorical variables, the χ2 statistic was used. A total of 235 patients were identified: 51 patients (32.8%) had acute CS, and 184 patients (64.3%) had acute decompensation of chronic HF with no differences in age (52 ± 22 vs. 55 ± 14 years, P = 0.28) or gender (26% vs. 23%, P = 0.75) between the two groups. Patients with acute CS were more likely to suffer in‐hospital death (31.4% vs. 9.8%, P < 0.01) despite higher usage of temporary mechanical circulatory support (52% vs. 25%, P < 0.01) compared with patients presenting with acute on chronic HF. The only clinically significant haemodynamic differences at admission were a higher heart rate (101 ± 29 vs. 82 ± 17 b.p.m., P < 0.01) and wider pulse pressure (34 ± 19 vs. 29 ± 10 mmHg, P < 0.01) in the acute CS group. There were no significant differences in degree of shock based on commonly used CS parameters including mean arterial pressure (72 ± 12 vs. 74 ± 10 mmHg, P = 0.23), cardiac output (3.9 ± 1.2 vs. 3.8 ± 1.2 L/min, P = 0.70), or cardiac power index (0.32 ± 0.09 vs. 0.30 ± 0.09 W/m2, P = 0.24) between the two groups. Conclusions Current definitions and risk stratification models for CS based on clinical trials performed in the setting of acute coronary syndrome may not accurately reflect CS in patients with acute on chronic HF. Further investigation into CS in patients with acute on chronic HF is warranted.
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Affiliation(s)
- Tara L Jones
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA.,Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - Michael C Tan
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - Vidang Nguyen
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - Kathleen E Kearney
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - Charles C Maynard
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Emily Anderson
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
| | - James M McCabe
- Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA
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Samsky M, Krucoff M, Althouse AD, Abraham WT, Adamson P, Aguel F, Bilazarian S, Dangas GD, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Laschinger J, Masters RG, Michelson E, Morrow DA, Morrow V, Ohman EM, Pina I, Proudfoot AG, Rogers J, Sapirstein J, Senatore F, Stockbridge N, Thiele H, Truesdell AG, Waksman R, Rao S. Clinical and regulatory landscape for cardiogenic shock: A report from the Cardiac Safety Research Consortium ThinkTank on cardiogenic shock. Am Heart J 2020; 219:1-8. [PMID: 31707323 DOI: 10.1016/j.ahj.2019.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 02/04/2023]
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15
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Kawabori M, Pramil V, Shindgikar P, Zhan Y, Warner KG, Rastegar H, Kapur NK, Chen FY, Couper GS. Distal Embolic Protection in Impella 5.0 Explantation: Loop and Snare Technique. Ann Thorac Surg 2019; 109:e145-e146. [PMID: 31563488 DOI: 10.1016/j.athoracsur.2019.08.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 11/15/2022]
Abstract
The left ventricular assist device Impella 5.0 (Abiomed Inc, Danvers, MA) has become widely accepted as a temporary mechanical circulatory support for patients in cardiogenic shock. The Impella 5.0 is placed through an anastomosed graft. When removing the device, blood clot formation has been noted in the anastomosed graft. The blood clot has been reported to dislodge and embolize distally, causing acute limb ischemia. Here, we present our simple, inexpensive, and effective "loop and snare" technique for safer device removal, preventing distal embolic complications. In our experience of 6 patients who had Impella 5.0 removal with this technique, the distal embolic complication was 0%.
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Affiliation(s)
- Masashi Kawabori
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts.
| | | | | | - Yong Zhan
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Kenneth G Warner
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Hassan Rastegar
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Navin K Kapur
- Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Frederick Y Chen
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Gregory S Couper
- Department of Cardiovascular Surgery, Tufts Medical Center, Boston, Massachusetts
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16
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Jones TL, Nakamura K, McCabe JM. Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019; 6:e000960. [PMID: 31168376 PMCID: PMC6519403 DOI: 10.1136/openhrt-2018-000960] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/18/2019] [Accepted: 04/14/2019] [Indexed: 02/03/2023] Open
Abstract
Cardiogenic shock (CS) is a complex and highly morbid entity conceptualised as a vicious cycle of injury, cardiac and systemic decompensation, and further injury and decompensation. The pathophysiology of CS is incompletely understood but limited clinical trial experience suggests that early and robust support of the failing heart to allow for restoration of systemic homoeostasis appears critical for survival. We review the pathophysiology, clinical features and trial data to construct a contemporary model of CS as a systemic process characterised with maladaptive compensatory mechanisms requiring prompt and appropriately tailored medical and mechanical support for optimal outcomes. We conclude with an algorithmic approach to acute CS incorporating clinical and haemodynamic data to match the patient’s cardiac and systemic needs as a template for contemporary management.
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Affiliation(s)
- Tara L Jones
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kenta Nakamura
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - James M McCabe
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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17
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Hunziker L, Radovanovic D, Jeger R, Pedrazzini G, Cuculi F, Urban P, Erne P, Rickli H, Pilgrim T, Hess F, Simon R, Hangartner P, Hufschmid U, Hornig B, Altwegg L, Trummler S, Windecker S, Rueff T, Loretan P, Roethlisberger C, Evéquoz D, Mang G, Ryser D, Müller P, Jecker R, Kistler W, Hongler T, Stäuble S, Freiwald G, Schmid H, Stauffer J, Cook S, Bietenhard K, Roffi M, Wojtyna W, Schönenberger R, Simonin C, Waldburger R, Schmidli M, Federspiel B, Weiss E, Marty H, Weber K, Zender H, Poepping I, Hugi A, Koltai E, Iglesias J, Erne P, Heimes T, Jordan B, Pagnamenta A, Feraud P, Beretta E, Stettler C, Repond F, Widmer F, Heimgartner C, Polikar R, Bassetti S, Iselin H, Giger M, Egger P, Kaeslin T, Fischer A, Herren T, Eichhorn P, Neumeier C, Flury G, Girod G, Vogel R, Niggli B, Yoon S, Nossen J, Stoller U, Veragut U, Bächli E, Weber A, Schmidt D, Hellermann J, Eriksson U, Fischer T, Peter M, Gasser S, Fatio R, Vogt M, Ramsay D, Wyss C, Bertel O, Maggiorini M, Eberli F, Christen S. Twenty-Year Trends in the Incidence and Outcome of Cardiogenic Shock in AMIS Plus Registry. Circ Cardiovasc Interv 2019; 12:e007293. [DOI: 10.1161/circinterventions.118.007293] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lukas Hunziker
- Department of Cardiology, Bern University Hospital, Switzerland (L.H., T.P.)
| | - Dragana Radovanovic
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland (D.R.)
| | - Raban Jeger
- Division of Cardiology, University Hospital Basel, Switzerland (R.J.)
| | | | - Florim Cuculi
- Heart Centre Lucerne, Luzerner Kantonsspital, Switzerland (F.C.)
| | - Philip Urban
- Cardiology Department, La Tour Hospital, Geneva, Switzerland (P.U.)
| | - Paul Erne
- Department of Biomedicine, University of Basel, Switzerland (P.E.)
