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Blumer V, Kanwar MK, Barnett CF, Cowger JA, Damluji AA, Farr M, Goodlin SJ, Katz JN, McIlvennan CK, Sinha SS, Wang TY. Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1051-e1065. [PMID: 38406869 PMCID: PMC11067718 DOI: 10.1161/cir.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.
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Kanwar M, Thayer KL, Garan AR, Hernandez-Montfort J, Whitehead E, Mahr C, Sinha SS, Vorovich E, Harwani NM, Zweck E, Abraham J, Burkhoff D, Kapur NK. Impact of Age on Outcomes in Patients With Cardiogenic Shock. Front Cardiovasc Med 2021; 8:688098. [PMID: 34368248 PMCID: PMC8342768 DOI: 10.3389/fcvm.2021.688098] [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: 03/30/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Advanced age is associated with poor outcomes in cardiovascular emergencies. We sought to determine the association of age, use of support devices and shock severity on mortality in cardiogenic shock (CS). Methods: Characteristics and outcomes in CS patients included in the Cardiogenic Shock Work Group (CSWG) registry from 8 US sites between 2016 and 2019 were retrospectively reviewed. Patients were subdivided by age into quintiles and Society for Cardiovascular Angiography & Interventions (SCAI) shock severity. Results: We reviewed 1,412 CS patients with a mean age of 59.9 ± 14.8 years, including 273 patients > 73 years of age. Older patients had significantly higher comorbidity burden including diabetes, hypertension and coronary artery disease. Veno-arterial extracorporeal membrane oxygenation was used in 332 (23%) patients, Impella in 410 (29%) and intra-aortic balloon pump in 770 (54%) patients. Overall in-hospital survival was 69%, which incrementally decreased with advancing age (p < 0.001). Higher age was associated with higher mortality across all SCAI stages (p = 0.003 for SCAI stage C; p < 0.001 for SCAI stage D; p = 0.005 for SCAI stage E), regardless of etiology (p < 0.001). Conclusion: Increasing age is associated with higher in-hospital mortality in CS across all stages of shock severity. Hence, in addition to other comorbidities, increasing age should be prioritized during patient selection for device support in CS.
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Affiliation(s)
- Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, United States
| | - Katherine L Thayer
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
| | | | | | - Evan Whitehead
- Massachusetts General Hospital, Boston, MA, United States
| | - Claudius Mahr
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, United States
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
| | - Elric Zweck
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
| | - Jacob Abraham
- Providence Center for Cardiovascular Analytics, Research, and Data Science, Portland, OR, United States
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, NY, United States
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
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Llaó I, Ariza Solé A. Mortality in elderly patients with cardiogenic shock: why and how? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:613-615. [PMID: 34131738 DOI: 10.1093/ehjacc/zuab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Isaac Llaó
- Cardiology Department, Intensive Cardiac Care Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
| | - Albert Ariza Solé
- Cardiology Department, Intensive Cardiac Care Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
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Vallabhajosyula S, Vallabhajosyula S, Dunlay SM, Hayes SN, Best PJM, Brenes-Salazar JA, Lerman A, Gersh BJ, Jaffe AS, Bell MR, Holmes DR, Barsness GW. Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults. Mayo Clin Proc 2020; 95:1916-1927. [PMID: 32861335 PMCID: PMC7582223 DOI: 10.1016/j.mayocp.2020.01.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/11/2020] [Accepted: 01/31/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). MATERIALS AND METHODS A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay. RESULTS In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality. CONCLUSION Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN.
| | | | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Jorge A Brenes-Salazar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Geriatric Medicine and Gerontology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Damluji AA, Bandeen-Roche K, Berkower C, Boyd CM, Al-Damluji MS, Cohen MG, Forman DE, Chaudhary R, Gerstenblith G, Walston JD, Resar JR, Moscucci M. Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. J Am Coll Cardiol 2020; 73:1890-1900. [PMID: 30999991 DOI: 10.1016/j.jacc.2019.01.055] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. OBJECTIVES The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. METHODS We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). RESULTS Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53). CONCLUSIONS This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.
