Trends in acute myocardial infarction complicated by cardiogenic shock, 1979-2003, United States

Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction

Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.

Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction: An 18-Year Analysis of Temporal Trends, Epidemiology, Management, and Outcomes

BACKGROUND

There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS).

METHODS

Adult (>18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay.

RESULTS

In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P < 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P < 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P < 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P < 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P > 0.05).

CONCLUSIONS

In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock

This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.

Sex differences in acute cardiovascular care: a review and needs assessment

Despite significant progress in the care of patients suffering from cardiovascular disease, there remains a persistent sex disparity in the diagnosis, management, and outcomes of these patients. These sex disparities are seen across the spectrum of cardiovascular care, but, are especially pronounced in acute cardiovascular care. The spectrum of acute cardiovascular care encompasses critically ill or tenuous patients with cardiovascular conditions that require urgent or emergent decision-making and interventions. In this narrative review, the disparities in the clinical course, management, and outcomes of six commonly encountered acute cardiovascular conditions, some with a known sex-predilection will be discussed within the basis of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where improvement in clinical approaches are needed.

Improved Outcome of Cardiogenic Shock Triggered by Takotsubo Syndrome Compared With Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) is a severe complication of myocardial infarction (MI) or of takotsubo syndrome (TTS). For both diseases, CS is related to a worse long-term outcome. The outcome of CS has not been studied in a direct comparison of patients with MI and patients with TTS.

METHODS

Mortality and cardiovascular complications were compared in patients presenting with CS based on MI or TTS between 2003 and 2017 during a follow-up of 5 years. A total of 138 patients with TTS and 532 patients with MI were included. Of these, 66 patients with MI and 25 patients with TTS developed CS (12% vs 18%, P = 0.08).

RESULTS

Patients with MI and CS had more often malignant arrhythmias (74% vs 28%, P < 0.01), and need for resuscitation (80% vs 24%, P < 0.01) or death (71% vs 24%, P < 0.01) than patients with TTS and CS during the first 30 days. Although the overall rate of death remained higher in MI than in TTS (75.8% vs 52%, log rank, P < 0.01), deaths occurred in TTS constantly throughout the follow-up time, but not in MI. The incidence of heart failure increased in MI but not in TTS (31.8% vs 4%, P < 0.01) during follow-up.

CONCLUSIONS

Patients with MI and CS have a worse prognosis than patients with TTS and CS. This is driven by cardiovascular events or death during the first 30 days after the index event. However, patients with TTS and CS show high mortality as well, especially during long-term follow-up.

Temporal trends in clinical characteristics and management according to sex in patients with cardiogenic shock after acute myocardial infarction: The FAST-MI programme

BACKGROUND

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) occurs more frequently in women, but little is known about its potential specificities according to sex.

AIMS

To analyse the incidence, management and 1-year mortality of CS according to sex using the FAST-MI programme.

METHODS

The FAST-MI programme consists of four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive patients with AMI over a 1-month period, and with a 1-year follow-up.

RESULTS

Among the 10,610 patients included in the surveys, the incidence of CS was 4.8% in men and 8.2% in women (P<0.001). Absolute incidence of CS decreased from 1995 to 2010 in both sexes. Mean age in patients with CS tended to decrease in men (from 72±12 to 69±13 years) and to increase in women (from 78±10 to 80±9 years). One-year mortality decreased significantly in men (from 70% in 1995 to 48% in 2010) and in women (from 81% to 54%). Using Cox multivariable analysis, female sex was not an independent correlate of 1-year mortality [hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.78-1.22]. Early use of percutaneous coronary intervention was, however, an independent predictor of 1-year survival in women (HR: 0.55, 95% CI: 0.37-0.81), but showed only a non-significant trend in men (HR: 0.85, 95% CI: 0.61-1.19).

CONCLUSIONS

The incidence of CS-AMI has decreased in both men and women, but remains higher in women. One-year mortality has significantly decreased for both men and women, and the role of early percutaneous coronary intervention as a potential mediator of decreased mortality seems greater in women than in men.