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St. Gallen, Switzerland (H.R.)
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Switzerland (L.H., T.P.)
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18
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[Infarct-related cardiogenic shock : Prognosis and treatment]. Med Klin Intensivmed Notfmed 2018; 113:267-276. [PMID: 29721682 DOI: 10.1007/s00063-018-0428-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Abstract
Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.
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19
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Braile-Sternieri MCVB, Mustafa EM, Ferreira VRR, Braile Sabino S, Braile Sternieri G, Buffulin de Faria LA, Sbardellini BC, Vianna Queiroz CO, Braile DM, Zotarelli Filho IJ. Main Considerations of Cardiogenic Shock and Its Predictors: Systematic Review. Cardiol Res 2018; 9:75-82. [PMID: 29755623 PMCID: PMC5942235 DOI: 10.14740/cr715w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/10/2018] [Indexed: 01/17/2023] Open
Abstract
The mortality rate of post-infarction cardiogenic shock (CS) was 80.0-90.0%. Recent studies show a significant reduction of hospital mortality to approximately 50.0%. CS is defined as systemic tissue hypoperfusion resulting from systolic and/or diastolic heart dysfunction, the main cause of which is acute myocardial infarction (AMI). The main predictors are biological markers such as troponin, CKMB and lactate. A systematic literature review and meta-analysis is performed in order to present and correlate the main literary findings on CS and its evolution with possible changes in biomarkers such as troponin, lactate and CKMB. After criteria of literary search with the use of the mesh terms: cardiogenic shock; acute myocardial infarction; biomarkers; troponin; CKMB; lactate; clinical trials and use of the bouleanos "and" between the mesh terms and "or" among the historical findings. In the main databases such as Pubmed, Medline, Bireme, EBSCO, Scielo, etc., a total of 96 papers that were submitted to the eligibility analysis were collated and, after that, 41 studies were selected, following the rules of systematic review - PRISMA (Transparent reporting of systematic reviews and meta-analyzes-http://www.prisma-statement.org/). Some risk factors for its development in AMI are advanced age, female gender, anterior wall infarction, diabetes mellitus, systemic arterial hypertension, previous history of infarction and angina. The CS associated with AMI depends on its extent and its complications, being the main ones: mitral regurgitation, rupture of the interventricular septum and rupture of the free wall of the left ventricule. The diagnosis is based on the clinical manifestations, such as mental confusion, oliguria, hypotension, tachycardia, fine pulse, sweating, and cold extremities; in hemodynamic aspects: systolic blood pressure was < 90.0 mm Hg or 30 mm Hg below baseline, pulmonary capillary pressure was > 18.0 mm Hg and cardiac index was < 2.2 L/min/m2. Laboratory and imaging exams should be requested to evaluate the possible etiology of CS, its systemic repercussions and comorbidities. The treatment aims at the rapid reestablishment of the blood flow in the affected artery, to improve the patient's prognosis. The biomarkers dosage in the daily clinical practice of the different cardiological centers can facilitate the diagnosis and the conduction of the dubious cases and the best evaluation of the degree of myocardial suffering after CS.
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Affiliation(s)
| | - Eliana Migliorini Mustafa
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Victor Rodrigues Ribeiro Ferreira
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil.,Faceres - Medical School of Sao Jose do Rio Preto, Av. Anisio Haddad, 6751 - Jardim Francisco Fernandes, Sao Jose do Rio Preto - SP, 15090-305, Sao Paulo, Brazil
| | - Sofia Braile Sabino
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Giovanni Braile Sternieri
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Lucia Angelica Buffulin de Faria
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Bethina Canaroli Sbardellini
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Cibele Olegario Vianna Queiroz
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Domingo Marcolino Braile
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
| | - Idiberto Jose Zotarelli Filho
- Domingo Braile Institute of Sao Jose do Rio Preto (SP), Rua Luiz Vaz de Camoes, 3111 - Vila Redentora, Sao Jose do Rio Preto - SP, 15015-750, Sao Paulo, Brazil
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20
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Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock: A Prospective Cohort Study With Long-Term Follow-Up. Shock 2018; 47:86-92. [PMID: 27984534 DOI: 10.1097/shk.0000000000000710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Relative adrenal insufficiency (RAI) is common in intensive care unit patients, particularly during septic shock (SS). Cardiogenic shock (CS) may share some pathophysiological features with SS. The aim of this study was to evaluate the prevalence and long-term prognosis of RAI during CS. PATIENTS AND METHODS Prospective observational study conducted in the intensive care and cardiology units in one university hospital in France. Patients meeting the criteria for CS without prior corticosteroid therapy were included. Total blood cortisol levels were assessed immediately before (T0) a short corticotropin stimulation test (0.25 mg i.v. of tetracosactrin) and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. RESULTS Of the 92 patients enrolled, 42 (46%) (95% confidence interval [CI] [36%-56%]) died in hospital and 7 more died during a median follow-up of 616 [57-2,498] days, for an overall mortality rate of 53% (95% CI [43%-63%]). Three groups were identified based on the corticotropin test: group 1 (T0 ≤798 nmol/L and Δmax >473 nmol/L), group 2 ([T0 >798 nmol/L and Δmax >473 nmol/L] or [T0 ≤798 nmol/L and Δmax ≤473 nmol/L]), and group 3 (T0 >798 nmol/L and Δmax ≤473 nmol/L) with an overall survival of 76%, 43%, and 15%, respectively (log rank P = 0.003). In the multivariable analysis, adrenal nonresponse (group 3) was an independent predictor of mortality (P = 0.04), along with left ventricular ejection fraction, Simplified Acute Physiology Score II, and cardiac arrest. CONCLUSIONS These data suggest that a short corticotropin test has a good prognostic value in CS and allows identifying patients at higher risk of death.
