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Picariello C, Lazzeri C, Valente S, Chiostri M, Attanà P, Gensini GF. Kinetics of procalcitonin in cardiogenic shock and in septic shock. Preliminary data. ACTA ACUST UNITED AC 2010; 12:96-101. [PMID: 20698733 DOI: 10.3109/17482941.2010.498920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock. AIMS to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock. RESULTS In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178). CONCLUSIONS differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the 'dynamic' approach may be more reliable that the static one especially in cardiogenic shock.
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Affiliation(s)
- Claudio Picariello
- Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Dhar G, Jolly N. Mechanical versus pharmacologic support for cardiogenic shock. Catheter Cardiovasc Interv 2010; 75:626-9. [PMID: 20049971 DOI: 10.1002/ccd.22229] [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] [Indexed: 11/06/2022]
Abstract
Dynamic left ventricular outflow tract obstruction is a rare cause of cardiogenic shock after an acute myocardial infarction. A case is presented where inotropic support and an intra-aortic balloon pump aggravated the cardiac hemodynamics by this mechanism. The circulatory support provided by Impella 2.5 heart pump, in addition to discontinuation of inotropic support and intra-aortic balloon pump, allowed stabilization and successful percutaneous revascularization.
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Affiliation(s)
- Gaurav Dhar
- Department of Medicine, The University of Chicago Medical Center, Chicago, Illinois 60637, USA
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Chiu FC, Chang SN, Lin JW, Hwang JJ, Chen YS. Coronary artery bypass graft surgery provides better survival in patients with acute coronary syndrome or ST-segment elevation myocardial infarction experiencing cardiogenic shock after percutaneous coronary intervention: A propensity score analysis. J Thorac Cardiovasc Surg 2009; 138:1326-30. [DOI: 10.1016/j.jtcvs.2009.03.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 02/24/2009] [Accepted: 03/20/2009] [Indexed: 10/20/2022]
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Spillner J, Kopp R, Finocchiaro T, Behbahani M, Rossaint R, Steinseifer U, Behr M, Autschbach R. [Assisted circulation: an overview from a clinical perspective]. BIOMED ENG-BIOMED TE 2009; 54:255-67. [PMID: 19807289 DOI: 10.1515/bmt.2009.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A higher grade cardiac failure is associated with poor prognosis. In addition to medical conservative treatment and traditional cardiac surgery, in the past years different forms of an assisted circulation evolved. Short-term devices serve to bridge an acute life-threatening situation. The chosen system is dependent on the anticipated clinical course. It is possible to fall back on slightly assisting techniques up to a complete takeover of the cardiac pump function. In the case of severe cardiac failure, the question for transplantation has to be addressed because transplantation is the treatment of choice to date. For an assisted circulation in cases of chronic congestive failure, devices of different generations are available. First generation pulsatile systems are used for assistance of the left ventricle and results have been shown to be superior to medical therapy (REMATCH). With second generation continuous-flow systems, results regarding infections, thromboembolism and also quality of life appear to be further improved. Contact-free centrifugal pumps as third generation systems are in clinical evaluation. So-called "total artificial hearts" are successfully used for bridge-to-transplantation. Taken together, a graded safe treatment of cardiac failure is available today. In the near future, it could be possible to reach results similar to those of cardiac transplantation.
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Affiliation(s)
- Jan Spillner
- Klinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum RWTH Aachen, Aachen, Deutschland.
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Picariello C, Lazzeri C, Chiostri M, Gensini G, Valente S. Procalcitonin in patients with acute coronary syndromes and cardiogenic shock submitted to percutaneous coronary intervention. Intern Emerg Med 2009; 4:403-8. [PMID: 19585221 DOI: 10.1007/s11739-009-0277-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 06/04/2009] [Indexed: 11/29/2022]
Abstract
Procalcitonin (PCT) is known to be a biological diagnostic marker for severe sepsis, or septic shock in critically ill patients. There are still contrasting data about a role of procalcitonin in patients with acute myocardial infarction or cardiogenic shock, and in those with acute coronary syndromes, that is, non-ST-elevation myocardial infarction or unstable angina. We evaluated plasma levels of procalcitonin and C-reactive protein (CRP) in 52 patients admitted to our intensive cardiac care unit (ICCU): 14 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI), 15 patients with uncomplicated ST-elevation myocardial infarction (STEMI), and 24 with non-ST-elevation myocardial infarction or unstable angina (NSTEMI/UA). In all patients, infective processes were excluded. Procalcitonin values were significantly higher in CS patients with respect to the other two subgroups (P < 0.001, P < 0.001) while CRP levels were higher than NSTEMI/UA patients (P < 0.001) but not with respect to STEMI patients (P = 0.063). No correlations were found in cardiogenic shock patients between CRP and PCT values (R = 0.02; P = 0.762, ns). Procalcitonin levels measured on ICCU admission are significantly higher in patients with cardiogenic shock following the acute myocardial infarction, and they are not correlated with those of CRP. The degree of myocardial ischemia (clinically indicated by the whole spectrum of ACS, from unstable angina to cardiogenic shock ST-elevation following myocardial infarction) and the related inflammatory-induced response are better reflected by CRP (which was positive in most acute cardiac care patients of all our subgroups), than by PCT which seems more reflective of a higher degree of inflammatory activation, being positive only in all CS patients.
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Affiliation(s)
- Claudio Picariello
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni 85, 50184 Florence, Italy.
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Abstract
Documented mortality from acute myocardial infarction (AMI) has significantly decreased from around 30% in the 1960s to currently 6-7%, following the introduction of intensive-care treatment, thrombolysis, effective antithrombotic therapy, and coronary angioplasty. However, the approximate mortality of 70-80% of patients with cardiogenic shock following AMI has hardly improved despite the introduction of modern treatment strategies. The major cause of in-hospital AMI mortality remains myocardial failure with consecutive cardiogenic shock and multiorgan failure. Reduction of heart rate is one of the most important energy-saving maneuvers, which can be achieved by administration of beta-receptor-blocking agents. In patients with clinical signs of hypotension, however, the guidelines recommend to stabilize the patient before administering an oral beta-receptor blocker, mainly because of the hypotensive effects of the substance class. In this situation, selective heart rate reduction, e.g., via administration of ivabradine without side effects of hypotension may be advantageous and better tolerated in patients with cardiogenic shock. The aim of the present review is to briefly summarize the treatment options of cardiogenic shock and the mechanisms of action of ivabradine as well as to present a case report of a patient with cardiogenic shock due to main trunk occlusion, where treatment with ivabradine seemed to beneficially influence the outcome.
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Jeger RV, Assmann SF, Yehudai L, Ramanathan K, Farkouh ME, Hochman JS. Causes of death and re‐hospitalization in cardiogenic shock. ACTA ACUST UNITED AC 2009; 9:25-33. [PMID: 17453536 DOI: 10.1080/17482940601178039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In cardiogenic shock, causes of death usually are cardiac. However, a systemic inflammatory response syndrome may influence outcome. METHODS SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? (SHOCK) Trial patients (n = 302) were analyzed regarding cause of death and re-hospitalization. RESULTS Deaths (n = 180) occurred < or =30 days in 86% and >30 days in 14%. Known causes of death < or =30 days were cardiac in 88% (37% arrhythmic) and non-cardiac in 12% (29% septic). Non-cardiac deaths < or =30 days occurred later (206 [91,394] versus 41 [15,156] h, P<0.01) and were more frequently associated with signs of inflammation (43 versus 12%, P = 0.01) than cardiac deaths < or =30 days. Known causes of in-hospital death >30 days (n = 19) were cardiac in 58% and non-cardiac in 42%. Among deaths < or =30 days systemic vascular resistance index was higher (2,666+/-1,063 versus 2,090+/-731 dynes.sec.cm(-5) m(2), P = 0.05) than among deaths >30 days. Among the 116 survivors of the initial hospitalization with data available, 52 (45%) were readmitted, most of which due to heart failure (n = 22, 42%) and myocardial ischemia (n = 16, 31%). CONCLUSIONS In CS, early deaths < or =30 days are mainly cardiac. Non-cardiac deaths are associated with signs of inflammation. In survivors of the initial hospitalization, re-hospitalizations are due to heart failure and myocardial ischemia.
