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Kochar A, Vallabhajosyula S, John K, Sinha SS, Esposito M, Pahuja M, Hirst C, Li S, Kong Q, Li B, Natov P, Kanwar M, Hernandez-Montfort J, Garan R, Walec K, Zazzali P, Sangal P, Ton VK, Zweck E, Kataria R, Guglin M, Vorovich E, Nathan S, Abraham J, Harwani NM, Hickey GW, Wencker D, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Blumer V, Faugno A, Burkhoff D, Kapur NK. Factors associated with Acute Limb Ischemia in Cardiogenic Shock and downstream Clinical Outcomes: Insights from the Cardiogenic Shock Working Group. J Heart Lung Transplant 2024:S1053-2498(24)01705-4. [PMID: 38944132 DOI: 10.1016/j.healun.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/29/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND There are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients. METHODS We employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality. RESULTS There were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% versus 29.4%) and have peripheral arterial disease (13.8% versus 8.3%). Stratified by maximum SCAI shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53 - 3.23; p < 0.01) and ≥ 2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24 - 2.21, p < 0.01). ALI was highest for VA-ECMO patients (11.6%) or VA-ECMO + IABP/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01 - 1.95, p < 0.01). CONCLUSIONS The rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.
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Affiliation(s)
| | | | - Kevin John
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | | | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | - Colin Hirst
- St. Peter's Health Partners Medical Associates, Albany, NY
| | - Song Li
- Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, TX
| | - Qiuyue Kong
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Natov
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Manreet Kanwar
- Cardiovascular Instittue at Allegheny Health Network, Pittsburgh, PA
| | | | - Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Karol Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA
| | - Elric Zweck
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rachna Kataria
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI
| | - Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Esther Vorovich
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, IL
| | | | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Detlef Wencker
- Baylor Scott & White Health, Advanced Heart Failure Program Clinic, Temple, TX
| | | | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | - Anthony Faugno
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA.
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Zuccarelli V, Andreaggi S, Walsh JL, Kotronias RA, Chu M, Vibhishanan J, Banning AP, De Maria GL. Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention? J Clin Med 2024; 13:2923. [PMID: 38792463 PMCID: PMC11122374 DOI: 10.3390/jcm13102923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.
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Affiliation(s)
- Vittorio Zuccarelli
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Jason L. Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Miao Chu
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Jonathan Vibhishanan
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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Saito Y, Inohara T, Kohsaka S, Muramatsu T, Ishii H, Yamaji K, Amano T, Kobayashi Y, Kozuma K. Door-to-Balloon Time and Mortality in STEMI With Cardiogenic Shock: A Nationwide Registry. JACC. ASIA 2024; 4:421-422. [PMID: 38765661 PMCID: PMC11099802 DOI: 10.1016/j.jacasi.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Affiliation(s)
- Yuichi Saito
- Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taku Inohara
- Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Keio University School of Medicine, Tokyo, Japan
| | | | - Hideki Ishii
- Gunma University Graduate School of Medicine, Gunma, Japan
| | | | | | | | - Ken Kozuma
- Teikyo University Hospital, Tokyo, Japan
| | - The J-PCI Registry Investigators
- Chiba University Graduate School of Medicine, Chiba, Japan
- Keio University School of Medicine, Tokyo, Japan
- Fujita Health University Hospital, Toyoake, Japan
- Gunma University Graduate School of Medicine, Gunma, Japan
- Kyoto University, Kyoto, Japan
- Aichi Medical University, Nagakute, Japan
- Teikyo University Hospital, Tokyo, Japan
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van Diepen S, Zheng Y, Senaratne JM, Tyrrell BD, Das D, Thiele H, Henry TD, Bainey KR, Welsh RC. Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times. Circ Cardiovasc Interv 2024; 17:e013415. [PMID: 38293830 DOI: 10.1161/circinterventions.123.013415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times. METHODS In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation. RESULTS Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08). CONCLUSIONS In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Janek M Senaratne
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | | | - Debraj Das
- CK Hui Heart Center, Edmonton, Alberta, Canada (B.D.T., D.D.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Germany (H.T.)