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21
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Rhyou HI, Park TH, Cho YR, Park K, Park JS, Kim MH, Kim YD. Clinical factors associated with the development of atrial fibrillation in the year following STEMI treated by primary PCI. J Cardiol 2018; 71:125-128. [DOI: 10.1016/j.jjcc.2017.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/26/2017] [Accepted: 08/24/2017] [Indexed: 11/30/2022]
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22
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Aissaoui N, Riant E, Lefèvre G, Delmas C, Bonello L, Henry P, Bonnefoy E, Schiele F, Ferrières J, Simon T, Danchin N, Puymirat E. Long-term clinical outcomes in patients with cardiogenic shock according to left ventricular function: The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme. Arch Cardiovasc Dis 2017; 111:678-685. [PMID: 29290598 DOI: 10.1016/j.acvd.2017.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains a major concern. Failure of the left ventricular (LV) pump is the primary insult in most forms of CS, but other parts of the circulatory system and diastolic function contribute to shock. However, little is known of the clinical presentation, management and outcomes according to LV function in these patients. OBJECTIVES To assess the presentation, management and clinical outcomes in patients admitted for AMI with CS according to early LV ejection fraction (LVEF), using long-term data from the French registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2010. METHODS We analysed baseline characteristics, management and 3-year mortality in patients with CS, according to LVEF (≤40% vs>40%). The analyses were replicated in the FAST-MI 2005 cohort. RESULTS Among 4169 patients with AMI included in the survey, the incidence of CS was 3.3%. LVEF was>40% in 43%. Early PCI (≤24hours) was used more often in patients with LV dysfunction (61% vs 42%), as was the use of optimal medical therapy at discharge (66% vs 40%). CS remained associated with a major increase in 3-year mortality, both in patients with LVEF ≤40% (55%) and in those with LVEF>40% (44%). Using Cox multivariable analysis, LVEF ≤40% was associated with higher 3-year mortality (hazard ratio 2.08, 95% confidence interval 1.15-3.78) in patients with AMI with CS. Consistent results were found in the replication cohort. CONCLUSIONS Despite the many circulatory system contributors to the physiopathology of CS in patients with AMI, the occurrence of early LV systolic dysfunction is associated with higher long-term mortality.
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Affiliation(s)
- Nadia Aissaoui
- Department of Critical Care Unit, hôpital Européen-Georges-Pompidou (HEGP), Assistance Publique-hôpitaux de Paris (AP-HP), 75015 Paris, France; Université Paris-Descartes, Inserm U970, 75015 Paris, France.
| | - Elisabeth Riant
- Department of Cardiology, HEGP, AP-HP, 75015 Paris, France; Université Paris-Descartes, 75006 Paris, France
| | - Grégoire Lefèvre
- Department of Cardiology, HEGP, AP-HP, 75015 Paris, France; Université Paris-Descartes, 75006 Paris, France
| | - Clément Delmas
- Department of Cardiology, Rangueil University Hospital, 31400 Toulouse, France; Institut des maladies métaboliques et cardiovasculaires, Inserm UMR-1048, 31432 Toulouse, France
| | - Laurent Bonello
- Department of Cardiology, hôpital Nord, Assistance Publique-hôpitaux de Marseille (AP-HM), 13015 Marseille, France
| | - Patrick Henry
- Department of Cardiology, hôpital Lariboisière, AP-HP, 75475 Paris, France
| | - Eric Bonnefoy
- Hôpital cardiologique Louis-Pradel, 69500 Lyon, France; Université Lyon-1, 69100 Lyon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean-Minjoz, 25000 Besançon, France
| | - Jean Ferrières
- Department of Cardiology B and Epidemiology, Toulouse University Hospital, 31059 Toulouse, France; Inserm UMR 1027, 31000 Toulouse, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Unité de Recherche Clinique (URCEST), hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Université Pierre-et-Marie-Curie (UPMC-Paris-06), 75005 Paris, France; Inserm U-698, 75877 Paris, France
| | - Nicolas Danchin
- Department of Cardiology, HEGP, AP-HP, 75015 Paris, France; Université Paris-Descartes, 75006 Paris, France
| | - Etienne Puymirat
- Department of Cardiology, HEGP, AP-HP, 75015 Paris, France; Université Paris-Descartes, 75006 Paris, France
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Deppe AC, Weber C, Liakopoulos OJ, Zeriouh M, Slottosch I, Scherner M, Kuhn EW, Choi YH, Wahlers T. Preoperative intra-aortic balloon pump use in high-risk patients prior to coronary artery bypass graft surgery decreases the risk for morbidity and mortality-A meta-analysis of 9,212 patients. J Card Surg 2017; 32:177-185. [DOI: 10.1111/jocs.13114] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Antje-Christin Deppe
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Oliver J. Liakopoulos
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Ingo Slottosch
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Maximilian Scherner
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Elmar W. Kuhn
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
- Center of Molecular Medicine Cologne; University of Cologne; Cologne Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery; Heart Center of the University of Cologne; Cologne Germany
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Tsai IT, Wang CP, Lu YC, Hung WC, Wu CC, Lu LF, Chung FM, Hsu CC, Lee YJ, Yu TH. The burden of major adverse cardiac events in patients with coronary artery disease. BMC Cardiovasc Disord 2017; 17:1. [PMID: 28052754 PMCID: PMC5210314 DOI: 10.1186/s12872-016-0436-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/07/2016] [Indexed: 12/30/2022] Open
Abstract
Background Patients with a history of cardiovascular disease are at high risk of developing secondary major adverse cardiac events (MACE). This study aimed to identify independent predictors of MACE after hospital admission which could be used to identify of high-risk patients who may benefit from preventive strategies. Methods This study included 1,520 consecutive patients with coronary artery disease (CAD) (654 with acute coronary syndrome (ACS) and 866 with elective percutaneous coronary intervention (PCI) patients) who received PCI and/or stenting. MACE was defined as all-cause mortality or rehospitalization for a cardiovascular- related illness. Cardiovascular-related illnesses included heart failure, reinfarction (nonfatal), recurrence of angina pectoris and repeat PCI or coronary artery bypass graft. Results During a mean follow-up period of 32 months, 558 of the 1,520 patients developed at least one MACE. Cox regression analysis showed that the baseline clinical and biochemical variables which associated with MACE were age, being illiterate, a widow or widower, and/or economically dependent, having triple vessel disease, stent implantation, anemia, and/or diabetes mellitus, waist to hip ratio (WHR), diastolic blood pressure, fasting glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), creatinine, estimated glomerular filtration rate (eGFR), red blood cell count, hemoglobin, hematocrit, and mean corpuscular-hemoglobin concentration (MCHC) in ACS patients, and age, malnourished, and/or economically dependent, taking hypoglycemic medication, having triple vessel disease, stent implantation, anemia, diabetes mellitus, and/or hypertension, WHR, fasting glucose, HDL-C, uric acid, creatinine, eGFR, high-sensitivity C-reactive protein, mean corpuscular volume, and MCHC in elective PCI patients. Using multivariate Cox regression analysis, we found the MACE’s independent factors are triple vessel disease, stent implantation, hypertension, and eGFR in ACS patients, and having triple vessel disease, stent implantation, hypertension, and uric acid in elective PCI patients. Conclusions Having triple vessel disease, stent implantation, hypertension, and eGFR or uric acid independently predicted MACE in patients with CAD after long-term follow-up. Fortunately, these factors are modifiable and should be identified and monitored early.