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Affiliation(s)
- Raban V Jeger
- Cardiovascular Clinical Research Center, New York University School of Medicine, 530 First Avenue, New York, NY 10016, USA
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58
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Panzer-Knodle SG, Jacqmin P, Page JD, Nicholson NS, Zablocki JA, Engleman VW, Feigen LP. Characterization of Binding of an RGD Mimetic, [3H]-SC-52012, to Platelet GPIIb/IIIa. Platelets 2009; 6:288-95. [DOI: 10.3109/09537109509023569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hypoxic hepatitis: underlying conditions and risk factors for mortality in critically ill patients. Intensive Care Med 2009; 35:1397-405. [PMID: 19506833 DOI: 10.1007/s00134-009-1508-2] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 04/30/2009] [Indexed: 12/28/2022]
Abstract
PURPOSE Hypoxic hepatitis (HH) is a frequent cause of acute hepatocellular damage at the intensive care unit. Although mortality is reported to be high, risk factors for mortality in this population are unknown. METHODS One-hundred and seventeen consecutive patients with HH were studied prospectively at three medical intensive care units of a university hospital. RESULTS The main causes of hypoxic hepatitis were low cardiac output and septic shock, and most patients (74%) had more than one underlying factor. Peak aspartate transaminase (P = 0.02), lactate dehydrogenase (P = 0.03), INR (P < 0.001) and lactate (P < 0.01) were higher in non-survivors. Prolonged duration of HH caused higher overall mortality rate (P = 0.03). INR > 2 (P = 0.02), septic shock (P = 0.01) and SOFA score >10 (P = 0.04) were risk factors of mortality in the regression model. CONCLUSIONS Hypoxic hepatitis is the consequence of multiorgan injury. Outcome is influenced by the severity of liver impairment and the etiology and severity of the basic disease.
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Goldberg RJ, Spencer FA, Gore JM, Lessard D, Yarzebski J. Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective. Circulation 2009; 119:1211-9. [PMID: 19237658 DOI: 10.1161/circulationaha.108.814947] [Citation(s) in RCA: 473] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited information is available about potentially changing and contemporary trends in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction. The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the incidence rates of cardiogenic shock complicating acute myocardial infarction, patient characteristics and treatment practices associated with this clinical complication, and hospital death rates in residents of a large central New England community hospitalized with acute myocardial infarction at all area medical centers. METHODS AND RESULTS The study population consisted of 13 663 residents of the Worcester (Mass) metropolitan area hospitalized with acute myocardial infarction at all greater Worcester medical centers during 15 annual periods between 1975 and 2005. Overall, 6.6% of patients developed cardiogenic shock during their index hospitalization. The incidence rates of cardiogenic shock remained stable between 1975 and the late 1990s but declined in an inconsistent manner thereafter. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (65.4%) than those who did not develop cardiogenic shock (10.6%) (P<0.001). Encouraging increases in hospital survival in patients with cardiogenic shock, however, were observed from the mid-1990s to our most recent study years. Several patient demographic and clinical characteristics were associated with an increased risk for developing cardiogenic shock. CONCLUSIONS Our findings indicate improving trends in the hospital prognosis associated with cardiogenic shock. Given the high death rates associated with this clinical complication, monitoring future trends in the incidence and death rates and the factors associated with an increased risk for developing cardiogenic shock remains warranted.
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Affiliation(s)
- Robert J Goldberg
- Department of Medicine, University of Massachusetts Medical School, Worcester, 01655, USA.
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Buchwald AB, Meyer T, Scholz K, Schorn B, Unterberg C. Efficacy of balloon valvuloplasty in patients with critical aortic stenosis and cardiogenic shock--the role of shock duration. Clin Cardiol 2009; 24:214-8. [PMID: 11288967 PMCID: PMC6655224 DOI: 10.1002/clc.4960240308] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Because of limited long-term success, aortic balloon valvuloplasty is considered to be a palliative procedure, including patients at excessive risk for standard therapy-aortic valve replacement-that is, those in cardiogenic shock. HYPOTHESIS The study was undertaken to evaluate the outcome of balloon valvuloplasty for critical aortic stenosis complicated by cardiogenic shock. METHODS Over a 10-year-period, we followed 14 patients (age 74+/-11 years, range 50-91) presenting in cardiogenic shock and critical aortic stenosis, who underwent valvuloplasty, together with 19 patients with critical aortic stenosis requiring urgent major noncardiac surgery. RESULTS In patients in shock, calculated aortic valve area could be increased successfully by at least 0.3 cm2, from 0.38+/-0.09 to 0.81+/-0.12 cm2, with an insignificant increase in cardiac index from 1.89+/-0.33 to 2.01+/-0.41 l/min * m2. In-hospital mortality was 71% (10 patients). Two patients underwent valve replacement within 16 days and survived after 1 year, as did two patients refusing surgery. By multivariate logistic regression analysis, only an interval between onset of shock symptoms and valvuloplasty of > 48 h was significantly associated with fatal outcome (p < 0.01). In those patients requiring noncardiac surgery, this was possible after valvuloplasty in 95% who survived 1 year after hospital discharge. One patient in this group died of pulmonary embolism the day after the procedure. CONCLUSION These data support the concept of causal treatment in patients with cardiogenic shock, as well as in the setting of cardiogenic shock and critical aortic stenosis, at the earliest possible convenience.
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Affiliation(s)
- A B Buchwald
- Departments of Cardiology Surgery, University Clinic Göttingen, Germany
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63
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Abstract
Cardiogenic shock is defined as profound circulatory failure resulting in insufficient tissue perfusion to meet resting metabolic demands. It occurs in approximately 7.5% of patients with acute myocardial infarction. Treatment strategies include inotropic agents, use of intra-aortic balloon counterpulsation, and revascularization. Current evidence supports the use of primary angioplasty. Surgery should be considered in patients with triple-vessel disease. If early catheterization is not available, thrombolytic therapy should be given to eligible patients and transfer to an interventional facility should be considered. Effective therapy for shock must also include a prevention strategy. This requires identification of patients at high risk for shock development and selection of patients who are candidates for aggressive intervention.
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Affiliation(s)
- W L Barry
- Department of Internal Medicine, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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Kim JH, Jeong MH, Choi JS, Rhee JA, Kim IS, Choi OJ, Kim EJ, Sim DS, Hong YJ, Kim JH, Ahn YK, Cho JG, Park JC, Kang JC. Predictors of Mortality in Acute Myocardial Infarction Patients with Cardiogenic Shock Who Underwent Percutaneous Coronary Intervention with the Aid of an Intra-Aortic Balloon Pump. Chonnam Med J 2009. [DOI: 10.4068/cmj.2009.45.2.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jeong Hun Kim
- Department of Public Health, Chonnam National University Graduate School, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Public Health, Chonnam National University Graduate School, Gwangju, Korea
| | - Jin Su Choi
- Department of Public Health, Chonnam National University Graduate School, Gwangju, Korea
| | - Jung Ae Rhee
- Department of Public Health, Chonnam National University Graduate School, Gwangju, Korea
| | - In Soo Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ok Ja Choi
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Eun Jeong Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Young Keun Ahn
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jung Chaee Kang
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
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Valente S, Lazzeri C, Chiostri M, Sori A, Giglioli C, Salvadori C, Gensini GF. Time of onset and outcome of cardiogenic shock in acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2008; 9:1235-40. [DOI: 10.2459/jcm.0b013e3283168a27] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ferrari M, Figulla HR. [Therapy of cardiogenic shock after myocardial infarction]. Internist (Berl) 2008; 49:1047-51. [PMID: 18633582 DOI: 10.1007/s00108-008-2076-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The therapy of infarct related cardiogenic shock should primarily focus on fastest possible revascularization. In addition, rapid restoration of sufficient organ perfusion pressure is recommended for the prevention of a multi-organ dysfunction syndrome (MODS). This can be achieved by mechanical circulatory assist devices as well as individual catecholamine therapy. Since assist devices require specially trained physicians, their use is limited to specialized cardiac care centers. However, future technologies such as portable heart-lung-machines may help to further improve transfer to specialized centers and therapy of shock patients.