| | - Timothy D Henry
- Carl and Edyth Lindner Research Center at the Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Kevin R Bainey
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
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5
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Bloom JE, Wong N, Nehme E, Dawson LP, Ball J, Anderson D, Cox S, Chan W, Kaye DM, Nehme Z, Stub D. Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:89-98. [PMID: 36808236 DOI: 10.1093/ehjqcco/qcad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023]
Abstract
AIMS The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). METHODS AND RESULTS This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. CONCLUSION This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shelley Cox
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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Nishihira K, Honda S, Takegami M, Kojima S, Takahashi J, Itoh T, Watanabe T, Yamashita J, Saji M, Tsujita K, Takayama M, Sumiyoshi T, Kimura K, Yasuda S. Percutaneous coronary intervention for ST-elevation myocardial infarction complicated by cardiogenic shock in a super-aging society. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:847-855. [PMID: 37724765 DOI: 10.1093/ehjacc/zuad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/07/2023] [Accepted: 09/14/2023] [Indexed: 09/21/2023]
Abstract
AIMS ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMICS) is associated with substantial mortality. As life expectancy increases, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study sought to investigate the characteristics and impact of PCI on in-hospital mortality in patients with STEMICS. METHODS AND RESULTS The Japan AMI Registry (JAMIR) is a retrospective, nationwide, real-world database. Among 46 242 patients with AMI hospitalized in 2011-2016, 2760 patients with STEMICS (median age, 72 years) were studied. We compared 2396 (86.8%) patients who underwent PCI with 364 (13.2%) patients who did not. The percentage of mechanical circulatory support use in patients with STEMICS was 69.3% and in-hospital mortality was 34.6%. Compared with patients who did not undergo PCI, patients undergoing PCI were younger and had a higher rate of intra-aortic balloon pump use. A higher proportion was male or current smokers. In-hospital mortality was significantly lower in the PCI group than in the no-PCI group (31.3% vs. 56.0%, P < 0.001). Percutaneous coronary intervention was independently associated with lower in-hospital mortality [adjusted odds ratio (OR), 0.508; 95% confidence interval (CI), 0.347-0.744]. In 789 (28.6%) patients aged ≥80 years, PCI was associated with fewer in-hospital cardiac deaths (adjusted OR, 0.524; 95% CI, 0.281-0.975), but was not associated with in-hospital mortality (adjusted OR, 0.564; 95% CI, 0.300-1.050). CONCLUSION In Japan, PCI was effective in reducing in-hospital cardiac death in elderly patients with STEMICS. Age alone should not preclude potentially beneficial invasive therapy.
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Affiliation(s)
- Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki 880-2102, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Public Health and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sunao Kojima
- Department of Cardiology, Sakura-jyuji Yatsushiro Rehabilitation Hospital, Kumamoto, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomonori Itoh
- Division of Community Medicine, Department of Medical Education/Division of Cardiology, Department of Medicine, Iwate Medical University, Morioka, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | | | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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7
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Solangi BA, Shah JA, Kumar R, Batra MK, Ali G, Butt MH, Nisar A, Qamar N, Saghir T, Sial JA. Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock. World J Cardiol 2023; 15:439-447. [PMID: 37900262 PMCID: PMC10600783 DOI: 10.4330/wjc.v15.i9.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates. Primary percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with CS. AIM To investigate the immediate mortality rates in patients with CS undergoing primary PCI and identify mortality predictors. METHODS We conducted a retrospective analysis of 305 patients with CS who underwent primary PCI at the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between January 2018 and December 2022. The primary outcome was immediate mortality, defined as mortality within index hospitalization. Univariate and multivariate logistic regression analyses were performed to identify predictors of immediate mortality. RESULTS In a sample of 305 patients with 72.8% male patients and a mean age of 58.1 ± 11.8 years, the immediate mortality rate was found to be 54.8% (167). Multivariable analysis identified Killip class IV at presentation [odds ratio (OR): 2.0; 95% confidence interval (CI): 1.2-3.4; P = 0.008], Multivessel disease (OR: 3.5; 95%CI: 1.8-6.9; P < 0.001), and high thrombus burden (OR: 2.6; 95%CI: 1.4-4.9; P = 0.003) as independent predictors of immediate mortality. CONCLUSION Immediate mortality rate in patients with CS undergoing primary PCI remains high despite advances in treatment strategies. Killip class IV at presentation, multivessel disease, and high thrombus burden (grade ≥ 4) were identified as independent predictors of immediate mortality. These findings underscore the need for aggressive management and close monitoring of patients with CS undergoing primary PCI, particularly in those with these high-risk characteristics.
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Affiliation(s)
- Bashir Ahmed Solangi
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan.
| | - Jehangir Ali Shah
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Rajesh Kumar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Mahesh Kumar Batra
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Gulzar Ali
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Muhammad Hassan Butt
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Ambreen Nisar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Nadeem Qamar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Tahir Saghir
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Jawaid Akbar Sial
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
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Kochan A, Lee T, Moghaddam N, Milley G, Singer J, Cairns JA, Wong GC, Jentzer JC, van Diepen S, Alviar C, Fordyce CB. Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock. Circ Cardiovasc Interv 2023; 16:e012810. [PMID: 37339233 DOI: 10.1161/circinterventions.122.012810] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. METHODS We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. RESULTS 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. CONCLUSIONS Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.
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Affiliation(s)
- Andrew Kochan
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - Nima Moghaddam
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Grace Milley
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - John A Cairns
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (J.C.J.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Canada (S.v.D.)
| | - Carlos Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY (C.A.)