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Affiliation(s)
- Abdulla A Damluji
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland; Division of Cardiology, Johns Hopkins University, Baltimore, Maryland.
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Carol Berkower
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland
| | - Mohammed S Al-Damluji
- Department of Internal Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | | | - Daniel E Forman
- Geriatric Cardiology Section, University of Pittsburgh, Pittsburgh, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Rahul Chaudhary
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland
| | - Gary Gerstenblith
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | - Mauro Moscucci
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland; University of Michigan Health System, Ann Arbor, Michigan.
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Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States. Clin Res Cardiol 2017; 107:287-303. [DOI: 10.1007/s00392-017-1182-2] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/08/2017] [Indexed: 10/18/2022]
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Prognostic Analysis for Cardiogenic Shock in Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8530539. [PMID: 28251160 PMCID: PMC5303841 DOI: 10.1155/2017/8530539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
Abstract
Cardiogenic shock (CS) is uncommon in patients suffering from acute myocardial infarction (AMI). Long-term outcome and adverse predictors for outcomes in AMI patients with CS receiving percutaneous coronary interventions (PCI) are unclear. A total of 482 AMI patients who received PCI were collected, including 53 CS and 429 non-CS. Predictors for AMI patients with CS including recurrent MI, cardiovascular (CV) mortality, all-cause mortality, and repeated-PCI were analyzed. The CS group had a lower central systolic pressure and central diastolic pressure (both P < 0.001). AMI patients with hypertension history were less prone to develop CS (P < 0.001). Calcium channel blockers and statins were less frequently used by the CS group than the non-CS group (both P < 0.05) after discharge. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, CV mortality, and all-cause mortality were higher in the CS group than the non-CS group (all P < 0.005). For patients with CS, stroke history was a predictor of recurrent MI (P = 0.036). CS, age, SYNTAX score, and diabetes were predictors of CV mortality (all P < 0.05). CS, age, SYNTAX score, and stroke history were predictors for all-cause mortality (all P < 0.05). CS, age, and current smoking were predictors for repeated-PCI (all P < 0.05).
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De Luca L, Olivari Z, Farina A, Gonzini L, Lucci D, Di Chiara A, Casella G, Chiarella F, Boccanelli A, Di Pasquale G, De Servi S, Bovenzi FM, Gulizia MM, Savonitto S. Temporal trends in the epidemiology, management, and outcome of patients with cardiogenic shock complicating acute coronary syndromes. Eur J Heart Fail 2015; 17:1124-32. [DOI: 10.1002/ejhf.339] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 07/06/2015] [Accepted: 07/18/2015] [Indexed: 11/10/2022] Open
Affiliation(s)
- Leonardo De Luca
- Department of Cardiovascular Sciences; European Hospital; Rome Italy
| | - Zoran Olivari
- Department of Cardiology; Ca' Foncello Hospital; Treviso Italy
| | - Andrea Farina
- Division of Cardiology; Ospedale A. Manzoni; Lecco Italy
| | | | | | | | - Gianni Casella
- Department of Cardiology; Maggiore Hospital; Bologna Italy
| | - Francesco Chiarella
- Division of Cardiology; Azienda Ospedaliera-Universitaria; S. Martino Genova Italy
| | | | | | - Stefano De Servi
- Division of Cardiology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
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Lim HS, Andrianopoulos N, Sugumar H, Stub D, Brennan AL, Lim CC, Barlis P, Van Gaal W, Reid CM, Charter K, Sebastian M, New G, Ajani AE, Farouque O, Duffy SJ, Clark DJ. Long-term survival of elderly patients undergoing percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock. Int J Cardiol 2015; 195:259-64. [DOI: 10.1016/j.ijcard.2015.05.130] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 11/16/2022]