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Affiliation(s)
- M Ferrari
- Klinik für Innere Medizin I, Universitätsklinikum, Friedrich-Schiller-Universität, Erlanger Allee 101, Jena, Germany.
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67
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Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction*. Crit Care Med 2008; 36:2257-66. [DOI: 10.1097/ccm.0b013e3181809846] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dick P, Mlekusch W, Delle-Karth G, Nikfardjam M, Schillinger M, Heinz G. Decreasing incidence of critical limb ischemia after intra-aortic balloon pump counterpulsation. Angiology 2008; 60:235-41. [PMID: 18599494 DOI: 10.1177/0003319708319782] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors investigated the incidence of critical limb ischemia (CLI) in 187 patients with intra-aortic balloon pump (IABP) support during a 6-year study period and determined risk factors and long-term outcome (median 5 years) after discharge from a cardiac intensive care unit. Cardiogenic shock following acute myocardial infarction was the predominant cause of IABP support. CLI occurred in 10% of the patients after IABP implantation. Nevertheless, in light of the overall high mortality in this patient population, CLI seems not a primary concern. Furthermore, its incidence significantly decreased during recent years. Duration of IABP support was a significant predictor for CLI.
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Affiliation(s)
- Petra Dick
- Department of Angiology, Medical University of Vienna, Vienna, Austria
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Abstract
PURPOSE OF REVIEW Fluid (volume) therapy is an integral component in the management of critically ill patients and fluid management may influence outcome. There is much controversy, however, about the type, timing and amount of fluid therapy. Here, we discuss the evidence available to guide such choices. RECENT FINDINGS Fluid therapy is widely endorsed for resuscitation of critically ill patients across a range of conditions. Yet, the approach to fluid therapy is subject to substantial variation in clinical practice. Emerging data show that the choice, timing and amount of fluid therapy may affect clinical outcomes. Synthetic colloids may increase the risk of acute kidney injury. Albumin may benefit hypoalbuminemic patients with sepsis and acute lung injury but may worsen outcome in traumatic brain injury. Early administration of fluid therapy in sepsis may improve survival but may be unnecessary in patients with penetrating trauma. Later fluid therapy in acute lung injury patients will increase the duration of ventilator dependence without achieving better survival. A positive cumulative balance likely contributes to increased morbidity and mortality after major surgery. SUMMARY Emerging evidence shows that choice, timing and amount of fluid therapy affect outcome. Future studies need to focus on these aspects of fluid therapy by means of larger, more rigorous and blinded controlled trials.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
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71
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Shock and Resuscitation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Khattab AA, Abdel-Wahab M, Röther C, Liska B, Toelg R, Kassner G, Geist V, Richardt G. Multi-vessel stenting during primary percutaneous coronary intervention for acute myocardial infarction. A single-center experience. Clin Res Cardiol 2007; 97:32-8. [PMID: 17694377 DOI: 10.1007/s00392-007-0570-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 07/02/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recanalization of the culprit lesion is the main goal of primary angioplasty for acute ST-segment elevation myocardial infarction (STEMI). Patients presenting with acute myocardial infarction and multivessel disease are, therefore, usually subjected to staged procedures, with the primary percutaneous coronary intervention (PCI) confined to recanalization of the infarct-related artery (IRA). Theoretically at least, early relief of stenoses of non-infarct-related arteries could promote collateral circulation, which could help to limit the infarct size. However, the safety and feasibility of such an approach has not been adequately established. METHODS In this single-center prospective study we examined 73 consecutive patients who had an acute STEMI and at least one or more lesions > or = 70% in a major epicardial vessel other than the infarct-related artery. In the first 28 patients, forming the multi-vessel (MV) PCI group, all lesions were treated during the primary procedure. In the following 45 patients, forming the culprit-only (CO) PCI group, only the culprit lesion was treated during the initial procedure, followed by either planned-staged or ischemia-driven revascularization of the non-culprit lesions. Fluoroscopy time and contrast dye amount were compared between both groups, and patients were followed up for one year for major adverse cardiac events (MACE) and other significant clinical events. RESULTS The two groups were well balanced in terms of clinical characteristics, number of diseased vessels and angiographic characteristics of the culprit lesion. In the MV-PCI group, 2.51 lesions per patient were treated using 2.96 +/- 1.34 stents (1.00 lesions and 1.76 +/- 1.17 stents in the CO-PCI group, both p < 0.001). The fluoroscopy time increased from 10.3 (7.2-16.9) min in the CO-PCI group to 12.5 (8.5-19.3) min in the MV-PCI group (p = 0.22), and the amount of contrast used from 200 (180-250) ml to 250 (200-300) ml, respectively (p = 0.16). Peak CK and CK-MB were significantly lower in patients of the MV-PCI group (843 +/- 845 and 135 +/- 125 vs 1652 +/- 1550 and 207 +/- 155 U/l, p < 0.001 and 0.01, respectively). Similar rates of major adverse cardiac events at one year were observed in the two groups (24% and 28% in multi-vessel and culprit treatment groups, p = 0.73). The incidence of new revascularization in both infarct- and non-infarct-related arteries was also similar (24% and 28%, respectively, p = 0.73). CONCLUSION We may state from this limited experience that a multi-vessel stenting approach for patients with acute STEMI and multi-vessel disease is feasible and probably safe during routine clinical practice. Our data suggest that this approach may help to limit the infarct size. However, larger studies, perhaps using drug-eluting stents, are still needed to further evaluate the safety and efficiency of this procedure, and whether it is associated with a lower need of subsequent revascularization and lower costs.
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Affiliation(s)
- A A Khattab
- Herz-Kreislauf-Zentrum, Segeberger Kliniken, GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany.
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Fang J, Mensah GA, Alderman MH, Croft JB. Trends in acute myocardial infarction complicated by cardiogenic shock, 1979-2003, United States. Am Heart J 2006; 152:1035-41. [PMID: 17161048 DOI: 10.1016/j.ahj.2006.07.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Accepted: 07/11/2006] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with high morbidity and mortality. METHODS Using the National Hospital Discharge Survey data from 1979 to 2003, we measured trends in the incidence of AMI complicated by cardiogenic shock, the use of percutaneous transluminal coronary angioplasty (PTCA), and the inhospital death. RESULTS Age-adjusted hospitalization rates (per 100,000 populations) in 1979 and 2003, respectively, were 213 and 261 for AMI, and 8.6 and 4.3 for AMI complicated by cardiogenic shock. Among patients with AMI, the proportion with cardiogenic shock was 3.9% (n = 17,000) in 1979 and 1.7% (n = 13,000) in 2003. Patients with acute myocardial infarction with cardiogenic shock, compared with those without cardiogenic shock, were more likely to be women (48% vs 43%, P < .0001), more likely to have anterior wall AMI (33% vs 14%, P < .0001), and had much higher inhospital mortality (43% vs 7%, P < .0001). Over the years, among AMI complicated by cardiogenic shock, PTCA use increased substantially from 0% to 28%. During this period, inhospital death decreased from 84% to 43%. After adjustment for age, sex, location of AMI, health insurance, and survey year, PTCA use was significantly associated with decreased inhospital deaths among patients with AMI with cardiogenic shock. CONCLUSIONS Although hospitalization for AMI has increased over the past 25 years, the hospitalization rate of AMI complicated by cardiogenic shock has decreased by 50%. At the same time, PTCA use and hospital survival have increased substantially among cardiogenic shock patients.