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
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9
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Miyachi H, Yamamoto T, Takayama M, Miyauchi K, Yamasaki M, Tanaka H, Yamashita J, Kishi M, Higuchi S, Abe K, Mase T, Shinke T, Yahagi K, Wakabayashi K, Asano T, Minatsuki S, Saji M, Iwata H, Mitsuhashi Y, Ito R, Kondo S, Shimizu W, Nagao K. 10-Year Temporal Trends of In-Hospital Mortality and Emergency Percutaneous Coronary Intervention for Acute Myocardial Infarction. JACC: ASIA 2022; 2:677-688. [PMID: 36444314 PMCID: PMC9700040 DOI: 10.1016/j.jacasi.2022.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/13/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
Abstract
Background The mortality rate of acute myocardial infarction (AMI) has improved dramatically because of reperfusion therapy during the last 40 years; however, recent temporal trends for AMI have not been fully clarified in Japan. Objectives The purpose of this study was to elucidate the temporary trend in in-hospital mortality and treatment of AMI for the last decade in the Tokyo Metropolitan area. Methods We enrolled 30,553 patients from the Tokyo Cardiovascular Care Unit Network Registry, diagnosed with AMI from 2007 to 2016, as part of an ongoing, multicenter, cohort study. We analyzed the temporal trends in basic characteristics, treatment, and in-hospital mortality of AMI. Results The overall emergency percutaneous coronary intervention (PCI) rate significantly increased (P < 0.001). In particular, it remarkably increased in patients older than 80 years of age (58.3% to 70.3%, P < 0.001) and patients with Killip III or IV (Killip III, 46.9% to 65.7%; Killip IV, 65.2% to 76.6%, P < 0.001 for both). The crude and age-adjusted in-hospital mortality remained low (5.2% to 8.2% and 3.4% to 5.5%, respectively) and significantly decreased during the decade (P < 0.001). The in-hospital mortality remarkably decreased in patients older than 80 years of age (17.3% to 12.7%, P < 0.001) and in those with cardiogenic shock (38.5% to 27.3%, P < 0.001). Conclusions This large cohort study from Tokyo revealed that in-hospital mortality of AMI significantly decreased with the increase in emergency percutaneous coronary intervention rate over the decade, particularly for high-risk patients such as older patients and those with cardiogenic shock.
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10
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Hao K, Takahashi J, Sato K, Suda A, Sindo T, Godo S, Nishimiya K, Kikuchi Y, Shiroto T, Yasuda S. The influence of COVID-19 pandemic on management of acute myocardial infarction in Japan; Insight from the Miyagi AMI Registry Study. IJC HEART & VASCULATURE 2022; 43:101116. [PMID: 36127895 PMCID: PMC9477968 DOI: 10.1016/j.ijcha.2022.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022]
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11
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Solomonchuk A, Rasputina L, Didenko D. PREVALENCE, CLINICAL AND FUNCTIONAL CHARACTERISTICS OF PATIENTS WITH ACUTE MYOCARDIAL INFARCTION COMPLICATED BY ACUTE HEART FAILURE. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1741-1746. [PMID: 35962691 DOI: 10.36740/wlek202207124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The aim: The study was designed to establish the prevalence of acute heart failure in patients with acute myocardial infarction, to determine the sex-age characteristics of acute myocardial infarction course in case of complications by acute heart failure of high classes (Killip III and Killip IV). PATIENTS AND METHODS Materials and methods: We analyzed medical records of inpatients of the myocardial infarction department of the municipal non-profit enterprise Vinnytsia Regional Center for Cardiovascular Pathology in 2019. The survey covered 828 medical records of patients with acute myocardial infarction, average age (64.6 ± 0.38), including 569 (64.7%) males and 311 (35.3%) females. RESULTS Results: 129 (15.6%) patients with acute myocardial infarction were diagnosed high-class acute heart failure. Patients with high-class acute heart failure were statistically significantly elderly individuals of the average age (69.0 ± 1.3), (p <0.001), including 53.7% of males, and 46.3% (p <0.001) female patients. Patients with acute myocardial infarction complicated by acute heart failure were hospitalized within 2 hours of symptoms` onset with statistically significantly higher probability (p = 0.004). Patients with acute myocardial infarction complicated by acute high-class heart failure were statistically significantly more likely diagnosed with concomitant hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease than individuals with uncomplicated acute myocardial infarction. Acute myocardial infarction patients` mortality was 3.4%, while the one in patients with acute heart failure was 38% (p <0.001). CONCLUSION Conclusions: Patients with complicated myocardial infarction are characterized by statistically significantly higher comorbidity and increased lethality.