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Yoo YP, Kang KW, Yoon HS, Myung JC, Choi YJ, Kim WH, Park SH, Jung KT, Jeong MH. One-year clinical outcomes in invasive treatment strategies for acute ST-elevation myocardial infarction complicated by cardiogenic shock in elderly patients. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2013; 10:235-41. [PMID: 24133510 PMCID: PMC3796696 DOI: 10.3969/j.issn.1671-5411.2013.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/11/2013] [Accepted: 08/24/2013] [Indexed: 01/04/2023]
Abstract
Objective To investigate the clinical outcomes of an invasive strategy for elderly (aged ≥ 75 years) patients with acute ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). Methods Data on 366 of 409 elderly CS patients from a total of 6,132 acute STEMI cases enrolled in the Korea Acute Myocardial Infarction Registry between January 2008 and June 2011, were collected and analyzed. In-hospital deaths and the 1-month and 1-year survival rates free from major adverse cardiac events (MACE; defined as all cause death, myocardial infarction, and target vessel revascularization) were reported for the patients who had undergone invasive (n = 310) and conservative (n = 56) treatment strategies. Results The baseline clinical characteristics were not significantly different between the two groups. There were fewer in-hospital deaths in the invasive treatment strategy group (23.5% vs. 46.4%, P < 0.001). In addition, the 1-year MACE-free survival rate after invasive treatment was significantly lower compared with the conservative treatment (51% vs. 66%, P = 0.001). Conclusions In elderly patients with acute STEMI complicated by CS, the outcomes of invasive strategy are similar to those in younger patients at the 1-year follow-up.
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Affiliation(s)
- Yeon Pyo Yoo
- Division of Cardiology, Hyosung General Hospital, 162-90 Sandang dong, Chungju 360-802, South Korea
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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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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1724] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 902] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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In-hospital outcomes of emergent and elective percutaneous coronary intervention in octogenarians. Coron Artery Dis 2009; 20:118-23. [DOI: 10.1097/mca.0b013e3283292ae1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Survival of Elderly Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2009; 2:146-52. [DOI: 10.1016/j.jcin.2008.11.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 10/14/2008] [Accepted: 11/07/2008] [Indexed: 11/20/2022]
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Ellender TJ, Skinner JC. The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin North Am 2008; 26:759-86, ix. [DOI: 10.1016/j.emc.2008.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Chang SN, Hwang JJ, Chen YS, Lin JW, Chiang FT. Clinical experience with intra-aortic balloon counterpulsation over 10 years: A retrospective cohort study of 459 patients. Resuscitation 2008; 77:316-24. [DOI: 10.1016/j.resuscitation.2008.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Revised: 12/12/2007] [Accepted: 01/06/2008] [Indexed: 10/22/2022]
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The evaluation and management of cardiogenic shock. Crit Pathw Cardiol 2008; 5:1-6. [PMID: 18340210 DOI: 10.1097/01.hpc.0000202247.12684.7d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cardiogenic shock (CS) continues to be the leading cause of death in patients who present to the hospital with acute myocardial infarction (AMI). Mortality in patients with AMI complicated by CS remains extremely high, with 1-month mortality rates ranging from 40% to 60%. Although pump failure is the dominant etiologic feature of CS after AMI, the inflammatory system has been implicated in its pathogenesis. The dominant therapy for treatment of CS is early mechanical revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. Supportive measures such as intravenous vasopressors or intra-aortic balloon counterpulsation can complement the benefit of definitive revascularization. Newer therapies are directed at mitigating the inflammatory response or supporting cardiovascular function until either patient recovery or until other destination therapy is available. The strategies in this critical pathway outline the general approach in treating CS after AMI at our institution.