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Affiliation(s)
- I-Ting Tsai
- Department of Emergency, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,Department of Nursing, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Chao-Ping Wang
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Yung-Chuan Lu
- Division of Endocrinology and Metabolism, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan.,School of Medicine for International Students, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Wei-Chin Hung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Cheng-Ching Wu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Li-Fen Lu
- Division of Cardiac Surgery, Department of Surgery, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Fu-Mei Chung
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan
| | - Chia-Chang Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | | | - Teng-Hung Yu
- Division of Cardiology, E-Da Hospital, I-Shou University, No. 1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao District, Kaohsiung, 82445, Taiwan.
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Kardiologie. REPETITORIUM INTERNISTISCHE INTENSIVMEDIZIN 2017. [PMCID: PMC7418110 DOI: 10.1007/978-3-662-53182-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In der internistischen Intensivmedizin stellen die kardiologischen Erkrankungen die häufigsten Akutfälle dar. Das Management des akuten Koronarsyndroms, der akuten Herzinsuffizienz bzw. des kardiogenen Schocks sowie der Umgang mit Herzrhythmusstörungen nehmen entsprechend der Häufigkeiten einen bedeutsamen Platz ein. Die orientierende Echokardiographie findet dabei nicht nur als Notfalldiagnostikum, sondern auch zur Beurteilung der Hämodynamik zunehmende intensivmedizinische Anwendung. Dieses Kapitel berücksichtigt daher sowohl die hämodynamische Überwachung als auch die Behandlung aller relevanten kardiologischen Krankheitsbilder in der internistischen Intensivmedizin.
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Abstract
Snake venoms affect blood coagulation and platelet function in a complex manner. However, two classes of venom proteins, snaclecs and disintegrins have been shown to specifically target receptors including GPIb, α2β1, GPVI, CLEC-2 and integrins αIIbβ3, αvβ3, α5β1 expressed on platelets, endothelial cells, phagocytes, tumor cells, thus affecting cell-matrices and cell-cell interactions. Here, we focus on disintegrins, a class of low molecular mass Arg-Gly-Asp(RGD)/Lys-Gly-Asp(KGD)-containing, cysteine-rich polypeptide derived from various viper snake venoms. This review describes the potential applications of disintegrins in field of integrin-related diseases, especially arterial thrombosis, angiogenesis, tumor progression and septic inflammation. In addition, a novel RGD-containing disintegrin TMV-7 is being developed as a safer antithrombotic agent with minimal side effects, such as thrombocytopenia and bleeding.
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Affiliation(s)
- Tur-Fu Huang
- Institute of Pharmacology, College of Medicine, National Taiwan University, No.1, Sec. 1, Jen-Ai Rd, Taipei, Taiwan
| | - Chun-Chieh Hsu
- Institute of Pharmacology, College of Medicine, National Taiwan University, No.1, Sec. 1, Jen-Ai Rd, Taipei, Taiwan
| | - Yu-Ju Kuo
- Institute of Pharmacology, College of Medicine, National Taiwan University, No.1, Sec. 1, Jen-Ai Rd, Taipei, Taiwan
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Drolz A, Horvatits T, Roedl K, Rutter K, Staufer K, Haider DG, Zauner C, Heinz G, Schellongowski P, Kluge S, Trauner M, Fuhrmann V. Outcome and features of acute kidney injury complicating hypoxic hepatitis at the medical intensive care unit. Ann Intensive Care 2016; 6:61. [PMID: 27392655 PMCID: PMC4938842 DOI: 10.1186/s13613-016-0162-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/21/2016] [Indexed: 12/23/2022] Open
Abstract
Background Hypoxic hepatitis (HH) is a frequent and potentially life-threatening event typically occurring in critically ill patients as a consequence of hemodynamic impairment. While acute kidney injury (AKI) has been well described in patients with acute liver failure, incidence and outcome of AKI accompanying HH are unclear. The aim of this study was to assess incidence, clinical implications and outcome of AKI and renal replacement therapy (RRT) in critically ill patients with HH. Methods A total of 1948 consecutive critically ill admissions were studied at the Medical University of Vienna. Laboratory and clinical parameters as well as the presence of HH and AKI were assessed on a daily basis. Outcome, renal recovery and length of stay were assessed and documented, and patients were followed for 1 year. Results A total of 295 admissions (15 %) developed HH. Main precipitators were cardiogenic (44 %) and septic shock (36 %). Occurrence of HH was significantly associated with AKI [OR 4.50 (95 % CI 3.30–6.12)] and necessity of renal replacement therapy [RRT; OR 3.36 (95 % CI 2.58–4.37)], p < 0.001 for both. Two hundred forty admissions with HH (81 %) developed AKI, 159 of whom (66 %) had AKI stage 3. Both HH and AKI were significantly linked to mortality. AKI stage 3, international normalized ratio (INR, during HH) and the presence of septic shock were identified as independent predictors of 28-day mortality in admissions with HH, whereas RRT was identified as an independent protective factor. There was a synergistic effect of HH and AKI on length of stay at the ICU. Of all HH survivors treated with RRT, 71 % showed renal recovery during follow-up. Conclusion HH is frequently complicated by occurrence of AKI. Severity of HH, AKI stage and the presence of septic shock seem to contribute to poor outcome in these patients. Initiation of RRT in HH with AKI may enable renal recovery and should not be withheld in medical ICU patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0162-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andreas Drolz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Thomas Horvatits
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Katharina Staufer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik G Haider
- Division of Nephrology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Christian Zauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Intensive Care Unit 13H3, Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Intensive Care Unit 13I2, Division of Oncology and Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Jorge JDG, Santos MAA, Barreto Filho JAS, Oliveira JLM, de Melo EV, de Oliveira NA, Faro GBDA, Sousa ACS. Level of Physical Activity and In-Hospital Course of Patients with Acute Coronary Syndrome. Arq Bras Cardiol 2015; 106:33-40. [PMID: 26690692 PMCID: PMC4728593 DOI: 10.5935/abc.20160006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/04/2015] [Indexed: 11/20/2022] Open
Abstract
Background Acute coronary syndrome (ACS) is one of the main causes of morbidity and
mortality in the modern world. A sedentary lifestyle, present in 85%
of the Brazilian population, is considered a risk factor for the
development of coronary artery disease. However, the correlation of a
sedentary lifestyle with cardiovascular events (CVE) during
hospitalization for ACS is not well established. Objective To evaluate the association between physical activity level, assessed
with the International Physical Activity Questionnaire (IPAQ), with
in-hospital prognosis in patients with ACS. Methods Observational, cross-sectional, and analytical study with 215 subjects
with a diagnosis of ACS consecutively admitted to a referral hospital
for cardiac patients between July 2009 and February 2011. All
volunteers answered the short version of the IPAQ and were observed
for the occurrence of CVE during hospitalization with a standardized
assessment conducted by the researcher and corroborated by data from
medical records. Results The patients were admitted with diagnoses of unstable angina (34.4%),
acute myocardial infarction (AMI) without ST elevation (41.4%), and
AMI with ST elevation (24.2%). According to the level of physical
activity, the patients were classified as non-active (56.3%) and
active (43.7%). A CVE occurred in 35.3% of the cohort. The occurrence
of in-hospital complications was associated with the length of
hospital stay (odds ratio [OR] = 1.15) and physical inactivity (OR =
2.54), and was independent of age, systolic blood pressure, and prior
congestive heart failure. Conclusion A physically active lifestyle reduces the risk of CVE during
hospitalization in patients with ACS.