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Affiliation(s)
| | - Lesya Rasputina
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | - Daria Didenko
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
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12
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Fanaroff AC, Nathan AS. Percutaneous Coronary Intervention in Acute Coronary Syndrome and Cardiogenic Shock: Ensuring Access While Maintaining Quality. JACC Cardiovasc Interv 2022; 15:887-889. [PMID: 35450688 DOI: 10.1016/j.jcin.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA.
| | - Ashwin S Nathan
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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13
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Yagi Y, Mizunoya K, Mori T, Saito H, Morimoto Y. Intraoperative myocardial infarction and refractory cardiogenic shock during major hepatectomy: a case report. JA Clin Rep 2022; 8:19. [PMID: 35266074 PMCID: PMC8907374 DOI: 10.1186/s40981-022-00510-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
Abstract
Background Myocardial infarction (MI) complicated by cardiogenic shock during non-cardiac surgery is a rare but fatal complication. The management of intraoperative MI is challenging. Case presentation A 77-year-old hypertensive man with good functional capacity was scheduled for hepatectomy. After the start of liver resection, the electrocardiogram monitor showed ST depression, and the patient developed refractory cardiogenic shock. Transesophageal echocardiography revealed severe hypokinesis of the anteroseptal wall. The surgery was suspended, and an intra-aortic balloon pump was placed following immediate abdominal closure. Coronary angiography revealed severe stenosis of the left main coronary trunk, and percutaneous coronary intervention (PCI) was performed. Myocardial wall motion improved, and blood pressure stabilized. Two days after PCI, hepatectomy, which had been suspended, was successfully completed. Conclusions Once intraoperative MI has occurred, early diagnosis and multidisciplinary approaches are important to manage the difficult clinical situation.
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Affiliation(s)
- Yasunori Yagi
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Kazuyuki Mizunoya
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Toshihiro Mori
- Department of Anesthesiology, Sapporo City Hospital, N11, W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
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14
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Tehrani BN, Damluji AA, Batchelor WB. Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories. Curr Cardiol Rev 2022; 18:e251121198293. [PMID: 34823461 PMCID: PMC9413732 DOI: 10.2174/1573403x17666211125090929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 11/22/2022] Open
Abstract
Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.
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Affiliation(s)
- Behnam N Tehrani
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| | - Abdulla A Damluji
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Wayne B Batchelor
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
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15
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Proudfoot AG, Kalakoutas A, Meade S, Griffiths MJD, Basir M, Burzotta F, Chih S, Fan E, Haft J, Ibrahim N, Kruit N, Lim HS, Morrow DA, Nakata J, Price S, Rosner C, Roswell R, Samaan MA, Samsky MD, Thiele H, Truesdell AG, van Diepen S, Voeltz MD, Irving PM. Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach. Circ Heart Fail 2021; 14:e008635. [PMID: 34807723 PMCID: PMC8692411 DOI: 10.1161/circheartfailure.121.008635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
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Affiliation(s)
- Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
- Department of Anaesthesiology & Intensive Care, German Heart Centre Berlin, Germany
- Queen Mary University of London, London, UK
- Corresponding author: Alastair Proudfoot, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, Mobile: 07779011194,
| | | | - Susanna Meade
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Mark JD Griffiths
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mir Basir
- Department of Cardiology, Henry Ford Health System, Detroit, MI USA
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine and Division of Respirology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Natalie Kruit
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Hoong Sern Lim
- Department of Cardiology, University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - David A. Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Mark A Samaan
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Marc D. Samsky
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Peter M Irving
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King’s College London, UK
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16
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Thiele H, de Waha-Thiele S, Freund A, Zeymer U, Desch S, Fitzgerald S. Management of cardiogenic shock. EUROINTERVENTION 2021; 17:451-465. [PMID: 34413010 PMCID: PMC9724885 DOI: 10.4244/eij-d-20-01296] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.
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Affiliation(s)
- Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Strümpellstr. 39, 04289 Leipzig, Germany
| | | | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Sean Fitzgerald
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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17
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Kiefer JJ, Augoustides JG. Acute Myocardial Infarction With Cardiogenic Shock: - Navigating the Invasive Options in Clinical Management. J Cardiothorac Vasc Anesth 2021; 35:3154-3157. [PMID: 34373181 DOI: 10.1053/j.jvca.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jesse J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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18
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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19
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Alrawashdeh A, Nehme Z, Williams B, Smith K, Brennan A, Dinh DT, Liew D, Lefkovits J, Stub D. Impact of emergency medical service delays on time to reperfusion and mortality in STEMI. Open Heart 2021; 8:openhrt-2021-001654. [PMID: 33963080 PMCID: PMC8108686 DOI: 10.1136/openhrt-2021-001654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives To explore the relationship between emergency medical service (EMS) delay time, overall time to reperfusion and clinical outcome in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods This was a retrospective observational study of 2976 patients with STEMI who presented to EMS and underwent PPCI between January 2014 and December 2017. We performed multivariable logistic models to assess the relationship between EMS delay time and 30-day mortality and to identify factors associated with system delay time. Results EMS delay time accounted for the first half of total system delay (median=59 min (IQR=48–77)). Compared with those who survived, those who died had longer median EMS delay times (59 (IQR=11–74) vs 74 (IQR=57–98), p<0.001). EMS delay time was independently associated with a higher risk of mortality (adjusted OR 1.20; 95% CI 1.02 to 1.40, for every 30 min increase), largely driven by complicated patients with cardiogenic shock or cardiac arrest. Independent predictors of longer EMS delay times were older age, women, cardiogenic shock, cardiac arrest, prehospital notification and intensive care management. Although longer EMS delay times were associated with shorter door-to-balloon times, total system delay times increased with increasing EMS delay times. Conclusion Increasing EMS delay times, particularly those result from haemodynamic complications, increase total time to reperfusion and are associated with 30-day mortality after STEMI. All efforts should be made to monitor and reduce EMS delay times for timely reperfusion and better outcome.