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Klein LW. Optimal revascularization strategies for ST-segment elevation myocardial infarction in the elderly patient. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2007; 16:295-303. [PMID: 17786059 DOI: 10.1111/j.1076-7460.2007.07328.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Patients older than 75 years account for >60% of all deaths from acute myocardial infarction. Although there are accepted guidelines for treatment of acute ST-segment elevation myocardial infarction, elderly patients tend to have a variety of conditions that can complicate decisions about the best therapy. Many elderly patients do not receive potentially lifesaving treatments, such as percutaneous coronary intervention or thrombolytic therapy, for fear of an adverse event. Those who do receive appropriate revascularization therapy often receive it later in the course of the infarct, when irreversible damage has occurred. Yet studies show that patients older than 75 years will benefit substantially from these therapies. Early treatment improves outcomes in this population, as in younger patients, despite a higher risk of complications. In this review, the evidence regarding medical and revascularization therapies in ST-segment elevation myocardial infarction is critically examined.
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Yamaguchi T. [Percutaneous coronary intervention for the elderly patients]. Nihon Ronen Igakkai Zasshi 2007; 44:39-41. [PMID: 17337846 DOI: 10.3143/geriatrics.44.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Holmes DR. Percutaneous Coronary Intervention for Acute Myocardial Infarction. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Migliorini A, Moschi G, Valenti R, Parodi G, Dovellini EV, Carrabba N, Buonamici P, Antoniucci D. Routine percutaneous coronary intervention in elderly patients with cardiogenic shock complicating acute myocardial infarction. Am Heart J 2006; 152:903-8. [PMID: 17070154 DOI: 10.1016/j.ahj.2005.12.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Accepted: 12/24/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Age is a strong predictor of cardiogenic shock (CS) and death in patients with acute myocardial infarction (AMI). Few data on the impact of a routine early percutaneous revascularization strategy in elderly patients with CS complicating AMI exist. METHODS We performed an analysis of age-related differences in outcome in 280 consecutive patients with AMI complicated by CS who underwent primary percutaneous coronary intervention (PCI) between January 1995 and September 2004 and who were included in a single-center prospective registry of primary PCI for AMI. RESULTS Of the 280 patients with CS, 104 (37%) were > or = 75 years. The mean age of the elderly group was 81 +/- 5 years, and half of the patients were > or = 80 years. Most patients in both groups underwent PCI within 6 hours of their symptom onset. The PCI success rates were 92% in the elderly group and 97% in the younger patient group (P = .062). The 6-month mortality rates were 56% in the elderly group and 26% in the younger patient group (P < .001). At multivariate analysis, the variables independently related to the risk of 1-year mortality in the elderly group were age (hazard ratio 1.07, 95% CI 1.02-1.12, P = .005) and PCI failure (hazard ratio 4.01, 95% CI 1.53-10.51, P = .005). CONCLUSION A strategy of routine emergency PCI in elderly patients with CS complicating AMI is highly feasible. Among elderly patients, age remains to be a strong predictor of mortality. However, outcome after successful PCI is better than previously reported.
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Kato K, Sato N, Fujita N, Yamamoto T, Iwasaki YK, Yodogawa K, Takayama M, Tanaka K, Takano T. Combined therapy with percutaneous coronary intervention and percutaneous aortic valvuloplasty under mechanical support for an elderly patient with cardiogenic shock. J NIPPON MED SCH 2006; 73:158-63. [PMID: 16790984 DOI: 10.1272/jnms.73.158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Percutaneous aortic valvuloplasty is reportedly a useful tool for the management of critical and severe aortic stenosis with cardiogenic shock. However, early percutaneous coronary intervention for cardiogenic shock is beneficial for elderly patients with acute myocardial infarction. We describe a patient with critical aortic stenosis who presented with severe coronary stenosis of the left main trunk and the ostium of the right coronary artery. We performed percutaneous coronary intervention and percutaneous aortic valvuloplasty under intra-aortic balloon pump and percutaneous cardiopulmonary support. After these procedures, the cardiogenic shock was reversed, and the patient could be weaned from both intra-aortic balloon pump support and percutaneous cardiopulmonary support.
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Affiliation(s)
- Koji Kato
- Intensive and Cardiac Care Unit, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan.