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Affiliation(s)
- Juliana de Goes Jorge
- Núcleo de Pós-graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, SE, Brazil
| | | | | | | | - Enaldo Vieira de Melo
- Núcleo de Pós-graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, SE, Brazil
| | - Norma Alves de Oliveira
- Núcleo de Pós-graduação em Ciências da Saúde, Universidade Federal de Sergipe, Aracaju, SE, Brazil
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Bonadei I, Sciatti E, Vizzardi E, D'Aloia A, Metra M. Ivabradine during cardiogenic shock: a clinical case and review of the literature. Heart Lung 2014; 44:57-8. [PMID: 25240447 DOI: 10.1016/j.hrtlng.2014.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 08/06/2014] [Indexed: 11/24/2022]
Abstract
Although the introduction of novel medical and invasive therapies in recent years has led to a significant reduction in mortality from heart failure, the same cannot be said for mortality due to cardiogenic shock. Drug therapy with inotropic agents and catecholamines has the disadvantage of causing increased myocardial oxygen consumption resulting in increased heart rate which may lead to the widening of the ischemic area. A reduction in heart rate with the administration of β-blockers is contraindicated due to negative inotropic and blood pressure lowering effects, typical of this group of drugs. Thus the theoretical possibility of ivabradine administration for an isolated reduction in heart rate, associated with the absence of a negative inotropic effect, could favorably influence hemodynamics in patients with cardiogenic shock. We report a case of cardiogenic shock treated by adding ivabradine to the currently used therapy.
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Affiliation(s)
- Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy.
| | - Antonio D'Aloia
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
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Secundo Junior JA, Santos MAA, Faro GBDA, Soares CB, Silva AMP, Secundo PFC, Teixeira CKC, Oliveira JLM, Barreto Filho JAS, Sousa ACS. Left atrial volume index and prediction of events in acute coronary syndrome: Solar Registry. Arq Bras Cardiol 2014; 103:282-91. [PMID: 25119895 PMCID: PMC4206358 DOI: 10.5935/abc.20140122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/30/2014] [Indexed: 12/21/2022] Open
Abstract
Background According to some international studies, patients with acute coronary syndrome
(ACS) and increased left atrial volume index (LAVI) have worse long-term
prognosis. However, national Brazilian studies confirming this prediction are
still lacking. Objective To evaluate LAVI as a predictor of major cardiovascular events (MCE) in patients
with ACS during a 365-day follow-up. Methods Prospective cohort of 171 patients diagnosed with ACS whose LAVI was calculated
within 48 hours after hospital admission. According to LAVI, two groups were
categorized: normal LAVI (≤ 32 mL/m2) and increased LAVI (> 32
mL/m2). Both groups were compared regarding clinical and
echocardiographic characteristics, in- and out-of-hospital outcomes, and
occurrence of ECM in up to 365 days. Results Increased LAVI was observed in 78 patients (45%), and was associated with older
age, higher body mass index, hypertension, history of myocardial infarction and
previous angioplasty, and lower creatinine clearance and ejection fraction. During
hospitalization, acute pulmonary edema was more frequent in patients with
increased LAVI (14.1% vs. 4.3%, p = 0.024). After discharge, the occurrence of
combined outcome for MCE was higher (p = 0.001) in the group with increased LAVI
(26%) as compared to the normal LAVI group (7%) [RR (95% CI) = 3.46
(1.54-7.73) vs. 0.80 (0.69-0.92)]. After Cox regression, increased LAVI
increased the probability of MCE (HR = 3.08, 95% CI = 1.28-7.40, p = 0.012). Conclusion Increased LAVI is an important predictor of MCE in a one-year follow-up.
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Cardiac Power Index, Mean Arterial Pressure, and Simplified Acute Physiology Score II Are Strong Predictors of Survival and Response to Revascularization in Cardiogenic Shock. Shock 2014; 42:22-6. [DOI: 10.1097/shk.0000000000000170] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Drolz A, Horvatits T, Michl B, Roedl K, Schellongowski P, Holzinger U, Zauner C, Heinz G, Madl C, Trauner M, Fuhrmann V. Statin therapy is associated with reduced incidence of hypoxic hepatitis in critically ill patients. J Hepatol 2014; 60:1187-93. [PMID: 24509409 DOI: 10.1016/j.jhep.2014.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Hypoxic hepatitis (HH) is a frequent and life-threatening complication associated with states of oxygen depletion in critically ill patients. Ischemia and reperfusion contribute to liver injury in HH. Experimental data suggest beneficial effects of statins in hepatic ischemia/reperfusion injury. This study was conducted to investigate whether statin treatment prior to intensive care unit (ICU) admission affects incidence rates and severity of HH. METHODS Eight hundred fifty-one patients admitted consecutively to three medical ICUs between December 2008 and December 2009 were prospectively screened for new occurrence of HH within 48 h following ICU admission. Statin treatment prior to ICU admission was assessed. 28-day-, 90-day-, and 1-year-survival as well as new-onset of complications in HH patients were prospectively documented. RESULTS Eighty-seven patients (10%) developed HH. Statin treatment prior to ICU admission was significantly associated with decreased incidence of HH within 48 h after ICU admission in the multivariate analysis (adjusted OR=0.42 (95% CI 0.19-0.95); p<0.05). Cardiogenic shock (p<0.001), septic shock (p<0.001) and active alcohol consumption (p<0.01) were identified as independent risk factors for development of HH. 28-day-, 90-day-, and 1-year-mortality rates in HH were 58%, 67%, and 74%, respectively. Statins were associated with improved 28-day-survival in the total study cohort (p<0.05), but did not affect 90-day- and 1-year-mortality, respectively. CONCLUSIONS Cardiogenic shock, septic shock, and active alcohol consumption were independent factors predisposing patients to new onset of HH. Statin treatment prior to ICU admission was the only protective factor regarding the new occurrence of HH in critically ill patients.