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Affiliation(s)
- Ahmad Alrawashdeh
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziad Nehme
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Brett Williams
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Alfred Hospital, Prahran, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia .,Alfred Hospital, Prahran, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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20
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Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Piña IL, Kapur NK, Dangas GD. Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e815-e829. [DOI: 10.1161/cir.0000000000000959] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.
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21
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Schrage B, Becher PM, Goßling A, Savarese G, Dabboura S, Yan I, Beer B, Söffker G, Seiffert M, Kluge S, Kirchhof P, Blankenberg S, Westermann D. Temporal trends in incidence, causes, use of mechanical circulatory support and mortality in cardiogenic shock. ESC Heart Fail 2021; 8:1295-1303. [PMID: 33605565 PMCID: PMC8006704 DOI: 10.1002/ehf2.13202] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/23/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
Aim The management of cardiogenic shock remains a clinical challenge even in well‐developed healthcare systems, best illustrated by its high mortality despite numerous innovative proposals for management. The aim of this study was to describe temporal trends in incidence, causes, use of mechanical circulatory support, and mortality in cardiogenic shock in Germany. Methods and results Data on all cardiogenic shock patients treated in German hospitals between 2005 and 2017 were obtained from the Federal Bureau of Statistics. The data set comprised 441 696 patients with cardiogenic shock, mean age 71 (±13.8) years, 171 383 (39%) female patients. Incidence rates increased from 33.1/100 000 population in 2005 (27 246 cases) to 51.7/100 000 population in 2017 (42 779 cases). Acute myocardial infarction was the most common cause of cardiogenic shock in 2005–07 (43 422 of 82 037 cases, 52.9%), but the proportion of cases caused by it decreased until 2014–17 (73 274 of 165 873 cases, 44.2%). Over time, intra‐aortic balloon pump (2005: 5104; 2017: 973 cases) was used less frequently, whereas use of extracorporeal‐membrane‐oxygenation (2007: 35; 2017: 2414 cases) and percutaneous left ventricular assist devices (2005: 27; 2017: 1323 cases) increased. Mortality remained high at around 60% without relevant temporal trends in patients without acute myocardial infarction and slightly decreased in patients with acute myocardial infarction. Conclusions In this large, nation‐wide study, annual incidence of cardiogenic shock was growing, its causes were changing, and mortality was high despite a shift towards use of novel mechanical circulatory support devices. This highlights the need to address the evidence gap in this field, in particular for cardiogenic shock caused by diseases other than acute myocardial infarction.
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Affiliation(s)
- Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Peter Moritz Becher
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Salim Dabboura
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Isabell Yan
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Benedikt Beer
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Martinistr. 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
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22
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Predictors of Hospital Mortality in Patients with Acute Coronary Syndrome Complicated by Cardiogenic Shock. SENSORS 2021; 21:s21030969. [PMID: 33535491 PMCID: PMC7867036 DOI: 10.3390/s21030969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/17/2022]
Abstract
As demonstrated by earlier studies, pre-hospital triage with trans-telephonic electrocardiogram (TTECG) and direct referral for catheter therapy shows great value in the management of out-of-hospital chest pain emergencies. It does not only improve in-hospital mortality in ST-segment elevation myocardial infarction, but it has also been identified as an independent predictor of higher in-hospital survival rate. Since TTECG-facilitated triage shortens both transport time and percutaneous coronary intervention (PCI)-related procedural time intervals, it was hypothesized that even high-risk patients with acute coronary syndrome (ACS) and cardiogenic shock (CS) might also benefit from TTECG-based triage. Here, we decided to examine our database for new triage- and left ventricular (LV) function-related parameters that can influence in-hospital mortality in ACS complicated by CS. ACS patients were divided into two groups, namely, (1) hospital death patients (n = 77), and (2) hospital survivors (control, n = 210). Interestingly, TTECG-based consultation and triage of CS and ACS patients were confirmed as significant independent predictors of lower hospital mortality risk (odds ratio (OR) 0.40, confidence interval (CI) 0.21–0.76, p = 0.0049). Regarding LV function and blood chemistry, a good myocardial reperfusion after PCI (high area at risk (AAR) blush score/AAR LV segment number; OR 0.85, CI 0.78–0.98, p = 0.0178) and high glomerular filtration rate (GFR) value at the time of hospital admission (OR 0.97, CI 0.96–0.99, p = 0.0042) were the most crucial independent predictors of a decreased risk of in-hospital mortality in this model. At the same time, a prolonged time interval between symptom onset and hospital admission, successful resuscitation, and higher peak creatine kinase activity were the most important independent predictors for an increased risk of in-hospital mortality. In ACS patients with CS, (1) an early TTECG-based teleconsultation and triage, as well as (2) good myocardial perfusion after PCI and a high GFR value at the time of hospital admission, appear as major independent predictors of a lower in-hospital mortality rate.