Acute Complications of Myocardial Infarction in the Current Era: Diagnosis and Management

Coronary heart disease is a major cause of mortality and morbidity worldwide. The incidence of mechanical complications of acute myocardial infarction (AMI) has gone down to less than 1% since the advent of percutaneous coronary intervention, but although mortality resulting from AMI has gone down in recent years, the burden remains high. Mechanical complications of AMI include cardiogenic shock, free wall rupture, ventricular septal rupture, acute mitral regurgitation, and right ventricular infarction. Detailed knowledge of the complications and their risk factors can help clinicians in making an early diagnosis. Prompt diagnosis with appropriate medical therapy and timely surgical intervention are necessary for favorable outcomes.

Decade-Long Trends (2001-2011) in the Incidence and Hospital Death Rates Associated with the In-Hospital Development of Cardiogenic Shock after Acute Myocardial Infarction

BACKGROUND

Limited information is available about relatively contemporary trends in the incidence and hospital case-fatality rates of cardiogenic shock in patients hospitalized with acute myocardial infarction. The purpose of this population-based study was to describe decade long trends (2001-2011) in the incidence and hospital case-fatality rates for patients who developed cardiogenic shock during hospitalization for an acute myocardial infarction.

METHODS AND RESULTS

The study population consisted of 5686 residents of central Massachusetts hospitalized with acute myocardial infarction at all 11 medical centers in the Worcester, MA, metropolitan area during 6 biennial periods between 2001 and 2011, who did not have cardiogenic shock at the time of hospital presentation. On average, 3.7% of these patients developed cardiogenic shock during their acute hospitalization with nonsignificant and inconsistent trends noted over time in both crude (3.7% in 2001/2003; 4.5% in 2005/2007; 2.7% in 2009/2011; P=0.19) and multivariable adjusted analyses. The overall in-hospital case-fatality rate for patients who developed cardiogenic shock was 41.4%. The crude and multivariable adjusted odds of dying after cardiogenic shock declined during the most recent study years (47.1% dying in 2001/2003, 42.0% dying in 2005/2007, and 28.6% dying in 2009/2011). Increases in the use of evidence-based cardiac medications, and interventional procedures paralleled the increasing hospital survival trends.

CONCLUSIONS

We found suggestions of a decline in the death, but not incidence, rates of cardiogenic shock over time. These encouraging trends in hospital survival are likely because of advances in the early recognition and aggressive management of patients who develop cardiogenic shock.

In-Hospital Outcome of Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction: Results from Royal Hospital Percutaneous Coronary Intervention Registry, Oman

OBJECTIVES

Cardiogenic shock (CS) is still the leading cause of in-hospital mortality in patients presenting with acute myocardial infarction (AMI). The aim of this study was to determine the in-hospital mortality and clinical outcome in AMI patients presenting with CS in a tertiary hospital in Oman.

METHODS

This retrospective observational study included patients admitted to the cardiology department between January 2013 and December 2014. A purposive sampling technique was used, and 63 AMI patients with CS admitted to (36.5%) or transferred from a regional hospital (63.5%) were selected for the study.

RESULTS

Of 63 patients, 73% (n = 46) were Omani and 27% (n = 17) were expatriates: 79% were male and 21% were female. The mean age of patients was 60±12 years. The highest incidence of CS (30%) was observed in the 51-60 year age group. Diabetes mellitus (43%) and hypertension (40%) were the predominant risk factors. Ninety-two percent of patients had ST-elevation MI, 58.7% patients were thrombolysed, and 8% had non-ST-elevation MI. Three-quarters (75%) of CS patients had severe left ventricular systolic dysfunction (defined as ejection fraction <30%). Coronary angiogram showed single vessel disease in 17%, double vessel disease in 40%, and triple vessel disease in 32% and left main disease in 11%. The majority of the patients (93.6%) underwent percutaneous coronary intervention (PCI), among them 23 (36.5%) underwent primary PCI. In-hospital mortality was 52.4% in this study.

CONCLUSIONS

CS in AMI patients presenting to a tertiary hospital in Oman have high in-hospital mortality despite the majority undergoing PCI. Even though the in-hospital mortality is comparable to other studies and registries, there is an urgent need to determine the causes and find any remedies to provide better care for such patients, specifically concentrating on the early transfer of patients from regional hospitals for early PCI.