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Affiliation(s)
- Jing Fang
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341-3717, USA.
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74
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Abstract
Cardiogenic shock remains the major cause of death among patients with acute myocardial infarction. Besides supportive therapy there is clear evidence that revascularization of the infarct related artery should be performed as soon as possible with percutaneous transluminal coronary angioplasty. Placement of coronary stents and administration of platelet glycoprotein IIb/IIIa antagonists may further improve outcome. Intra-aortic balloon pumping should be integral part of this treatment strategy but is unfortunately underused in clinical practice. Routine bypass surgery for cardiogenic shock patients is deferred and restricted to selected patients.
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Affiliation(s)
- U Janssens
- Medizinische Klinik, St.-Antonius-Hospital Eschweiler.
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75
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Geppert A, Dorninger A, Delle-Karth G, Zorn G, Heinz G, Huber K. Plasma concentrations of interleukin-6, organ failure, vasopressor support, and successful coronary revascularization in predicting 30-day mortality of patients with cardiogenic shock complicating acute myocardial infarction. Crit Care Med 2006; 34:2035-42. [PMID: 16775569 DOI: 10.1097/01.ccm.0000228919.33620.d9] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Inflammation may play an important role in the pathogenesis, persistence, and prognosis of cardiogenic shock. We analyzed whether elevated plasma concentrations of inflammatory markers are independently associated with an adverse prognosis (increased 30-day mortality rate) in patients with cardiogenic shock. DESIGN Retrospective study. SETTING Single-center study, eight-bed intensive care unit at a university hospital. PATIENTS Retrospective study on stored plasma samples from 38 patients with cardiogenic shock complicating acute myocardial infarction. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-day nonsurvivors (n = 23, 61%) had been less frequently successfully revascularized, exhibited more frequently renal failure, needed higher vasopressor doses, and presented with significantly higher interleukin-6 plasma concentrations on intensive care unit admission than 30-day survivors. Univariate hazard ratios (95% confidence interval) for 30-day mortality were 1.49 (1.24-1.80) for every 50 pg/mL increase in the interleukin-6 plasma concentration (p = .00003), 1.06 (1.02-1.10) for every 0.1 microg x kg x min increase in the total vasopressor dose (p = .007), 1.14 (1.04-1.25) for every mmol/L increase in serum lactate (p = .006), 2.47 (1.06-5.73) for acute renal failure (p = .036), and 0.34 (0.14-0.82) for successful revascularization (p = .016). However, interleukin-6 plasma concentrations were correlated with vasopressor need and were significantly higher in patients with acute renal failure and in patients without or unsuccessful revascularization. In a multivariate Cox-proportional hazard model, interleukin-6 was the only significant predictor of 30-day mortality with a hazard ratio of 1.42 (1.12-1.80, p = .004). Accordingly, interleukin-6 concentrations > or =200 pg/mL (the point of maximum interest by receiver operating characteristic analysis with a specificity of 87% and a sensitivity of 74%) were associated with a significantly increased 30-day mortality rate in both patients with and patients without successful revascularization. CONCLUSIONS Interleukin-6 concentrations are an independent predictor of 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock.
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Affiliation(s)
- Alexander Geppert
- Intensive Care Unit, Third Department of Medicine with Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna
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76
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Affiliation(s)
- Gottfried Heinz
- OA Intensivstation 13H3, Abteilung für Kardiologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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77
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Predictors of in-hospital mortality after percutaneous coronary intervention for cardiogenic shock. Int J Cardiol 2006; 114:176-82. [PMID: 16737749 DOI: 10.1016/j.ijcard.2006.01.024] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 12/09/2005] [Accepted: 01/08/2006] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The mortality of patients with cardiogenic shock (CS) complicating ST elevation acute myocardial infarction (STEMI) remains high, despite early revascularization. Current knowledge of predictors of death is limited. BACKGROUND The pathophysiologic understanding of CS after acute myocardial infarction has shifted from a mere hemodynamic disorder to a more complex approach including imbalance in metabolic functions. METHODS In 45 consecutive patients (71.4+/-13 years) with CS complicating STEMI treated with primary percutaneous coronary intervention (PCI) serum levels of lactate, glucose and uric acid on coronary care unit (CCU) admission were measured. The end-point was in-hospital death. RESULTS The following parameters, on CCU admission, were univariate predictors of in-hospital mortality: serum glucose >200 mg/dl (OR=11.3, p=0.002), serum creatinine >1.5 mg/dl (OR=12.7, p=0.003), uric acid >6.5 mg/dl (OR=6.7, p=0.016), lactate >6.5 mmol/l (OR=54, p<0.0001), age > or =75 years (OR=8.5, p=0.002), history of hypertension (OR=8.3, p=0.003) and TIMI flow post PCI < or = 2 (OR=12.9, p=0.02). At multivariate analysis, after adjustment for sex, age, hypertension and diabetes, lactate >6.5 mmol/l and TIMI flow post PCI < or = 2 were still independent predictors of in-hospital mortality (OR=295, p=0.01; OR=19.5, p=0.04, respectively). CONCLUSIONS Hyperlactatemia, hyperglycemia and increased levels of uric acid on CCU admission are univariate predictors of in-hospital death. Moreover, at multivariate analysis, hyperlactatemia (>6.5 mmol/l) is an independent indicator of in-hospital death in CS patients complicating STEMI.
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78
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La Manna A, Goktekin O, Fiscella D, Dalby M, Tanigawa J, Fiscella A, Tamburino C, Di Mario C. Which strategy should be used for acute ST-elevation myocardial infarction in patients aged more than 75 years? J Cardiovasc Med (Hagerstown) 2006; 7:388-96. [PMID: 16721199 DOI: 10.2459/01.jcm.0000228687.94709.be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The optimal management of acute myocardial infarction in elderly people (>or= 75 years) is controversial because elderly patients have been excluded or are under-represented in most acute myocardial infarction trials. Randomized studies show that, also in the elderly, thrombolytic therapy is effective in reducing mortality after acute myocardial infarction but the benefit in terms of mortality, recurrent infarction and stroke is smaller compared to primary percutaneous coronary intervention. Among the available mechanical therapeutic strategies, stenting is found to be superior to balloon angioplasty, whereas the role of drug-eluting stents in this setting still remains to be evaluated. The standard use of intravenous unfractionated heparin is still recommended because of the increased risk of intracranial haemorrhage by a combination of low molecular weight heparin or IIb/IIIa inhibitors and thrombolytic agents. Dedicated randomized clinical trials are needed to establish the best reperfusion therapy for this expanding population, especially in patients admitted to hospitals without percutaneous coronary intervention facilities and in patients developing cardiogenic shock.
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Affiliation(s)
- Alessio La Manna
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy
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79
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Seguin P, Laviolle B, Maurice A, Leclercq C, Mallédant Y. Atrial fibrillation in trauma patients requiring intensive care. Intensive Care Med 2006; 32:398-404. [PMID: 16496203 DOI: 10.1007/s00134-005-0032-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Accepted: 11/07/2005] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. DESIGN AND SETTING Prospective observational study in a surgical intensive care unit (ICU). PATIENTS All trauma patients admitted in the surgical ICU except those who had AF at admission. MEASUREMENTS AND RESULTS AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7-19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3-103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8-21.4), age 40 years or higher (OR = 6.3, CI 1.4-28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2-16.1). CONCLUSIONS In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality.
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Affiliation(s)
- Philippe Seguin
- Hôpital Pontchaillou, Surgical Intensive Care Unit, 2 rue Henri le Guilloux, Rennes Cedex 9, 35033 Rennes, France.
