Echocardiographic and angiographic correlations in patients with cardiogenic shock secondary to acute myocardial infarction

Transthoracic echocardiography compared with coronary angiography for patients with cardiogenic shock: A prospective cohort study

Cardiogenic shock is the most severe form of acute heart failure. The aim of the current study was to investigate correlations between diagnostic parameters and the estimated ejection fraction in patients with cardiogenic shock. A total of 2,445 patients with acute myocardial infarction were subjected to coronary angiograms and standard 2D transthoracic echocardiography. Information for culprit vessel(s) and mitral regurgitation were collected. The Spearman's correlation test was used to assess the correlation between diagnostic parameters and estimated ejection fractions at a 95% confidence level. The angiographically-derived numbers of culprit vessels had a significant correlation with mitral regurgitation (r=0.907; P=0.034). The echocardiographically-derived mitral regurgitation was significantly correlated with the numbers of culprit vessels (r=0.896; P=0.04). Positive correlation was established between angiographically- and echocardiographically-measured left ventricular ejection fraction (r=0.356; P=0.045). The numbers of culprit vessels (P=0.058) and mitral regurgitation (r=0.99; P=0.001) were similar for angiography and echocardiography. Echocardiography- and angiography-derived results were correlated with the estimated ejection fractions of patients with cardiogenic shock. However, there is a substantial difference in the procedures of the two operational techniques.

Evaluation and management of shock States: hypovolemic, distributive, and cardiogenic shock

Shock states have multiple etiologies, but all result in hypoperfusion to vital organs, which can lead to organ failure and death if not quickly and appropriately managed. Pharmacists should be familiar with cardiogenic, distributive, and hypovolemic shock and should be involved in providing safe and effective medical therapies. An accurate diagnosis is necessary to initiate appropriate lifesaving interventions and target therapeutic goals specific to the type of shock. Clinical signs and symptoms, as well as hemodynamic data, help with initial assessment and continued monitoring to provide adequate support for the patient. It is necessary to understand these hemodynamic parameters, medication mechanisms of action, and available mechanical support when developing a patient-specific treatment plan. Rapid therapeutic intervention has been proven to decrease morbidity and mortality and is crucial to providing the best patient outcomes. Pharmacists can provide their expertise in medication selection, titration, monitoring, and dose adjustment in these critically ill patients. This review will focus on parameters used to assess hemodynamic status, the major causes of shock, pathophysiologic factors that cause shock, and therapeutic interventions that should be employed to improve patient outcomes.

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.

Cardiogenic shock

Cardiogenic shock is the most common cause of death in patients hospitalized with acute myocardial infarction and is associated with a poor prognosis. More than 75% of cases are due to extensive left ventricular infarction and ventricular failure. Other causes include right ventricular infarction and papillary muscle rupture with acute severe mitral regurgitation. Activation of neurohormonal systems and the systemic inflammatory response worsens shock. To improve outcomes, cardiogenic shock needs to be recognized early in its course and its cause needs to be diagnosed rapidly. Treatment strategies using intra-aortic balloon counterpulsation and emergency revascularization by percutaneous coronary interventions or coronary bypass surgery have been shown to improve outcomes. To decrease the incidence of cardiogenic shock, public education regarding early presentation to hospital in the course of acute chest pain is important. Emergency medical transport systems may need to take patients with complicated acute myocardial infarction to hospitals with the capability to perform urgent revascularization.