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23
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Moghaddam N, van Diepen S, So D, Lawler PR, Fordyce CB. Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock. ESC Heart Fail 2021; 8:988-998. [PMID: 33452763 PMCID: PMC8006679 DOI: 10.1002/ehf2.13180] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/16/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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24
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Lang CN, Kaier K, Zotzmann V, Stachon P, Pottgiesser T, von Zur Muehlen C, Zehender M, Duerschmied D, Schmid B, Bode C, Wengenmayer T, Staudacher DL. Cardiogenic shock: incidence, survival and mechanical circulatory support usage 2007-2017-insights from a national registry. Clin Res Cardiol 2020; 110:1421-1430. [PMID: 33258007 PMCID: PMC8405485 DOI: 10.1007/s00392-020-01781-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
Background A central element in the management of cardiogenic shock (CS) comprises mechanical circulatory support (MCS) systems to maintain cardiac output (CO). This study aims to quantify incidence, outcome and influence of MCS in CS over the last decade. Methods All patients hospitalized with CS in a tertiary university hospital in Germany between 2007 and 2017 were identified utilizing the international coding system ICD-10 with code R57.0. Application of MCS was identified via German procedure classification codes (OPS). Results 383,983 cases of cardiogenic shock were reported from 2007 to 2017. Patients had a mean age of 71 years and 38.5% were female. The incidence of CS rose by 65.6% from 26,828 cases in 2007 (33.1 per 100,000 person-years, hospital survival 39.2%) to 44,425 cases in 2017 (53.7 per 100,000 person-years, survival 41.2%). In 2007, 16.0% of patients with CS received MCS (4.6 per 100,000 person-years, survival 46.6%), dropping to 13.9% in 2017 (6.6 per 100,000 person-years, survival 38.6%). Type of MCS changed over the years, with decreasing use of the intra-aortic balloon pump (IABP), an increase in extracorporeal membrane oxygenation (VA-ECMO) and percutaneous ventricular assist device (pVAD) usage. Significant differences regarding in-hospital survival were observed between the devices (survival: overall: 40.2%; medical treatment = 39.5%; IABP = 49.5%; pVAD = 36.2%; VA-ECMO = 30.5%; p < 0.001). Conclusions The incidence of CS is increasing, but hospital survival remains low. MCS was used in a minority of patients, and the percentage of MCS usage in CS has decreased. The use rates of the competing devices change over time. Graphical Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01781-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corinna N Lang
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torben Pottgiesser
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Muehlen
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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25
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[Cardiogenic shock]. Wien Klin Wochenschr 2020; 132:333-348. [PMID: 32095880 DOI: 10.1007/s00508-020-01612-1] [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: 10/24/2022]
Abstract
Cardiogenic shock (CS) is defined as end-organ hypoperfusion as the consequence of primary myocardial dysfunction. Among the diagnostic criteria are a systolic blood pressure < 90 mmHg, acute renal failure (oligoanuria), ischemic hepatitis, cyanosis and cold, clammy skin. Accepted hemodynamic cutoffs are a cardiac index < 2,2 (l/min)/m2 and a pulmonary capillary wedge pressure > 15 mmHg. It should be acknowledged, that a normal blood pressure does not rule out CS; there is a nonhypotensive variant of CS demonstrating all the signs mentioned above (including elevated lactate levels) while the blood pressure is compensated due to vasoconstriction.The single most frequent cause of CS is pump failure in the setting of an acute myocardial infarction and its mortality rate has been lowered to 40-50%, owing to the widespread availability of primary PCI. Regarding PCI, it has been demonstrated recently that a "culprit-lesion only strategy" should be followed in the setting of CS. Other important causes of CS to take into account are mechanical complications of myocardial infarction (papillary and ventricular septal rupture as well as rupture of the myocardial free wall leading to tamponade), valvular heart disease (mostly decompensated aortic stenosis) as well as myocarditis and end stage cardiomyopathy.The diagnosis of CS is made by patient history, physical examination, ECG, echocardiography and coronary angiography. Echocardiography should always be performed before coronary angiography because, in the case of mechanical complications, it significantly alters the management of the patients. Patients with clinical signs of CS but paradoxically preserved ejection fraction must be thoroughly evaluated for the presence of a papillary muscle rupture, particularly in the setting of a lateral wall infarction.Noradrenaline and dobutamine are the first-line agents for medical stabilization. When such conventional measures fail, extracorporeal support devices such as ECMO or Impella© may be used. Currently, trials are underway to assess wheter these devices confer a survival benefit in this high-risk population.