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80
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Müller-Werdan U, Buerke M, Christoph A, Flieger R, Loppnow H, Prondzinsky R, Reith S, Schmidt H, Werdan K. Schock. KLINISCHE KARDIOLOGIE 2006. [PMCID: PMC7143837 DOI: 10.1007/3-540-29425-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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81
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Lindholm MG, Boesgaard S, Torp-Pedersen C, Køber L. Diabetes mellitus and cardiogenic shock in acute myocardial infarction. Eur J Heart Fail 2005; 7:834-9. [PMID: 16051520 DOI: 10.1016/j.ejheart.2004.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Revised: 08/07/2004] [Accepted: 09/20/2004] [Indexed: 11/24/2022] Open
Abstract
AIMS Cardiogenic shock is the leading cause of in-hospital mortality after acute myocardial infarction (MI). This study investigates the importance of age and preexisting diabetes mellitus on the incidence and prognosis of cardiogenic shock in a large group of consecutive patients with MI. METHODS AND RESULTS Baseline characteristics and in-hospital complications to the infarction were prospectively recorded in 6676 patients with MI. Ten-year mortality was collected. Diabetes was present in 10.8% of the total population. A total of 443 developed cardiogenic shock with an incidence of 6.2% among nondiabetics and 10.6% among diabetics. Age, wall motion index, reinfarction, and the absence of thrombolytic treatment were significant independent predictors of mortality in patients with cardiogenic shock. Intriguingly, diabetes was not a significant predictor for short- and long-term mortality in this population. The 30-day and 5-year mortality rate was equally poor in both diabetic and nondiabetic patients with cardiogenic shock (diabetics: 30-day 63%, 5-year 91%; nondiabetics: 30-day 62%, 5-year 86%; p>0.05). CONCLUSIONS Cardiogenic shock develops approximately twice as often among diabetics as among nondiabetic patients with acute MI. The prognosis of diabetics with cardiogenic shock is similar to the prognosis of nondiabetic patients with cardiogenic shock.
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Affiliation(s)
- M G Lindholm
- Medical Department B, Division of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Denmark.
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82
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Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, Xie JX, Liu LS. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366:1622-32. [PMID: 16271643 DOI: 10.1016/s0140-6736(05)67661-1] [Citation(s) in RCA: 570] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite previous randomised trials of early beta-blocker therapy in the emergency treatment of myocardial infarction (MI), uncertainty has persisted about the value of adding it to current standard interventions (eg, aspirin and fibrinolytic therapy), and the balance of potential benefits and hazards is still unclear in high-risk patients. METHODS 45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated metoprolol (up to 15 mg intravenous then 200 mg oral daily; n=22,929) or matching placebo (n=22,923). 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 89% completed it. The two prespecified co-primary outcomes were: (1) composite of death, reinfarction, or cardiac arrest; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This study is registered with ClinicalTrials.gov, number NCT 00222573. FINDINGS Neither of the co-primary outcomes was significantly reduced by allocation to metoprolol. For death, reinfarction, or cardiac arrest, 2166 (9.4%) patients allocated metoprolol had at least one such event compared with 2261 (9.9%) allocated placebo (odds ratio [OR] 0.96, 95% CI 0.90-1.01; p=0.1). For death alone, there were 1774 (7.7%) deaths in the metoprolol group versus 1797 (7.8%) in the placebo group (OR 0.99, 0.92-1.05; p=0.69). Allocation to metoprolol was associated with five fewer people having reinfarction (464 [2.0%] metoprolol vs 568 [2.5%] placebo; OR 0.82, 0.72-0.92; p=0.001) and five fewer having ventricular fibrillation (581 [2.5%] vs 698 [3.0%]; OR 0.83, 0.75-0.93; p=0.001) per 1000 treated. Overall, these reductions were counterbalanced by 11 more per 1000 developing cardiogenic shock (1141 [5.0%] vs 885 [3.9%]; OR 1.30, 1.19-1.41; p<0.00001). This excess of cardiogenic shock was mainly during days 0-1 after admission, whereas the reductions in reinfarction and ventricular fibrillation emerged more gradually. Consequently, the overall effect on death, reinfarction, arrest, or shock was significantly adverse during days 0-1 and significantly beneficial thereafter. There was substantial net hazard in haemodynamically unstable patients, and moderate net benefit in those who were relatively stable (particularly after days 0-1). INTERPRETATION The use of early beta-blocker therapy in acute MI reduces the risks of reinfarction and ventricular fibrillation, but increases the risk of cardiogenic shock, especially during the first day or so after admission. Consequently, it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.
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Affiliation(s)
- Z M Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK.
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83
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Straumann E, Kurz DJ, Muntwyler J, Stettler I, Furrer M, Naegeli B, Frielingsdorf J, Schuiki E, Mury R, Bertel O, Spinas GA. Admission glucose concentrations independently predict early and late mortality in patients with acute myocardial infarction treated by primary or rescue percutaneous coronary intervention. Am Heart J 2005; 150:1000-6. [PMID: 16290985 DOI: 10.1016/j.ahj.2005.01.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2004] [Accepted: 01/19/2005] [Indexed: 01/08/2023]
Abstract
BACKGROUND In patients with acute myocardial infarction (MI), increased plasma glucose levels at hospital admission are associated with worse outcome. We aimed to assess the predictive value of admission glucose concentrations on short- and long-term mortality in patients with acute MI undergoing primary or rescue percutaneous coronary intervention (PCI). METHODS We analyzed the 30-day and long-term (mean follow-up 3.7 years) outcome of 978 patients prospectively included in a single-center registry of patients with acute MI treated with PCI within 24 hours after onset of symptoms. Patients were classified according to plasma glucose levels at admission: < 7.8 mmol/L (group I, n = 322), 7.8 to 11 mmol/L (group II, n = 348), and > 11.0 mmol/L (group III, n = 308). RESULTS Mortality at 30 days was 1.2% in group I, 6.3% in group II, and 16.6% in group III (P < .001). After multivariate adjustment for age, the presence of cardiogenic shock, and TIMI 3 flow after PCI, the association of mortality with glucose classification remained significant (P value for trend = .003). The relative risk of death at 30 days for group III versus group I was 3.9 (95% CI 1.2-13.2). During long-term follow-up, mortality was similar in groups I and II. However, in group III adjusted mortality remained significantly increased compared with group I (relative risk 1.76, CI 1.01-3.08). CONCLUSIONS In patients undergoing emergency PCI for acute MI, glucose levels at hospital admission are predictive for short- and long-term survival. Knowledge of admission glucose levels may improve initial bedside risk stratification.
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Affiliation(s)
- Edwin Straumann
- Division of Cardiology, Department of Internal Medicine, Triemli Hospital, Zurich, Switzerland.
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84
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Abstract
The acute coronary syndrome comprises unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. A successful and stable revascularisation of the infarct related vessel, and the prevention of the loss of myocardium are the main therapeutic targets, as cardiovascular mortality and long term quality of life are essentially determined by left ventricular function. The clinical diagnosis comprises clinical symptoms, ECG-changes, and cardiac troponins. Early percutaneous coronary intervention (PCI) has become the most common method of coronary revascularisation. If PCI is not available, systemic thrombolysis is an alternative after exclusion of contraindications. Parenteral anticoagulation with intravenous or subcutaneous heparines, antithrombotic therapy and HMG-CoA reductase inhibitors are the common secondary drug therapy. Moreover, to prevent left ventricular remodelling ACE-inhibitors, angiotension 2-receptor antagonists, and beta-blocker are indicated.
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Affiliation(s)
- M Kelm
- Klinik für Kardiologie, Pneumologie und Angiologie, Medizinische Klinik und Poliklinik B, Heinrich-Heine-Universität Düsseldorf.