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Affiliation(s)
- Andreas Drolz
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Thomas Horvatits
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Barbara Michl
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Kevin Roedl
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Peter Schellongowski
- Intensive Care Unit 13 I2, Department of Oncology and Infectious Diseases, Division of Internal Medicine I, Medical University of Vienna, Austria
| | - Ulrike Holzinger
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Christian Zauner
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Gottfried Heinz
- Intensive Care Unit 13 H3, Department of Cardiology, Division of Internal Medicine II, Medical University of Vienna, Austria
| | - Christian Madl
- Department of Gastroenterology and Hepatology, KA Rudolfstiftung, Austria
| | - Michael Trauner
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Valentin Fuhrmann
- Intensive Care Unit 13 H1, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria.
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Cooper HA, Najafi AH, Ghafourian K, Paixao AR, Aljaabari M, Iantorno M, Caños D, Asch FM, Panza JA. Diagnosis of cardiogenic shock without the use of a pulmonary artery catheter. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:88-95. [PMID: 24833639 DOI: 10.1177/2048872614534564] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current diagnostic criteria for cardiogenic shock (CS) require the use of a pulmonary artery catheter (PAC), which is time-consuming and may cause complications. A set of simple yet accurate noninvasive diagnostic criteria would be of significant utility. METHODS Candidate components for the Noninvasive Parameters for Assessment of Cardiogenic Shock (N-PACS) criteria were required to be objective, readily available, and noninvasive. Variables encompassing hypotension, hypoperfusion, predisposing conditions, and elevated intracardiac filling pressures were optimized versus a PAC-based standard in a retrospective developmental cohort of 122 patients with acute myocardial infarction (AMI). The finalized criteria were validated in a prospective cohort of coronary care unit patients in whom a PAC was placed for clinical indications. RESULTS According to invasive criteria, CS was present in 32 of 217 consecutive patients undergoing PAC. Compared to the PAC-based standard, the N-PACS criteria had a sensitivity of 96.9% (95% confidence interval (CI) 82.0-99.8), specificity of 90.8% (95% CI 85.5-94.4), positive predictive value of 64.6% (95% CI 49.4-77.4), negative predictive value of 99.4% (95% CI 96.2-100), positive likelihood ratio of 10.5 (95% CI 6.7-16.7), negative likelihood ratio of 0.03 (95% CI 0.00-0.24), and diagnostic odds ratio of 306.4. Results were similar among patients with and without AMI. CONCLUSION A simple, echocardiography-based set of noninvasive diagnostic criteria can be used to accurately diagnose CS.
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Affiliation(s)
- Howard A Cooper
- MedStar Heart Institute, MedStar Washington Hospital Center, USA
| | - Amir H Najafi
- MedStar Heart Institute, MedStar Washington Hospital Center, USA
| | | | | | | | - Micaela Iantorno
- Critical Care Medicine Department, National Institutes of Health, USA
| | - Daniel Caños
- Center for Devices and Radiological Health, Food and Drug Administration, USA
| | - Federico M Asch
- MedStar Heart Institute, MedStar Washington Hospital Center, USA
| | - Julio A Panza
- Westchester Medical Center, New York Medical College, USA
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Prise en charge du choc cardiogénique d’origine ischémique : mise au point. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Percutaneous coronary intervention for nonculprit vessels in cardiogenic shock complicating ST-segment elevation acute myocardial infarction. Crit Care Med 2014; 42:17-25. [PMID: 24105454 DOI: 10.1097/ccm.0b013e3182a2701d] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. DESIGN A prospective, multicenter, observational study. SETTING Cardiac ICU of a university hospital. PATIENTS Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46-383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61-1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62-1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51-6.89; p = 0.344). CONCLUSIONS Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.
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Moscarelli M, Harling L, Attaran S, Ashrafian H, Casula RP, Athanasiou T. Surgical revascularisation of the acute coronary artery syndrome. Expert Rev Cardiovasc Ther 2014; 12:393-402. [DOI: 10.1586/14779072.2014.890889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Wadke R, Sanborn TA. Cardiogenic Shock: Background, Shock Trial/Registry, Evolving Data, Changing Survival, Best Medical Therapy. Interv Cardiol Clin 2013; 2:397-406. [PMID: 28582101 DOI: 10.1016/j.iccl.2013.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cardiogenic shock remains associated with unacceptably high mortality, but recent improvements with early revascularization, continued support with pharmacologic agents, and use of an intra-aortic balloon pump have led to improvements in the rate of mortality. Timely intervention with cardiac surgery in patients with mechanical complications, 3-vessel disease, and left main disease is beneficial. Continued research and ever-improving understanding of this once deadly condition have helped further in improving prognosis. Cutting-edge technologies, such as myocyte cell implantation and the use of a cooling system, will help in pushing the boundaries farther.
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Affiliation(s)
- Rahul Wadke
- Hospitalist Division, Department of Internal Medicine, Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Timothy A Sanborn
- Head Cardiology Division, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building, Third Floor, Evanston, IL 60201, USA
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Attanà P, Lazzeri C, Chiostri M, Picariello C, Gensini GF, Valente S. Strong-ion gap approach in patients with cardiogenic shock following ST-elevation myocardial infarction. ACTA ACUST UNITED AC 2013; 15:58-62. [PMID: 23806089 DOI: 10.3109/17482941.2013.776691] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Assess if acid-base evaluation by Stewart's approach had a clinical role in cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI). SETTING There are three widely used approaches to investigate metabolic acidosis: base excess (BE), anion gap (AG) and the Stewart's approach or strong ion gap (SIG). Available studies suggest the usefulness of SIG in sepsis and trauma. No data are so far available in CS. MEASUREMENTS AND RESULTS We enrolled 63 consecutive patients with CS following STEMI submitted to Percutaneous Coronary Intervention (PCI). On admission, the APACHE II (Acute physiology and chronic health evaluation II) score and HOMA (Homeostasis model assessment) index were assessed together with glomerular filtration rate (eGFR), quantitative BE, AG, lactate values and 12 h lactate clearance. Non-survivors showed a higher incidence of PCI failure, higher APACHE II score, lower LVEF, lower eGFR, lower 12 h lactate clearance; a higher admission lactate and more negative BE. No difference was detectable in AG and SIG. Only 3 patients exhibited pathological values of SIG (≥ 2) and only 1 of these patients died. CONCLUSIONS According to our data the SIG approach does not seem to add further information to usual parameters in acid-base evaluation or early risk stratification in CS patients.