Acute kidney injury treated with renal replacement therapy and 5-year mortality after myocardial infarction-related cardiogenic shock: a nationwide population-based cohort study

Background

Myocardial infarction-related cardiogenic shock is frequently complicated by acute kidney injury. We examined the influence of acute kidney injury treated with renal replacement therapy (AKI-RRT) on risk of chronic dialysis and mortality, and assessed the role of comorbidity in patients with cardiogenic shock.

Methods

In this Danish cohort study conducted during 2005–2012, we used population-based medical registries to identify patients diagnosed with first-time myocardial infarction-related cardiogenic shock and assessed their AKI-RRT status. We computed the in-hospital mortality risk and adjusted relative risk. For hospital survivors, we computed 5-year cumulative risk of chronic dialysis accounting for competing risk of death. Mortality after discharge was computed with use of Kaplan-Meier methods. We computed 5-year hazard ratios for chronic dialysis and death after discharge, comparing AKI-RRT with non-AKI-RRT patients using a propensity score-adjusted Cox regression model.

Results

We identified 5079 patients with cardiogenic shock, among whom 13 % had AKI-RRT. The in-hospital mortality was 62 % for AKI-RRT patients, and 36 % for non-AKI-RRT patients. AKI-RRT remained associated with increased in-hospital mortality after adjustment for confounders (relative risk = 1.70, 95 % confidence interval (CI): 1.59–1.81). Among the 3059 hospital survivors, the 5-year risk of chronic dialysis was 11 % (95 % CI: 8–16 %) for AKI-RRT patients, and 1 % (95 % CI: 0.5–1 %) for non-AKI-RRT patients (adjusted hazard ratio: 15.9 (95 % CI: 8.7–29.3). The 5-year mortality was 43 % (95 % CI: 37–53 %) for AKI-RRT patients compared with 29 % (95 % CI: 29–31 %) for non-AKI-RRT patients. The adjusted 5-year hazard ratio for death was 1.55 (95 % CI: 1.22–1.96) for AKI-RRT patients compared with non-AKI-RRT patients. In patients with comorbidity, absolute mortality increased while relative impact of AKI-RRT on mortality decreased.

Conclusion

AKI-RRT following myocardial infarction-related cardiogenic shock predicted elevated short-term mortality and long-term risk of chronic dialysis and mortality. The impact of AKI-RRT declined with increasing comorbidity suggesting that intensive treatment of AKI-RRT should be accompanied with optimized treatment of comorbidity when possible.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1170-8) contains supplementary material, which is available to authorized users.

Correlates for mortality in patients presented with acute myocardial infarct complicated by cardiogenic shock

OBJECTIVE

This study aimed to explore the correlates for mortality in patients treated with both primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counter-pulsation (IABP).

BACKGROUND

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with high mortality rates.

METHODS

From a cohort of patients with AMI, treated with both primary PCI and IABP and who met strict definitions for CS to identify correlates associated with mortality, the study compared patients who died in-hospital to those who survived to discharge.

RESULTS

A cohort of 93 patients met the inclusion/exclusion criteria. Of them, 66.7% were male, and the average age was 64.96±13.06years. The overall in-hospital mortality rate for this cohort was 33%. The baseline characteristics were balanced save for older average age and left ventricular ejection fraction in those who died (p=0.049 and p=0.014, respectively). Insertion of IABP pre-PCI and cardiac arrest at the catheterization lab were more frequent in those who died (p=0.027 and p=0.008, respectively). The insertion of IABP pre-PCI, cardiac arrest at the cath lab, and lower ejection fraction were correlated with in-hospital mortality (ORs 2.68, 5.93, and 0.02, respectively).

CONCLUSIONS

In the era of primary PCI and IABP as standard of care in AMI complicated by CS, patients with low EF, those who necessitate IABP insertion pre-PCI, and those who necessitate cardiopulmonary resuscitation during PCI are at higher risk for in-hospital mortality and should be considered for more robust hemodynamic support devices with an attempt to improve their prognosis.

Temporal trends in the use of intraaortic balloon pump associated with percutaneous coronary intervention in the United States, 1998-2008

BACKGROUND

With conflicting evidence regarding the usefulness of intraaortic balloon pump (IABP), reports of IABP use in the United States have been inconsistent. Our objective was to examine trends in IABP usage in percutaneous coronary intervention (PCI) in the United States and to evaluate the association of IABP use with mortality.