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Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184:S1-S32. [PMID: 16618231 DOI: 10.5694/j.1326-5377.2006.tb00304.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 02/20/2006] [Indexed: 11/17/2022]
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Wang YC, Hwang JJ, Hung CS, Kao HL, Chiang FT, Tseng CD. Outcome of Primary Percutaneous Coronary Intervention in Octogenarians with Acute Myocardial Infarction. J Formos Med Assoc 2006; 105:451-8. [PMID: 16801032 DOI: 10.1016/s0929-6646(09)60184-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/PURPOSE Acute myocardial infarction (AMI) results in more complications and increased mortality in octogenarians compared to patients in younger age groups. This study investigated the short- and long-term outcomes in octogenarians after primary percutaneous coronary intervention (PCI). METHODS During the study period from May 1997 to August 2004, 54 patients > or = 80 years old with ST-elevation myocardial infarction (STEMI) were eligible for primary PCI. Data collected included baseline clinical characteristics and usage of cardiovascular medications. Diagnostic coronary angiography and revascularization procedures were performed using standard practices. During hospitalization, the clinical course including serial changes in cardiac enzymes, adverse events associated with myocardial infarction or treatment, and inhospital or long-term mortality of patients were recorded. RESULTS The mean age of the 54 patients (35 men, 19 women) was 82.8 +/- 2.5 years (range, 80-89 years). Among them, 27 (50%) had anterior infarction, six (11%) had anterolateral infarction, and 21 (39%) had inferior infarction, inclusive of three patients with accompanying right ventricular infarction. Among them, 20 (37%) patients were in Killip class I, nine (17%) were in class II, two (4%) in class III, and 23 (43%) in class IV. The mean delay from onset of symptoms to arrival in hospital was 220 +/- 167 minutes, and 189 +/- 169 minutes from hospital arrival to reperfusion. Diagnostic coronary angiography revealed that 48 (89%) patients had multivessel disease. Inhospital death occurred in 23 (43%) patients, with the leading causes of death being profound cardiogenic shock (61%), and free wall rupture (26%). CONCLUSION Octogenarian patients who developed STEMI tended to have multivessel disease. These patients had a high inhospital mortality rate that was most likely to be due to cardiogenic shock.
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Affiliation(s)
- Yi-Chih Wang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
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Silber S, Albertsson P, Avilés FF, Camici PG, Colombo A, Hamm C, Jørgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W. Guías de Práctica Clínica sobre intervencionismo coronario percutáneo. Rev Esp Cardiol 2005; 58:679-728. [PMID: 15970123 DOI: 10.1157/13076420] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26:804-47. [PMID: 15769784 DOI: 10.1093/eurheartj/ehi138] [Citation(s) in RCA: 855] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.
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Abstract
PURPOSE OF REVIEW Cardiogenic shock remains the most serious complication of acute MI, with an incidence of 6 to 8% and a 30-day mortality rate that remains close to 50%. While cardiogenic shock is due primarily to left ventricular failure, other causes such as acute mitral regurgitation and ventricular septal rupture must always be considered as emergency surgery may be life saving. The purpose of this review is to summarize recent advances in the care of these critically ill patients including the consideration of etiology and pathophysiology as well as the influence of age and adjunctive therapies. RECENT FINDINGS Early revascularization is now an American College of Cardiology/American Heart Association guideline class 1 indication for percutaneous coronary intervention (PCI) particularly for younger patients in cardiogenic shock. Recent studies suggest there may also be a benefit in elderly patients with cardiogenic shock. SUMMARY Prompt triage of all patients in cardiogenic shock for early angiography, intra-aortic balloon pump counterpulsation, and early revascularization with PCI or bypass surgery is now the preferred management strategy.
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Affiliation(s)
- Timothy A Sanborn
- Division of Cardiology , Evanston Northwestern Healthcare, and Department of Medicine, Northwestern University, Feinberg School of Medicine, Evanston, Illinois 60201, USA.
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French JK. Which elderly patients with cardiogenic shock should be treated with percutaneous coronary intervention? Am Heart J 2004; 147:950-2. [PMID: 15199339 DOI: 10.1016/j.ahj.2003.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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