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Affiliation(s)
- Paola Attanà
- Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. paola_
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Drolz A, Jäger B, Wewalka M, Saxa R, Horvatits T, Roedl K, Perkmann T, Zauner C, Kramer L, Ferenci P, Fuhrmann V. Clinical impact of arterial ammonia levels in ICU patients with different liver diseases. Intensive Care Med 2013; 39:1227-37. [DOI: 10.1007/s00134-013-2926-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 04/03/2013] [Indexed: 01/26/2023]
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Ünlüer EE, Karagöz A, Bayata S, Akoğlu H. An alternative approach to the bedside assessment of left ventricular systolic function in the emergency department: displacement of the aortic root. Acad Emerg Med 2013; 20:367-73. [PMID: 23701344 DOI: 10.1111/acem.12114] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/05/2012] [Accepted: 10/21/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Left ventricular ejection fraction (LVEF) is a crucial parameter in the management of patients with dyspnea in the emergency department (ED). The use of techniques other than echocardiography such as nuclear or magnetic resonance imaging to measure LVEF is unsuitable in the ED because of time constraints. This study aimed to compare echocardiographic aortic root (AR) excursion and LVEF measurement using the modified Simpson's method (biplane method of disks) as recommended by the American Society of Echocardiography. METHODS After 2 hours of theoretical video and hands-on training with 20 patients by an experienced echocardiographer, two emergency physicians prospectively evaluated patients with dyspnea. Two-dimensional echocardiograms of the parasternal long-axis view were obtained, and the displacement of the aortic root (DAR) was studied. M-mode DAR recordings were obtained, and distances were measured as the maximized anterior displacement of the AR from the horizontal axis at end-systole by using the leading-edge methodology. LVEF was measured by an experienced cardiologist using the modified Simpson's rule. The sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-), and positive and negative predictive values (PPV, NPV) were analyzed. A new formula for the prediction of the ejection fraction (EF) with the aid of DAR was then created. RESULTS The mean (±SD) age with of the 70 study patients was 69.7 (±11.91) years. In these patients, DAR was highly correlated with EF (point biserial correlation coefficient = 0.79, p < 0.001) and one-way analysis of variance (ANOVA) results were significant (F = 115.9; p < 0.001). The sensitivity was 94.4; specificity, 94.1; LR+, 16.6; LR-, 0.059; PPV, 94.4; and NPV, 94.1. CONCLUSIONS The results indicate that DAR is a sensitive index of left ventricular systolic function (SF) and can be used to reliably predict EF values using the rough formula of EF = 20 + 44 (DAR).
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Affiliation(s)
- Erden Erol Ünlüer
- Department of Emergency Medicine; Izmir Ataturk Research and Training Hospital; Izmir
| | - Arif Karagöz
- Department of Emergency Medicine; Izmir Ataturk Research and Training Hospital; Izmir
| | - Serdar Bayata
- Department of Cardiology; Izmir Ataturk Research and Training Hospital; Izmir
| | - Haldun Akoğlu
- Department of Emergency Medicine; Kartal Lütfi Kırdar Research and Training Hospital; Istanbul; Turkey
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[Intra-aortic balloon pump in infarction-related cardiogenic shock. Time to say goodbye]. Med Klin Intensivmed Notfmed 2012; 107:567-70. [PMID: 23052992 DOI: 10.1007/s00063-012-0168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
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Aissaoui N, Puymirat E, Tabone X, Charbonnier B, Schiele F, Lefèvre T, Durand E, Blanchard D, Simon T, Cambou JP, Danchin N. Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries. Eur Heart J 2012; 33:2535-43. [PMID: 22927559 DOI: 10.1093/eurheartj/ehs264] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS. METHOD AND RESULTS Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival. CONCLUSIONS Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.
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Affiliation(s)
- Nadia Aissaoui
- Division of Coronary Artery Disease and Intensive Cardiac Care, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France.
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Awad HH, Anderson FA, Gore JM, Goodman SG, Goldberg RJ. Cardiogenic shock complicating acute coronary syndromes: insights from the Global Registry of Acute Coronary Events. Am Heart J 2012; 163:963-71. [PMID: 22709748 DOI: 10.1016/j.ahj.2012.03.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 03/12/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite advances in the management of patients with an acute coronary syndrome (ACS), cardiogenic shock (CS) remains the leading cause of death in these patients. The objective of this observational study was to describe the characteristics, management, and hospital outcomes of patients with an ACS complicated by CS. Our secondary study objective was to describe trends in the incidence and hospital case-fatality rates (CFRs) of CS and predictors of increased hospital mortality in these high-risk patients. METHODS The population consisted of patients enrolled in the GRACE study between 1999 and 2007 who were hospitalized with an ACS. RESULTS During the years under study, 2,992 patients (4.6%) developed CS. Patients with CS were more likely to be older, have a history of diabetes or atrial fibrillation, and present with a higher pulse rate or cardiac arrest. Cardiac catheterization was performed on 1,706 (57%) and in-hospital revascularization on 1,408 patients (47%) with CS. Patients with CS were less likely to receive evidence-based cardiac medications compared with patients who did not develop CS. The in-hospital CFR of patients with CS was 59.4%, compared with 2.3% in those who did not develop CS. Factors associated with an increased risk of dying in patients with CS included advanced age, diabetes mellitus, angina, and stroke. Adjusted incidence rates and hospital CFRs of CS showed modest declines over time. CONCLUSION Continued efforts are needed to reduce the incidence and CFRs of CS complicating ACS.