METHODS

This is a retrospective, observational study using patient data obtained from the Nationwide Inpatient Sample database from 1998 to 2008. Patients undergoing any PCI (1,552,602 procedures) for a primary diagnosis of symptomatic coronary artery disease and acute coronary syndrome, including non-ST-elevation myocardial infarction and ST-elevation myocardial infarction, were evaluated.

RESULTS

The overall use of IABP significantly decreased during the study period from 0.99% in 1998 to 0.36% in 2008 (univariate and multivariate P for trend < .0001). Patients who received IABP had substantially higher rates of shock compared with those who did not receive IABP (38.09% vs 0.70%; P < .0001), which was associated with markedly higher inhospital mortality rates (20.31% vs 0.72%; P < .0001). However, IABP use significantly decreased in patients with shock (36.5%-13.4%) and acute myocardial infarction (2.23%-0.84%) (univariate and multivariate P for trend for both < .0001). A temporal reduction in all-cause PCI-associated mortality from 1.1% in 1998 to 0.86% in 2008 (univariate and multivariate P for trend < .0001) was also observed.

CONCLUSIONS

The utilization of IABP associated with PCI significantly decreased between 1998 and 2008 in the United States, even among patients with acute myocardial infarction and shock.

Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States

BACKGROUND

Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group.

CONCLUSIONS

The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.

What is the effect of area size when using local area practice style as an instrument?

OBJECTIVES

Discuss the tradeoffs inherent in choosing a local area size when using a measure of local area practice style as an instrument in instrumental variable estimation when assessing treatment effectiveness.

STUDY DESIGN

Assess the effectiveness of angiotensin converting-enzyme inhibitors and angiotensin receptor blockers on survival after acute myocardial infarction for Medicare beneficiaries using practice style instruments based on different-sized local areas around patients. We contrasted treatment effect estimates using different local area sizes in terms of the strength of the relationship between local area practice styles and individual patient treatment choices; and indirect assessments of the assumption violations.

RESULTS

Using smaller local areas to measure practice styles exploits more treatment variation and results in smaller standard errors. However, if treatment effects are heterogeneous, the use of smaller local areas may increase the risk that local practice style measures are dominated by differences in average treatment effectiveness across areas and bias results toward greater effectiveness.

CONCLUSION

Local area practice style measures can be useful instruments in instrumental variable analysis, but the use of smaller local area sizes to generate greater treatment variation may result in treatment effect estimates that are biased toward higher effectiveness. Assessment of whether ecological bias can be mitigated by changing local area size requires the use of outside data sources.

Interaction of chronic total occlusion and chronic kidney disease in patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

Chronic total occlusion (CTO) in a non-infarct-related artery and chronic kidney failure (CKD) are associated with worse outcomes after primary percutaneous coronary intervention (PCI). The aim of this study was to investigate the interaction of CTO and CKD in patients who underwent primary PCI for acute ST-segment elevation myocardial infarction (STEMI). Patients with STEMIs with or without CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2), were categorized into those with single-vessel disease and those with multivessel disease with or without CTO. The primary outcomes were the incidence of 30-day and 1-year mortality. Among 1,873 consecutive patients with STEMIs included between 2006 and 2011, 336 (18%) had CKD. The prevalence of CTO in a non-infarct-related artery was 13% in patients with CKD compared with 7% in those without CKD (p = 0.0003). There was a significant interaction between CKD and CTO on 30-day mortality (p = 0.018) and 1-year mortality (p = 0.013). Independent predictors of late mortality in patients with CKD were previous myocardial infarction (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.01 to 2.79), age >75 years (HR 1.86, 95% CI 1.19 to 2.95), a left ventricular ejection fraction after primary PCI <40% (HR 2.20, 95% CI 1.36 to 3.63), left main culprit artery (HR 4.46, 95% CI 1.64 to 10.25), and shock (HR 7.44, 95% CI 4.56 to 12.31), but multivessel disease with CTO was not a predictor. In contrast, multivessel disease with CTO was an independent predictor of mortality in patients without CKD (HR 3.30, 95% CI 1.70 to 6.17). In conclusion, in patients with STEMIs who underwent primary PCI, with preexisting CKD, the prevalence of CTO in a non-infarct-related artery was twice as great. In these patients, the clinical impact of CTO seems to be overshadowed by the presence of CKD.