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85
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García E. Intervencionismo en el contexto del infarto de miocardio. Conceptos actuales. Rev Esp Cardiol 2005. [DOI: 10.1157/13074847] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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86
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Bae EH, Lim SY, Jeong MH, Park HW, Lim JH, Hong YJ, Kim W, Kim JH, Cho JG, Ahn YK, Park JC, Suh SP, Ahn BH, Kim SH, Kang JC. Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock. Korean J Intern Med 2005; 20:8-14. [PMID: 15906947 PMCID: PMC3891418 DOI: 10.3904/kjim.2005.20.1.8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Cardiogenic shock (CS) after acute myocardial infarction (AMI) develops in 5-10% of patients and it is associated with high mortality. The aim of this study is to assess the predictive factors of mortality for patients with AMI and CS. METHODS Two hundred fifty five AMI patients with CS (the mean age was 66.0 +/- 11.0 years, M:F=156:99) out of 1268 AMI patients who admitted at Chonnam National University Hospital between July 2000 and June 2002 were analyzed according to the clinical characteristics, coronary angiographic findings and MACE during admission and for the 1-year clinical follow-up. RESULTS Among the enrolled patients, 129 patients survived without MACE (Group I, mean age 64.2 +/- 10.6 years, M:F=76:53), and 126 patients had MACE (Group II, mean age 68.1 +/- 10.0 years, M:F = 80:46) during admission or during the 1-year follow-up period. There were significant differences in age between the Groups I and II (64.2 +/- 10.6 vs. 68.1 +/- 11.0 years, respectively, p = 0.004) and the previous MI history (0 vs. 17.4%, respectively, p<0.001). The left ventricular ejection fraction (EF) was lower in Group II (Group I vs. II: 49.1 +/- 13.0 vs. 39.1 +/- 12.9%, p < 0.001). The levels of troponin (Tn) I and C-reactive protein (CRP) were higher in Group II (Group I vs. II: 29.2 +/- 7.72 vs. 50.8 +/- 5.17 ng/dL, p = 0.017, 3.8 +/- 0.48 vs. 9.9 +/- 1.21 mg/dL, p < 0.001 respectively). Left main stem lesion (LMSL) was more common in Group II than in Group I (0.7% vs. 22.0%, respectively, p = 0.004). In-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization. CONCLUSION Old age, a previous MI history, high Tn and CRP, low EF and LMSL are associated with higher MACE for patients with AMI and CS. Coronary revascularization with TIMI 3 flow lowers the in-hospital mortality.
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Affiliation(s)
- Eun Hui Bae
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Sang Yup Lim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Hyung Wook Park
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Ji Hyun Lim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Young Joon Hong
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Weon Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Young Keun Ahn
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Soon Pal Suh
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Byoung Hee Ahn
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Sang Hyung Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - Jung Chaee Kang
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
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87
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Störk S, Angermann CE, Ertl G. Akute Herzinsuffizienz und kardiogener Schock. Internist (Berl) 2005; 46:285-97. [PMID: 15702302 DOI: 10.1007/s00108-005-1359-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Irrespective of improved medical and interventional therapeutic options, mortality among patients with acute heart failure and cardiogenic shock has remained disappointingly high. Early diagnosis and rapid initiation of basic treatment measures to improve hemodynamics and metabolism are of vital importance until causal therapy, e. g. revascularization, is initiated. Due to the principal difficulty to set up larger clinical trials, in patients with cardiogenic shock empirical rather than firm evidence supports the various treatment and management strategies currently in use. Continuous hemodynamic monitoring to tailor fluid therapy, new drugs, and prognostic markers have been developed for the treatment and monitoring of cardiogenic shock, all of which await testing in larger-scale studies. Ongoing challenges remain the right ventricular pump failure or hemodynamically compromising arrhythmia which may be either cause or consequence of cardiogenic shock.
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Affiliation(s)
- S Störk
- Medizinische Poliklinik, Universität Würzburg
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88
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Iakobishvili Z, Behar S, Boyko V, Battler A, Hasdai D. Does current treatment of cardiogenic shock complicating the acute coronary syndromes comply with guidelines? Am Heart J 2005; 149:98-103. [PMID: 15660040 DOI: 10.1016/j.ahj.2004.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The purpose of our study was to evaluate the implementation of guidelines for the treatment of cardiogenic shock (CS) complicating the acute coronary syndromes (ACS). METHODS AND RESULTS Of the 10 136 patients in the Euro-Heart-Survey-ACS with complete data, CS occurred in 549 (5.4%), of whom 28.6% had CS upon presentation. We examined the use of coronary angiography (CA), percutaneous (PCI) and surgical (CABG) revascularization, and intra-aortic balloon counterpulsation (IABP) among ACS patients with and without CS. During the hospital course, there were no significant differences between patients with and without CS in referral to CA (52.4% vs 53.3%, respectively) or CABG (4.4% vs 4.5%), but CS patients were more likely to undergo IABP (17.7% vs 0.8%, P < .001) and PCI (40.8% vs 31.8%, P < .001), especially younger (<75 years) patients (52.2% vs 31.8%, P < .001). A similar trend was observed when comparing ST-elevation-ACS patients with (368 [8.5%]) and without CS (3945): CA (58.1% vs 56.2%), CABG (3.6% vs 3.3%), IABP (20.0% vs 0.9%, P < .01), and PCI (47.3% vs 40.6%, P < .01; 54.4% vs. 44.6% for patients <75 years, P < .003). Of the 94 ST-elevation-ACS patients presenting with CS, only 39 (41.4%) received any reperfusion treatment, more often fibrinolysis (64.1%). The in-hospital mortality was 52.1% for all CS pts vs 2.0% for all others ( P < .001). CONCLUSIONS Our contemporary survey demonstrates prohibitively-high mortality rates among ACS patients complicated by CS and poor implementation of recent guidelines advocating an aggressive invasive approach, including low rates of revascularization and IABP. Improved adherence to the guidelines pertaining to ACS patients developing CS may hopefully improve outcomes.
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89
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Lim SY, Jeong MH, Bae EH, Kim W, Kim JH, Hong YJ, Park HW, Kang DG, Lee YS, Kim KH, Lee SH, Yun KH, Hong SN, Cho JG, Ahn YK, Park JC, Ahn BH, Kim SH, Kang JC. Predictive Factors of Major Adverse Cardiac Events in Acute Myocardial Infarction Patients Complicated by Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention. Circ J 2005; 69:154-8. [PMID: 15671605 DOI: 10.1253/circj.69.154] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to assess in-hospital mortality and major adverse cardiac events (MACE) during long-term clinical follow-up of patients who developed cardiogenic shock (CS) after acute myocardial infarction (AMI) and who underwent primary percutaneous coronary intervention (PCI). METHODS AND RESULTS The data from 147 patients with CS after AMI (61.7 +/-10.4 years, M:F =156:99) who underwent primary PCI at Chonnam National University Hospital between January 1999 and December 2002 were analyzed: clinical characteristics, coronary angiographic findings and mortality during admission, and MACE during a 1-year clinical follow-up. Of the enrolled patients, 121 patients survived (group I, M:F =94:27) and 26 died (group II, M:F =14:12) during admission. By binary logistic regression analysis, in-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization (p=0.02, odds ratio (OR) =1.3). Eighty-nine patients (60.5%) survived without MACE during the 1-year clinical follow-up and MACE was associated with a C-reactive protein (CRP) of more than 1 mg/dl (p=0.002, OR =6.3) and low TIMI flow after coronary revascularization (p<0.001, OR =7.8). CONCLUSIONS Primary PCI achieving TIMI 3 flow reduces in-hospital death in AMI with CS. High concentration of CRP and low TIMI flow are associated with MACE during long-term clinical follow-up.