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Lang SH, Manning N, Armstrong N, Misso K, Allen A, Di Nisio M, Kleijnen J. Treatment with tirofiban for acute coronary syndrome (ACS): a systematic review and network analysis. Curr Med Res Opin 2012; 28:351-70. [PMID: 22292469 DOI: 10.1185/03007995.2012.657299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the efficacy of tirofiban in comparison to usual care or other GPIIb/IIIa antagonists (eptifibatide and abciximab). Results were analysed by drug administration with planned percutaneous coronary intervention (PCI) or as medical management without planned PCI, and separately for STEMI or NSTE ACS patients. RESEARCH DESIGN AND METHODS A systematic review was performed of randomized controlled trials of tirofiban, abciximab, eptifibatide or usual care given to patients with acute coronary syndrome. Nine databases were searched up to March 2010. Pair-wise meta-analysis was used to combine all available direct comparisons; indirect comparisons and network analysis were performed when this was not possible. The primary outcome was MACE (major adverse cardiac event). RESULTS The search yielded 8, 119 records and 50 trials were included (total number of patients = 52,958). Compared to usual care, high and medium-dose tirofiban (25 and 10 µg/kg/min) administered with planned PCI reduced MACE at 30 days for patients with STEMI (RR 0.67, 95% CI 0.45, 0.99; RR 0.28, 95% CI 0.10, 0.80), but was not effective as a medical management. Medium-dose tirofiban (10 µg/kg/min) administered with planned PCI or low dose (0.4 µg/kg/min) as medical management reduced the risk of MACE for patients with NSTE ACS (RR 0.39, 95% CI 0.21, 0.75; RR 0.58, 95% CI 0.41, 0.83) in comparison to usual care, but at the expense of increased thrombocytopenia (RR 3.26, 95% CI 1.31, 8.13). Evidence from RCTs and network analysis indicated tirofiban and abciximab were equally effective and safe. Comparing tirofiban and eptifibatide treatment by indirect and network analysis produced inconclusive results. CONCLUSIONS Tirofiban was more effective than usual care for STEMI and NSTE ACS patients receiving planned PCI, and NSTE ACS patients receiving medical management. Tirofiban and abciximab were equally effective. Comparisons of tirofiban and eptifibatide were inconclusive.
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Affiliation(s)
- S H Lang
- Kleijnen Systematic Reviews, Unit 6, Escrick Business Park, Riccall Road, Escrick, York YO19 6FD, UK.
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Picariello C, Lazzeri C, Attanà P, Chiostri M, Gensini GF, Valente S. The impact of admission procalcitonin on prognosis in acute coronary syndromes: a pilot study. Biomarkers 2011; 17:56-61. [PMID: 22149667 DOI: 10.3109/1354750x.2011.638398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Available evidence on the prognostic role of procalcitonin levels in acute coronary syndromes (ACS) is so far controversial. AIMS To evaluate the association between procalcitonin, major cardiovascular events (MACE) and total mortality in acute coronary syndromes. METHODS Procalcitonin levels were measured in 247 patients admitted to our Intensive Cardiac Care Unit (ICCU) with ACS. Three subgroups were considered according to procalcitonin levels. RESULTS At Cox regression analysis, procalcitonin levels were both an unadjusted and an adjusted predictor (corrected for diagnosis and TnI) of intra-ICCU mortality and of 1-year follow-up MACE and total mortality. CONCLUSIONS In ACS, admission procalcitonin values identify a "higher risk" group of patients for short and long-term mortality.
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Affiliation(s)
- Claudio Picariello
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Dillinger JG, Deye N, Logeart D, Megarbane B, Sideris G, Solal AC, Mebazaa A, Henry P, Baud FJ. Prognostic value of plasma B-type natriuretic peptide in patients with severe cardiotoxic drug poisoning. ACTA ACUST UNITED AC 2011; 13:174-80. [DOI: 10.3109/17482941.2011.606472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ng R, Yeghiazarians Y. Post myocardial infarction cardiogenic shock: a review of current therapies. J Intensive Care Med 2011; 28:151-65. [PMID: 21747126 DOI: 10.1177/0885066611411407] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Right ventricular (RV) MI must also be considered. Mechanical complications including acute mitral regurgitation, ventricular septal rupture, and ventricular free-wall rupture can also lead to cardiogenic shock. Rapid diagnosis of cardiogenic shock and its underlying cause is pivotal to delivering definitive therapy. Intravenous vasoactive agents and mechanical support devices may temporize the patient's hemodynamic status until definitive therapy by percutaneous or surgical intervention can be performed. Despite prompt management, post-MI cardiogenic shock mortality remains high.
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Affiliation(s)
- Ramford Ng
- University of California, San Francisco, CA 94143, USA
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Abstract
Early recognition and differentiation of shock, as well as goal-directed resuscitation, are fundamental principles in the care of the critically ill or injured patient. Substantial progress has been made over the last decade in the understanding of both shock and resuscitation. Specific areas of advancement, particularly pertaining to hemorrhagic shock, include a heightened appreciation of dynamic measurements of preload responsiveness (e.g., respiratory-induced pulse pressure and venous diameter variability), an improved awareness of the detrimental effects of blood product transfusion, and better recognition of the complications of overzealous volume expansion. However, several areas of controversy remain regarding the optimal resuscitation strategy. These include the optimal targets for perfusion pressure and oxygen delivery, endpoints of resuscitation, resuscitative fluid, and transfusion strategies for packed red blood cells and blood products. This article reviews the diagnosis and differentiation of shock, measurements of tissue perfusion, current evidence regarding various resuscitative techniques, and complications of resuscitation.
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Affiliation(s)
- Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
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Jeger RV, Urban P, Harkness SM, Tseng CH, Stauffer JC, Lejemtel TH, Sleeper LA, Pfisterer ME, Hochman JS. Early revascularization is beneficial across all ages and a wide spectrum of cardiogenic shock severity: A pooled analysis of trials. ACTA ACUST UNITED AC 2011; 13:14-20. [PMID: 21244231 DOI: 10.3109/17482941.2010.538696] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A pooled analysis in cardiogenic shock due to acute coronary syndromes is desirable to assess the effect of early revascularization (ERV) across all ages and a wide spectrum of disease severity. METHODS Only two randomized controlled trials (RCT), i.e. SMASH and SHOCK, met the inclusion criteria and were combined for a pooled analysis using individual patient data (n = 348). RESULTS SMASH patients (n = 54, 16%) had more severe disease than SHOCK patients (n = 294, 84%). After adjustment for age, anoxic brain damage, non-inferior myocardial infarction, prior coronary artery bypass graft surgery, renal failure, systolic blood pressure, and selection for coronary angiography, one-year mortality was similar (relative risk SHOCK versus SMASH 0.87, 95% CI: 0.61-1.25). Relative risk of one-year death for ERV versus initial medical stabilization was 0.82 (95% CI: 0.70-0.96). There was no significant difference in the treatment effect by age (≤75 years relative risk at one year 0.79, 95% CI: 0.63-0.99; > 75 years relative risk at one year 0.93, 95% CI: 0.56-1.53; interaction P = 0.10). CONCLUSIONS Only two RCT have been published emphasizing the difficulty of enrolling critically ill patients. Despite large differences in shock severity, ERV benefit is similar across all ages and not significantly different for the elderly.
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Affiliation(s)
- Raban V Jeger
- Cardiovascular Clinical Research Center, New York University School of Medicine, New York, NY, USA.
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