Deadly association of cardiogenic shock and chronic total occlusion in acute ST-elevation myocardial infarction

BACKGROUND

The association between cardiogenic shock and 1 or >1 chronic total occlusion (CTO) in unselected patients presenting with ST-elevation myocardial infarction (MI) (STEMI) has not been characterized.

METHODS

Patients with STEMI referred with or without cardiogenic shock were categorized into no CTO, 1 CTO, and >1 CTO. The primary end point was the 30-day mortality.

RESULTS

Between 2006 and 2011, 2,020 consecutive patients were included. A total of 141 patients (7%) presented with cardiogenic shock on admission. The prevalence of 1 CTO and >1 CTO in a non-infarct-related artery was 23% and 5%, respectively, among patients with shock compared with 6% and 0.5% in patients without shock (P < .0001). Independent predictors of cardiogenic shock included left main-related MI (odds ratio [OR] 6.55, 95% CI 1.39-26.82, P = .019), CTO (OR 4.20, 95% CI 2.64-6.57, P < .001), creatinine clearance <60 mL/min (OR 3.41, 95% CI 2.32-4.99, P < .0001), and left anterior descending-related MI (OR 2.20, 95% CI 1.51-3.23, P < .0001). Thirty-day mortality was 100% in shock patients with >1 CTO, 65.6% with 1 CTO, and 40.2% in patients without CTO (P < .0001). After adjustment for left ventricular ejection fraction and renal function, CTO remained an independent predictor for 30-day mortality (hazard ratio [HR] 1.83; 95% CI 1.10-3.01, P = .02).

CONCLUSION

In patients with STEMI, CTO was strongly associated with cardiogenic shock on admission. In this setting, mortality was substantially higher in patients with 1 CTO and exceedingly high in those with >1 CTO. The presence of CTO was an independent predictor of early mortality.

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries

AIM

The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS.

METHOD AND RESULTS

Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival.

CONCLUSIONS

Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.

Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy

Ischemic cardiogenic shock is a complex, self-perpetuating pathological process that frequently causes death irrespective of medical therapy. Early definition of coronary anatomy is a pivotal step towards survival. Those destined to develop shock are likely to have three-vessel or left main stem disease with previously impaired left ventricular function. Early reperfusion of the occluded artery can limit infarct size, but ischemia-reperfusion injury or the 'no-reflow' phenomenon can preclude improvement in myocardial contractility. Emergence of shock depends upon the volume of ischemic myocardium, stroke volume, and peripheral vascular resistance. If cytokine release triggers the systemic inflammatory response, systemic vascular resistance falls and inadequate coronary perfusion pressure heralds the downward spiral. Survival depends on early recognition of shock, followed by aggressive targeted treatment of left, right, or biventricular failure. The goal is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial pressure, which is achieved with inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption, and extended ischemia. The value of intra-aortic balloon counter-pulsation is now questioned in patients with advanced shock. When mean arterial pressure is <55 mmHg with serum lactate >11 mmol/l, death is likely and mechanical circulatory support becomes the only chance for survival.

Trends in Q-wave acute myocardial infarction case fatality from 1978 to 2007 and analysis of the effectiveness of different treatments

BACKGROUND

We sought to analyze the trends in first Q-wave acute myocardial infarction (AMI) case fatality from 1978 to 2007 in a population-based hospital register, to determine the variables related to these changes, and to assess the effectiveness of current AMI management.

METHODS

Population-based hospital registry included patients with first Q-wave AMI aged 25 to 74 years admitted between 1978 and 2007. Sociodemographic and clinical characteristics, treatments, and procedures used during hospital stay, and 28-day case fatality were recorded. Logistic regression was used for multivariate analysis of six 5-year periods.

RESULTS

The 30-year study included 3,982 patients. Mean 28-day case fatality was 8.96%, with a decreasing trend from 16.6% in the first 5-year period to 4.7% in the sixth (P for trend < .001). Study period was independently associated with case fatality. Case-fatality reduction attributable to pharmacologic treatments was 51% overall; in 24-hour survivors, pharmacologic treatments and broad use of invasive procedures explained 39% and 38%, respectively, of the difference between the observed case fatality in 2003-2007 and 1978-1982.