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Affiliation(s)
- Sang Yup Lim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
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90
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Fang J, Alderman MH. Revascularization among patients with acute myocardial infarction complicated by cardiogenic shock and impact of American College of Cardiology/American Heart Association guidelines. Am J Cardiol 2004; 94:1281-5. [PMID: 15541246 DOI: 10.1016/j.amjcard.2004.07.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2004] [Accepted: 07/22/2004] [Indexed: 11/28/2022]
Abstract
Using New York City hospital discharge data from 1995 to 2002, we examined revascularization use among patients who had acute myocardial infarction complicated by cardiogenic shock before and after publication of recommendations by the American College of Cardiology/American Heart Association (ACC/AHA). The modest increase in these procedures from 1995 to 1999 and from 2000 to 2002 most likely reflected a trend, not a response, to the ACC/AHA recommendation. Moreover, the increase appeared to have been due to more frequent admission of eligible patients to hospitals capable of the service, as opposed to increasing revascularization rates in hospitals capable of revascularization.
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91
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Brunschwig T, Eberli FR, Herren T. [Mechanical complications of acute myocardial infarction]. ZEITSCHRIFT FUR KARDIOLOGIE 2004; 93:897-907. [PMID: 15568150 DOI: 10.1007/s00392-004-0133-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Accepted: 06/21/2004] [Indexed: 05/01/2023]
Abstract
Rupture of the left ventricular myocardium during the course of an acute myocardial infarction may affect the free wall, the interventricular septum, or the papillary muscles. When a rupture occurs, it is referred to as a mechanical complication of acute myocardial infarction. All mechanical complications may lead to cardiogenic shock. However, the location of the rupture can often be suspected clinically. To confirm the diagnosis, echocardiography must be performed. Since the advent of thrombolytic therapy and percutaneous coronary intervention, the incidence of mechanical complications has declined. Even though mortality remains high, their recognition is important since survivors may have an excellent long-term prognosis. The cases convey two main messages: 1) Mechanical complications must be carefully searched for in any patient with an acute coronary syndrome and signs of cardiogenic shock and/or a systolic murmur. 2) Aggressive and timely medical and surgical treatment should be provided even though in a substantial proportion of these patients prognosis may be dismal.
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Affiliation(s)
- T Brunschwig
- Medizinische Klinik, Spital Limmattal, Urdorferstrasse 100, 8952 Schlieren, Schweiz
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92
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El Banayosy A, Kizner L, Schueler V, Bergmeier S, Cobaugh D, Koerfer R. First use of the Molecular Adsorbent Recirculating System technique on patients with hypoxic liver failure after cardiogenic shock. ASAIO J 2004; 50:332-7. [PMID: 15307543 DOI: 10.1097/01.mat.0000131251.88146.cd] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The Molecular Adsorbent Recirculating System (MARS) has been proven to prolong survival in patients with hepatorenal syndrome. MARS is a modified dialysis that uses an albumin containing dialysate, which is recirculated and perfused online through charcoal and anion exchanger columns. It allows the selective removal of albumin bound substances. Despite advances in medical therapy and technology, the prognosis of patients with cardiogenic shock remains poor. Mortality rates are as high as 80%, often because of persistent multiple organ failure. To determine whether patients with hypoxic liver failure after cardiogenic shock after cardiac surgery might benefit from MARS, we performed a prospective, randomized, controlled, single center study. The primary objective was to prove that MARS improves survival. This article is a report on the interim analysis of the first 27 patients included between August 2000 and December 2001; 14 patients were in the MARS group, and 13 patients were in the non-MARS group. All had bilirubin levels greater than 8 mg/ml. Both groups had a similar risk profile. The MARS group received MARS for 3 consecutive days-if bilirubin was still greater than 6 mg/dl afterward, MARS was continued. The non-MARS group received conventional therapy. We had seven survivors in the MARS group (50%) compared with four (32%; p = ns) in the non-MARS group. We conclude that despite the limited number of patients included in this analysis, MARS can be recommended for patients with acute, hypoxic liver failure because it might prolong survival. Further studies in similar patient cohorts are needed to verify our results.
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Affiliation(s)
- A El Banayosy
- Heart Center NRW, Department of Cardiothoracic Surgery, Ruhr University Bochum, Georgstrasse, Bad Oeynhausen, Germany
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93
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Urban PM, Freedman RJ, Ohman EM, Stone GW, Christenson JT, Cohen M, Miller MF, Joseph DL, Bynum DZ, Ferguson JJ. In-hospital mortality associated with the use of intra-aortic balloon counterpulsation. Am J Cardiol 2004; 94:181-5. [PMID: 15246896 DOI: 10.1016/j.amjcard.2004.03.058] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 03/19/2004] [Accepted: 03/19/2004] [Indexed: 10/26/2022]
Abstract
We analyzed in-hospital mortality for patients treated with intra-aortic balloon counterpulsation from the Benchmark Counterpulsation Outcomes Registry (n = 25,136). In-hospital mortality was higher in patients who received only medical interventions (32.5%) than in those who underwent percutaneous (18.8%) and surgical (19.2%) interventions, and was greatest in the first days after hospital admission for all 3 intervention types. Therefore, diagnostic evaluation and treatment decisions should be made as early as possible, and physicians should be aware of associated risk factors in making choices for patients.
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94
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Appoloni O, Dupont E, Vandercruys M, Andrien M, Duchateau J, Vincent JL. Association Between the TNF-2 Allele and a Better Survival in Cardiogenic Shock. Chest 2004; 125:2232-7. [PMID: 15189946 DOI: 10.1378/chest.125.6.2232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
STUDY OBJECTIVES Tumor necrosis factor (TNF)-alpha has been implicated in the pathophysiology of heart failure. We explored a possible association between TNF-alpha, interleukin (IL)-6, IL-10, transforming growth factor (TGF)-beta, and interferon (IFN)-gamma cytokine polymorphisms, their in vivo production, and mortality from cardiogenic shock. DESIGN Prospective, observational study. SETTING Thirty-one bed, university, medicosurgical department of intensive care. PATIENTS Thirty-three adult patients with cardiogenic shock of recent (< 4 h) onset. INTERVENTIONS None. MEASUREMENTS AND RESULTS TNF-alpha, IL-6, IL-10, TGF-beta1, and IFN-gamma plasma levels were measured by enzyme-linked immunosorbent assay. Polymorphisms of TNF-alpha within the promoter at position -308a-->g, IL-6 within the promoter at position -174c-->g, IL-10 within the promoter at position -1082a-->g/-819t-->c and -819t-->c/-592a-->c, TGF-beta1 at codon 10t-->c and codon 25c-->g, and IFN-gamma at intron 1 at position + 874t-->a were studied. The 33 patients had a mean (+/- SD) age of 64 +/- 17 years and a mean simplified acute physiology score II of 62.3 +/- 15.3. Twenty-three patients (70%) died in the ICU, including 21 of 26 patients (81%) in the TNF-1 group but only 2 of 7 patients (29%) in the TNF-2 group (p = 0.016). There were no significant differences in median plasma TNF-alpha levels between the TNF-1 and the TNF-2 groups, but TGF-beta1 levels were higher in the survivors than in the nonsurvivors (median, 866 pg/mL; range, 384 to 1,966 pg/mL; vs median, 454 pg/mL; range, 167 to 1,266 pg/mL, respectively; p = 0.02). There were no significant differences in TNF-2 polymorphism between the patients with cardiogenic shock and a group of healthy control subjects (7 of 33 patients vs 13 of 48 subjects, respectively; p = 0.61), but IFN-gamma polymorphism was less common in the cardiogenic shock group (p = 0.034). CONCLUSIONS Patients with the TNF-2 allele have no greater risk of cardiogenic shock but a better survival rate when it develops. Different genetic factors appear to influence the risk of development of, and outcome from, cardiogenic shock.