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Implementation of a Comprehensive ST-Elevation Myocardial Infarction Protocol Improves Mortality Among Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock. Am J Cardiol 2020; 134:1-7. [PMID: 32933753 DOI: 10.1016/j.amjcard.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022]
Abstract
Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 ± 1.8 vs 2.8 ± 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 ± 156.0 vs 151.5 ± 98.5 ng/ml, p = 0.005), ejection fraction (40.8 ± 14.5% vs 46.7 ± 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.
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27
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Tehrani BN, Truesdell AG, Psotka MA, Rosner C, Singh R, Sinha SS, Damluji AA, Batchelor WB. A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock. JACC. HEART FAILURE 2020; 8:879-891. [PMID: 33121700 PMCID: PMC8167900 DOI: 10.1016/j.jchf.2020.09.005] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform. Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. Lastly, they discuss future research opportunities to address current gaps in clinical knowledge.
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Affiliation(s)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia; Virginia Heart, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
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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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Yildiz M, Sharkey S, Aguirre FV, Tannenbaum M, Garberich R, Smith TD, Shivapour D, Schmidt CW, Pacheco-Coronado R, Rohm HS, Chambers J, Coulson T, Garcia S, Henry TD. The Midwest ST-Elevation Myocardial Infarction Consortium: Design and Rationale. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:86-90. [PMID: 32883587 PMCID: PMC7425714 DOI: 10.1016/j.carrev.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Over the past 20 years, the development of regional ST-elevation myocardial infarction (STEMI) care systems has led to remarkable progress in achieving timely coronary reperfusion with attendant improvement in clinical outcomes, including survival. Despite this progress, contemporary STEMI care does not consistently meet the national guideline-recommended goals, which offers an opportunity for further improvement in STEMI outcomes. The lack of single, comprehensive, national STEMI registry complicates our ability to improve STEMI outcomes in particular for high-risk STEMI subsets such as cardiac arrest (CA) and/or cardiogenic shock (CS). OBJECTIVES To address this need, the Midwest STEMI Consortium (MSC) was created as a collaboration of 4 large, regional STEMI care systems to provide a comprehensive, multicenter, and prospective STEMI registry without any exclusionary criteria. METHODS The MSC is a collaboration of 4 large, regional STEMI care systems: Iowa Heart Center in Des Moines, IA; Minneapolis Heart Institute Foundation in Minneapolis, MN; Prairie Heart Institute in Springfield, IL; and The Christ Hospital in Cincinnati, OH. Each has similar standardized STEMI protocol and together include 6 percutaneous coronary intervention (PCI)-capable hospitals and over 100 non-PCI-capable hospitals. Each center had a prospective database that was transferred to a data coordinating center to create the multicenter database. The comprehensive database includes traditional risk factors, cardiovascular history, medications, time to treatment data, detailed angiographic characteristics, and short- and long-term clinical outcomes up to 5-year for myocardial infarction, stroke, and cardiovascular and all-cause mortality. Ten-year mortality rates were assessed by using national death index. RESULTS Currently, the comprehensive database (03/2003-01/2020) includes 14,911 consecutive STEMI patients with mean age of 62.3 ± 13.6 years, female gender (29%), and left anterior descending artery as the culprit vessel (34%). High risk features included: Age >75 years (19%), left ventricular ejection fraction <35% (15%), CA (10%), and CS (8%). CONCLUSION This collaboration of 4 large, regional STEMI care systems with broad entry criteria including high-risk STEMI subsets such as CA and/or CS provides a unique platform to conduct clinical research studies to optimize STEMI care.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Scott Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Frank V Aguirre
- Prairie Heart Institute at St John's Hospital, Springfield, IL, United States of America
| | | | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | | | - Christian W Schmidt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | | | - Heather S Rohm
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Jenny Chambers
- Prairie Heart Institute at St John's Hospital, Springfield, IL, United States of America
| | - Teresa Coulson
- Iowa Heart Center, Des Moines, IA, United States of America
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America.
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Scholz KH, Lengenfelder B, Jacobshagen C, Fleischmann C, Moehlis H, Olbrich HG, Jung J, Maier LS, Maier SK, Bestehorn K, Friede T, Meyer T. Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620907323. [PMID: 32723177 DOI: 10.1177/2048872620907323] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 01/24/2020] [Indexed: 02/24/2024]
Abstract
AIMS Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study. METHODS Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007. RESULTS From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001). CONCLUSIONS Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.