CONCLUSION

A dramatic decrease in 28-day case fatality occurred during this 30-year period and was mainly related to the use of antiplatelet drugs, β-blockers, thrombolysis, and invasive procedures. These data support the current guidelines for the management of acute coronary syndrome.

Cardiogenic shock and heart failure post-percutaneous coronary intervention in ST-elevation myocardial infarction: observations from "Assessment of Pexelizumab in Acute Myocardial Infarction"

BACKGROUND

Mortality after ST-elevation myocardial infarction (STEMI) has reduced with reperfusion by primary percutaneous coronary intervention (PCI), which may have impacted on the adverse outcomes of cardiogenic shock (CS) and congestive heart failure (CHF).

METHODS AND RESULTS

In the APEX-AMI trial, 5,745 patients with STEMI and planned primary PCI were randomly assigned pexelizumab or matching placebo. Post-randomization CS or CHF was adjudicated by a clinical endpoints committee. Treatment assignment to pexelizumab did not influence either endpoint or mortality rates. Cardiogenic shock developed in 196 patients (3.4%) at a median of 6.0 hours (interquartile range 3.9-28.3) post-randomization, and mortality at 90 days was 54.6%. Congestive heart failure occurred in 254 of patients (4.4%) at a median of 2.6 days (IQR 1.0-16.6), and mortality through 90 days was 10.2%; mortality among those with neither endpoint was 2.1%. Patients with CS or CHF were older, were more often female, and had more hypertension and diabetes, but smoked less compared with non-CS/CHF patients (all P < .05). Independent mortality predictors among those with CS or CHF were hyperlipidemia and a history of angina (interaction P = .011 and .008, respectively); procedural predictors among survivors to PCI were pre-PCI Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 and post-PCI TIMI flow <3 (P = .013 and <.0001, respectively).

CONCLUSIONS

Survival after CS remains poor despite aggressive reperfusion. Both CS and CHF remain the major causes of death among STEMI patients undergoing primary PCI. Future studies should examine treatments that aim to reduce mortality in these highest risk patients.

Temporal Trends in Cardiogenic Shock Treatment and Outcomes Among Ontario Patients With Myocardial Infarction Between 1992 and 2008

Background—

Clinical trials have demonstrated that emergent revascularization improves survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). However, rates of uptake and impact on outcomes remain uncertain.

Methods and Results—

We identified 9750 patients (3.1%) with CS among 311 183 AMI patients in the Ontario Myocardial Infarction Database between 1992 and 2008 (55.8% men; mean age, 73 years). CS incidence, mortality, revascularization, and transfers from nonrevascularization sites were studied over 3 periods: period 1, before the 1999 American College of Cardiology/American Heart Association AMI guidelines recommending urgent revascularization for patients <75 years; period 2 (1999 to 2004); and period 3, after 2004 guideline revisions suggesting revascularization for patients ≥75 years. Compared with period 1, period 3 was marked by significantly lower CS incidence (3.4% versus 2.6%), increase in transfers from nonrevascularization sites (10.6% versus 23.9%), and adjusted 1-year mortality rates (81.9% versus 71.5%; all comparisons statistically significant). Admission to nonrevascularization sites was associated with lower revascularization rates (8.6% versus 46.6%, P <0.001) and higher adjusted 1-year mortality rates (78.8% [95% confidence interval, 77.4 to 80.2] versus 71.9% [95% confidence interval, 69.8 to 74.1]). Patients ≥75 years of age were less likely to be revascularized or transferred. The greatest increase in transfers from nonrevascularization sites occurred between periods 1 and 2 for patients <75 years (16.5% to 31.4%; P <0.001) and between periods 2 and 3 for patients ≥75 years (6.7% to 12.8%; P <0.001).

Conclusions—

Publication of American College of Cardiology/American Heart Association guidelines was followed by increased revascularization and transfer rates, along with declining mortality rates among Ontario AMI patients with CS. These results highlight possibilities for further improvement, particularly among patients eligible for transfer from nonrevascularization sites.