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Affiliation(s)
- Olivier Appoloni
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
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95
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Seguin P, Signouret T, Laviolle B, Branger B, Mallédant Y. Incidence and risk factors of atrial fibrillation in a surgical intensive care unit*. Crit Care Med 2004; 32:722-6. [PMID: 15090953 DOI: 10.1097/01.ccm.0000114579.56430.e0] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the incidence and risks factors of atrial fibrillation (AF). DESIGN Prospective, observational study. SETTING A surgical intensive care unit of a university hospital. PATIENTS All patients with new onset of AF admitted in the surgical intensive care unit during a 6-month period. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Of the 460 patients included in the study, AF developed in 24 patients (5.3%). According to univariate analysis, age, preexisting cardiovascular disease, and previous treatment by calcium-channel blockers were significant predictors of AF. Patients with AF received significantly more fluids and catecholamines and experienced more sepsis, shock, and acute renal failure. Severity (Simplified Acute Physiologic Score II), intensive care unit workload (OMEGA), intensive care unit and hospital length of stay, and mortality were significantly increased in patients who developed AF. Multivariate analysis identified five independent predictors of AF: advanced age, blunt thoracic trauma, shock, pulmonary artery catheter, and previous treatment by calcium-channel blockers. CONCLUSIONS In surgical intensive care unit patients, the incidence of AF is greater than in the general population but less than in the cardiac surgery unit. The onset of AF reflects the severity of the disease. Five independent risk factors of AF were identified in surgical intensive care unit patients. The withdrawal of a calcium-channel inhibitor was also an independent risk factor of AF, and the weaning of this treatment must be carefully evaluated. Blunt thoracic trauma increases the chances of developing AF, as does the presence of shock, especially septic shock.
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Affiliation(s)
- Philippe Seguin
- Surgical Intensive Care Unit, Hôpital Pontchaillou, Rennes, France
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96
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Abstract
Magnetic resonance imaging and/or contrast-enhanced multidetector computed tomography may be used separately or, often more effectively, in an integrated fashion, to address important issues in patients with coronary artery disease causing ischemic cardiac disease (ICD). These issues include complications of myocardial infarction, such as ventricular dysfunction, myocardial wall rupture, aneurysm formation, intracavitary thrombus, mitral insufficiency, and pericarditis, as well as aspects of planning and monitoring therapy for ICD, such as revascularization and ventricular aneurysm repair.
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Affiliation(s)
- Richard D White
- Center for Integrated Non-Invasive Cardiovascular Imaging, Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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97
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Lim N, Dubois MJ, De Backer D, Vincent JL. Do All Nonsurvivors of Cardiogenic Shock Die With a Low Cardiac Index? *. Chest 2003; 124:1885-91. [PMID: 14605064 DOI: 10.1378/chest.124.5.1885] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
STUDY OBJECTIVES To characterize the hemodynamic course of cardiogenic shock and to relate the cause of death to ongoing cardiac failure or multiple organ dysfunction. DESIGN Retrospective study. SETTING A 31-bed department of intensive care in a university hospital. PATIENTS All patients admitted for cardiogenic shock from January 1999 to December 2000. INTERVENTIONS None. MEASUREMENTS AND RESULTS Charts were reviewed for demographic, clinical, hemodynamic, oxygen transport, inflammation, and organ dysfunction data. Of 62 patients with cardiogenic shock, 40 (65%) did not survive. Eight patients (20%) died from fatal arrhythmia, 14 patients (35%) died with low cardiac index (CI) [ie, < 2.2 L/min/m(2)], and 18 patients (45%) died with normalized CI (ie, > 2.2 L/min/m(2)) and a higher CI/oxygen extraction ratio. Of these 18 patients, 9 had evidence of infection. The patients with normalized CI were younger and stayed longer in the ICU than patients with low CI. CONCLUSION A substantial number of patients with cardiogenic shock die with a normalized CI, suggesting a distributive defect, in the absence of obvious infection. These patients are younger and have a longer ICU course. The release of mediators may be secondary to gut hypoperfusion.
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Affiliation(s)
- Noelle Lim
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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98
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Delle Karth G, Buberl A, Geppert A, Neunteufl T, Huelsmann M, Kopp C, Nikfardjam M, Berger R, Heinz G. Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines. Acta Anaesthesiol Scand 2003; 47:1251-6. [PMID: 14616323 DOI: 10.1046/j.1399-6576.2003.00252.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Levosimendan, a novel inodilator, has been shown to improve hemodynamic function in patients with decompensated heart failure with preserved arterial blood pressure. Data on its use in patients with cardiogenic shock are rare. The present series describes the 24-h hemodynamic effects of levosimendan as add-on therapy in desperately ill patients with cardiogenic shock requiring catecholamines. METHODS Ten patients with cardiogenic shock received levosimendan as continuous infusion of 0.1 microg kg(-1) min(-1) for 24 h. The patients were otherwise unselected. Hemodynamic measurements were routinely performed at baseline (time 0) and at 1, 8, 16 and 24 h after start of levosimendan (LS) using a Swan-Ganz thermodilution catheter. RESULTS During the levosimendan infusion there was a significant increase in cardiac index from 1.8 +/- 0.4 to 2.4 +/- 0.6 L*min-1*m-2 (P = 0.023) and a significant decrease in systemic vascular resistance from 1559 +/- 430 to 1109 +/- 202 dyn*s*cm-5 (P = 0.001), respectively. Changes in catecholamine dose, and in systolic and diastolic blood pressure were not significant. Given the individual response to LS, 8/10 patients showed an increase in left ventricular stroke work index under reduced or roughly unchanged preload conditions after 8 h. CONCLUSION This series shows that a LS infusion is feasible and able to improve hemodynamics in severely compromized, critically ill patients with cardiogenic shock requiring catecholamine therapy. Its potential advantages when compared with other inotropes are unclear. To clarify the potential role of LS in this clinical setting randomized controlled trials on hemodynamic and mortality endpoints are needed.
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Affiliation(s)
- G Delle Karth
- Department of Cardiology, University of Vienna, Vienna, Austria.
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99
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Ho TC, Ting CT, Liu TJ, Liang KW, Ho HY, Hsueh CW, Wang KY, Lin WW, Lee WL. Percutaneous coronary revascularization improves the prognosis of patients with cardiogenic shock in acute coronary syndrome: a chronological study. Int J Cardiol 2003; 89:135-43. [PMID: 12767535 DOI: 10.1016/s0167-5273(02)00432-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cardiogenic shock complicating acute coronary syndrome (ACS) implies grim prognosis with conventional management. Previous studies of coronary intervention yielded controversial results and were rarely analyzed chronologically. This study was to determine the impact of percutaneous coronary revascularization on outcome by studying two time periods 5 years apart in which the revascularization was more frequent and techniques more refined in the later period. METHODS AND MATERIALS All patients admitted to the intensive or coronary care unit for ACS in two 1.5-year study periods (Period I: Jan 1994-Jun 1995, Period II: Oct 1999-Apr 2000) were retrospectively screened. Patients who met strict criteria of cardiogenic shock within 24 h of ACS were enrolled. The demographics, management and in-hospital/3-month outcomes were analyzed. RESULTS Thirty-seven patients (33M/4F, aged 65+/-8 years) were enrolled in Period I and 32 patients (25M/7F, aged 68+/-13 years) in Period II. The incidence of cardiogenic shock was 11.8 and 9.3%, respectively. The demographics were similar except patients in Period II were older. Significantly more coronary angiography and interventions were done in the later period. The in-hospital (68 vs. 44%, P=0.047) and 3-month mortalities (70 vs. 44%, P=0.03) were significantly reduced in Period II. The in-hospital survivors in two study periods differed only in use of coronary angiography (94 vs. 50%, P=0.005) and interventions (83 vs. 33%, P=0.005) but not others. CONCLUSIONS Percutaneous coronary revascularization does improve the clinical outcome of cardiogenic shock when analyzed chronologically. This treatment is warranted in every such patient in the interventional era.
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Affiliation(s)
- Tung-Ching Ho
- Division of Cardiology, Department of Medicine, Taichung Veterans General Hospital, 160, Sector 3, Chung-Kang Road, 407, Taichung, Taiwan
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100
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Affiliation(s)
- Dale T Ashby
- The Lenox Hill Heart and Vascular Institute, New York, New York, USA.
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