Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie

Incidence, laboratory detection and prognostic relevance of hypoxic hepatitis in cardiogenic shock

BACKGROUND

Despite the improvement of therapeutic options for patients in acute myocardial infarction (AMI), cardiogenic shock (CS) remains a complication with high mortality rates. Organ failure centrally determines the prognosis of these high-risk patients. Aim of the current study was to assess the incidence of hypoxic hepatitis (HH) in CS, its laboratory detection evaluating novel and established biomarkers and to estimate the prognostic relevance of HH in current clinical practice.

METHODS

In 172 patients with CS complicating AMI, blood samples were collected at admission and after 1 day as prespecified subanalysis of the intra-aortic balloon pumping IABP-SHOCK II trial. Classic parameters of HH were measured in addition to argininosuccinate synthase 1 and sulfotransferase isoform SULT2A1 was determined as new biomarker using standard enzyme-linked immunosorbent assay kits. All-cause mortality at 30 days was used for outcome assessment.

RESULTS

The overall mortality rate was 40%. The incidence of HH with an increase of aminotransferase levels to be 20 times above the upper normal level was 18%. Patients with HH had a distinctly higher 30-day mortality rate compared to patients without HH (68 vs. 34%; p < 0.001). After multivariable adjustment aspartate-aminotransferase (ASAT) remained an independent predictor of 30-day mortality together with serum lactate and serum creatinine, while the new biomarkers failed to predict outcome. Comparing different liver markers using receiver operating characteristic analysis, ASAT showed the highest area under the curve for the prediction of outcome.

CONCLUSIONS

HH occurs frequently in CS and is associated with particular poor outcome. As conventional biomarker, ASAT is the strongest laboratory predictor of outcome. ClinicalTrials.gov Identifier: NCT00491036.

Evaluation of the microcirculation in critically ill patients

Adequate monitoring of patients on intensive care units is of highest priority to provide optimal treatment and to detect patients at risk. Within recent years the microcirculation became more and more attention due to its central importance for the outcome of patients. Microcirculatory disorders may include capillary flow disturbances as well as changes in the density of perfused vessels. In the clinical setting, the most often used parameter to detect alterations in the microcirculation is serum lactate. Since this parameter is characterized by major limitations, other strategies including non-invasive methods to quantify microvascular perfusion have been developed. A successful surveillance of the microcirculation in the individual patient may guide diagnostic and treatment strategies in order to optimize organ perfusion and oxygenation, subsequently leading to an individualized therapy. Intravital microscopy has been used to stratify patients at risk and to predict patients' outcome. The aim of this review is to evaluate clinical correlates of microcirculatory disorders as well as giving an overview of newer diagnostic devices that may directly or indirectly evaluate the microcirculation and are available for use in critically ill patients.