Impact of the post-World War II generation on intensive care needs in Norway

BACKGROUND

A high birth rate during the first two decades following World War II has increased the proportion of elderly people in present-day society and, consequently, the demand for health-care services. The impact on intensive care services may become dramatic because the age distribution of critically ill patients is skewed towards the elderly. We have used registry data and population statistics to forecast the demand for intensive care services in Norway up until the year 2025.

METHODS

Data collected by the Norwegian intensive care registry (NIR), showing the age distribution in Norwegian intensive care units (ICU) during the years 2006 and 2007, were used with three different Norwegian prognostic models of population growth for the years 2008-2025 to compute the expected increase in intensive care unit bed-days (ICU bed-days).

RESULTS

The elderly were overrepresented in Norwegian ICUs in 2006-2007, with patients from 60 to 79 years of age occupying 44% of ICU bed-days. Population growth from 2008 to 2025 was estimated to be from 11.1 to 26.4%, depending on the model used. Growth will be much larger in the age group 60-79 years. Other factors kept unchanged, this will result in an increase in the need for intensive care (ICU bed-days) of between 26.1 and 36.9%.

CONCLUSION

The demand for intensive care beds will increase markedly in Norwegian hospitals in the near future. This will have serious implications for the planning of infrastructure, education of health care personnel, as well as financing of our health care system.

Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission

OBJECTIVE

To evaluate the clinical and prognostic relevance of acute kidney injury (AKI) in the setting of ST-elevation acute myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

DESIGN

Prospective study.

SETTING

Single-center study, 13-bed intensive cardiac care unit at a University Cardiological Center.

PATIENTS

Ninety-seven consecutive STEMI patients with CS at admission, undergoing intra-aortic balloon pump (IABP) support and primary percutaneous coronary intervention (PCI).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured serum creatinine at baseline and each day for the following 3 days. Acute kidney injury was defined as a rise in creatinine >25% from baseline. Overall, AKI occurred in 52 (55%) patients, and in 12 of these patients, a renal replacement therapy was required. In multivariate analysis, age >75 yrs (p = .005), left ventricular ejection fraction < or = 40% (p = .009), and use of mechanical ventilation (p = .01) were independent predictors of AKI. Patients developing AKI had a longer hospital stay, a more complicated clinical course, and significantly higher mortality rate (50% vs. 2.2%; p <.001) than patients without AKI. In our population, AKI was the strongest independent predictor of in-hospital mortality (relative risk 12.3, 95% confidence intervals 1.78 to 84.9; p <.001).

CONCLUSIONS

In patients with STEMI complicated by CS, AKI represents a frequent clinical complication associated with a poor prognosis.

Predictors of 30-day mortality in patients with refractory cardiogenic shock following acute myocardial infarction despite a patent infarct artery

BACKGROUND

Little is known about predictors of survival in patients with persistent shock following acute myocardial infarction (MI) despite a patent infarct artery.

METHODS

We examined data from TRIUMPH, a multicenter randomized clinical trial of the nitric oxide synthase inhibitor, L-N(G)-monomethyl-arginine, in patients with persistent vasopressor-dependent cardiogenic shock complicating acute MI at least 1 hour after established infarct-related artery patency. Patients who died within 30 days were compared with those who survived. Continuous variables were assessed using the Wilcoxon rank sum and categorical variables using the chi(2) test. Prespecified baseline variables were included in a multivariable logistic regression model to predict mortality. A second model incorporating baseline vasopressors and dosages and a third model including change in systolic blood pressure at 2 hours were also developed. Bootstrapping was used to assess the stability of model variables.

RESULTS

Of 396 patients, 180 (45.5%) died within 30 days. Systolic blood pressure (SBP), measured on vasopressor support, and creatinine clearance were significant predictors of mortality in all models. The number of vasopressors and norepinephrine dose were also predictors of mortality in the second model, but the latter was no longer significant when change in SBP at 2 hours was added as a covariate in the third model.

CONCLUSIONS

The SBP, creatinine clearance, and number of vasopressors are significant predictors of mortality in patients with persistent vasopressor-dependent cardiogenic shock following acute MI despite a patent infarct artery. These prognostic variables may be useful for risk-stratification and in selecting patients for investigation of additional therapies.

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

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.