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Affiliation(s)
| | - Björn Lengenfelder
- Department of Cardiology, University of Würzburg, Germany
- Comprehensive Heart Failure Center Würzburg, Würzburg, Germany
| | - Claudius Jacobshagen
- Department of Cardiology, Heart Center, University of Göttingen, Göttingen, Germany
| | | | - Hiller Moehlis
- Department of Cardiology, Klinikum Darmstadt, Darmstadt, Germany
| | - Hans G Olbrich
- Department of Cardiology, Asklepios Klinik Langen, Langen, Germany
| | - Jens Jung
- Department of Cardiology, Klinikum Worms, Worms, Germany
| | - Lars S Maier
- Department of Cardiology, University Hospital Regensburg, Regensburg, Germany
| | - Sebastian Kg Maier
- Comprehensive Heart Failure Center Würzburg, Würzburg, Germany
- Department of Cardiology, Klinikum Straubing, Straubing, Germany
| | - Kurt Bestehorn
- Institute for Clinical Pharmacology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Thomas Meyer
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
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Gerbaud E, Elbaz M, Lattuca B. New insights into cardiogenic shock and coronary revascularization after acute myocardial infarction. Arch Cardiovasc Dis 2020; 113:276-284. [PMID: 32088156 DOI: 10.1016/j.acvd.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
Cardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality. Coronary revascularization is critical for improving prognosis in CS. Thus, a systematic protocol-driven approach to cardiogenic shock, the development of specialized cardiac care centres, technical advances in interventional cardiology enabling treatment of more complex and severe lesions, the availability of recent antithrombotic therapies and the evolution of new haemodynamic support devices are important considerations in current management of cardiogenic shock complicating acute ischaemic heart disease. Despite these potentially meaningful developments, several substantial gaps in knowledge still exist regarding optimal coronary revascularization of patients with cardiogenic shock. This review will describe current principles in the revascularization of these patients, with a focus on: the time to transfer and revascularize; the choice of vascular access site; the need for complete revascularization or only a culprit lesion strategy; the optimal antithrombotic therapy; the type, place and timing of haemodynamic support; and the medical care system network.
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Affiliation(s)
- Edouard Gerbaud
- Cardiology Intensive Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, 33600 Pessac, France; Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, 33000 Bordeaux, France
| | - Meyer Elbaz
- Department of Cardiology, CARDIOMET Institute, Rangueil Medical School, University Paul Sabatier, 31059 Toulouse, France.
| | - Benoit Lattuca
- Cardiology Department, Caremeau University Hospital, ACTION Study Group, Montpellier University, 30029 Nîmes, France
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Noaman S, Andrianopoulos N, Brennan AL, Dinh D, Reid C, Stub D, Biswas S, Clark D, Shaw J, Ajani A, Freeman M, Yip T, Oqueli E, Walton A, Duffy SJ, Chan W. Outcomes of cardiogenic shock complicating acute coronary syndromes. Catheter Cardiovasc Interv 2020; 96:E257-E267. [PMID: 32017332 DOI: 10.1002/ccd.28759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/24/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS). BACKGROUND CS remains the leading cause of mortality in patients presenting with ACS despite advances in care. METHODS We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS. RESULTS Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05. CONCLUSIONS Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy.
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Affiliation(s)
- Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Christopher Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Sinjini Biswas
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Thomas Yip
- Department of Cardiology, Geelong University Hospital, Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J 2019; 40:2671-2683. [DOI: 10.1093/eurheartj/ehz363] [Citation(s) in RCA: 234] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/17/2019] [Accepted: 05/11/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortality remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment.
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Affiliation(s)
- Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | - E Magnus Ohman
- Duke Heart Center, Duke University Medical Center, Box 3126 DUMC, Durham, NC 27710, USA
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Medizinische Klinik B, Bremserstraße 79, D-67063 Ludwigshafen, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
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34
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Kochar A, Al-Khalidi HR, Doerfler S, Granger CB. Reply: Delays From First Medical Contact to Revascularization in Patients With ST-Segment Elevation Myocardial Infarction Presenting With Cardiogenic Shock. JACC Cardiovasc Interv 2019; 12:107. [PMID: 30621969 DOI: 10.1016/j.jcin.2018.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
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35
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Meyer T, Scholz KH. Delays From First Medical Contact to Revascularization in Patients With ST-Segment Elevation Myocardial Infarction Presenting With Cardiogenic Shock. JACC Cardiovasc Interv 2019; 12:106. [PMID: 30621967 DOI: 10.1016/j.jcin.2018.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/23/2018] [Indexed: 11/25/2022]
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36
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Khot UN, Huded CP. Systems for Rapid Revascularization in ST-Segment Elevation Myocardial Infarction With Cardiogenic Shock: An Important Yet Elusive Goal. JACC Cardiovasc Interv 2018; 11:1834-1836. [PMID: 30236356 DOI: 10.1016/j.jcin.2018.07.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Umesh N Khot
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, Cleveland, Ohio.
| | - Chetan P Huded
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, Cleveland, Ohio
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