Results of primary percutaneous transluminal coronary angioplasty plus abciximab with or without stenting for acute myocardial infarction complicated by cardiogenic shock

Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES

Cardiogenic shock (CS) complicates 5-10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI).

METHODS

Between October 2010 and December 2019, 27578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding.

RESULTS

Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96-3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62-4.06), reinfarction (OR 0.77, 95% CI 0.15-3.90), or major bleeding (OR 1.68, 95% CI 0.75-3.74).

CONCLUSION

The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes.

Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression

Background

Cardiogenic shock complicates 5–10% of myocardial infarction (MI) cases. Data about the benefit of glycoprotein IIb/IIIa inhibitors (GPI) in these patients is sparse and conflicting.

Methods

We performed a systematic review, meta-analysis, and meta-regression of studies assessing the impact of GPI use in the setting of MI complicated cardiogenic shock on mortality, angiographic success, and bleeding events. We systematically searched for studies comparing GPI use as adjunctive treatment versus standard care in this setting. Random-effects meta-analysis and meta-regression were performed.

Results

Seven studies with a total of 1216 patients (GPI group, 720 patients; standard care group, 496 patients) were included. GPI were associated with a 45% relative reduction in the odds of death at 30 days (pooled OR 0.55; 95% CI 0.35–0.85; I² = 57%; P = 0.007) and a 49% reduction in the odds of death at 1 year (pooled OR 0.51; 95% CI 0.32–0.82; I² = 58%; P = 0.005). Reduction in short-term mortality seemed to be more important before 2000, as this benefit disappears if only the more recent studies are analyzed. GPI were associated with a 2-fold increase in the probability of achieving TIMI 3 flow (pooled OR, 2.05; 95% CI 1.37–3.05; I² = 37%, P = 0.0004). Major bleeding events were not increased with GPI therapy (pooled OR, 1.0; 95% CI 0.55–1.83; I² = 1%, P = 0.99). Meta-regression identified that patients not receiving an intra-aortic balloon pump seemed to benefit the most from GPI use (Z = − 1.57, P = 0.005).

Conclusion

GPI therapy as an adjunct to standard treatment in cardiogenic shock was associated with better outcomes, including both short- and long-term survival, without increasing the risk of bleeding.

Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.

Optimal course of treatment in acute cardiogenic shock complicating myocardial infarction

INTRODUCTION

About 5% of patients with myocardial infarction suffer from cardiogenic shock as a complication, with a mortality of ≥30%. Primary percutaneous coronary intervention as soon as possible is the most successful therapeutic approach. Prognosis depends not only on the extent of infarction, but also - and even more - on organ hypoperfusion with consequent development of multiple organ dysfunction syndrome. Areas covered: This review covers diagnostic, monitoring and treatment concepts relevant for caring patients with cardiogenic shock complicating myocardial infarction. All major clinical trials have been selected for review of the recent data. Expert commentary: For optimal care, not only primary percutaneous intervention of the occluded coronary artery is necessary, but also best intensive care medicine avoiding the development of multiple organ dysfunction syndrome and finally death. On contrary, intra-aortic balloon pump - though used for decades - is unable to reduce mortality of patients with cardiogenic shock complicating myocardial infarction.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Management of Cardiogenic Shock Due to Acute Coronary Syndromes

Despite advances in the treatment of patients with acute coronary syndromes, there has been no significant decrease in the incidence of cardiogenic shock, while its mortality remains frustratingly high. Shock is a progressive state of hypotension (systolic blood pressure <90 mm Hg) lasting at least 30 minutes, which leads to systemic hypoperfusion. It is more common in patients with ST-segment elevation myocardial infarction than in patients with other acute coronary syndromes. Revascularization is associated with better outcomes than intensive medical therapy, especially in patients <75 years of age with cardiogenic shock. Adjunctive therapies include inotropes, vasopressor therapy, intra-aortic balloon pump counterpulsation, and IIb/IIIa blockade to prevent no-reflow phenomenon during primary percutaneous transluminal coronary angioplasty. Other adjunctive therapies which are investigated are improved mechanical support devices, and as medical therapy for myocyte protection nicorandil, glucose/insulin/potassium infusions and direct inhibition of Na+/H+ exchanger.

Shock in acute myocardial infarction: the Cape Horn for trials?

Despite therapeutic improvements, cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, fluids, adjunctive medication, intra-aortic balloon counterpulsation, and also assist devices are widely used for treatment. However, currently, there is only limited evidence for any of the above treatments. This review will therefore outline the underlying causes, pathophysiology, and treatment of CS complicating AMI with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical.

Bivalirudin with provisional glycoprotein IIb/IIIa inhibitors in patients undergoing primary angioplasty in the setting of cardiogenic shock

In patients undergoing percutaneous coronary intervention (PCI), clinical trials have demonstrated that the use of bivalirudin with provisional glycoprotein IIb/IIIa inhibitors is not inferior to heparin with systematic glycoprotein IIb/IIIa inhibitors on major adverse cardiac events and is associated with lower rates of bleeding in various clinical settings. Patients with cardiogenic shock (CS), however, have been excluded from all pivotal trials. A retrospective analysis of 86 consecutive patients undergoing PCI for acute myocardial infarction complicated by CS in our center from April 2003 to September 2007 was performed. In-hospital death, major adverse cardiac events, and bleeding rates were compared in 37 patients who received bivalirudin with or without glycoprotein IIb/IIIa inhibitors and 49 patients who were treated with heparin and glycoprotein IIb/IIIa inhibitors as anticoagulation management. Baseline demographic, clinical, and biological characteristics were similar in the 2 groups. The in-hospital death rate was significantly lower in the bivalirudin group (5.4 vs 32.7%, p = 0.002). There were no differences in the rate of major hematoma between the bivalirudin group and the heparin group (3 vs 2.6%, p = 0.46). In conclusion, bivalirudin with provisional use of glycoprotein IIb/IIIa inhibitors appears to be a safe and effective anticoagualtion strategy in patients undergoing primary PCI for acute myocardial infarction complicated by CS.

Coronary stenting versus balloon angioplasty for acute myocardial infarction: A meta-regression analysis of randomized trials

INTRODUCTION

Although stenting has been shown to reduce the need for target vessel revascularization (TVR) in acute myocardial infarction (AMI), the benefits in terms of mortality and reinfarction are still unclear. Previous meta-analyses have failed to include all currently available randomized trials. The aim of the current study was to perform an updated meta-analysis to evaluate the benefits of coronary stenting for AMI in terms of mortality, reinfarction, and TVR, and whether these benefits correlated with the patient's risk profile.

METHODS

The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to September 2006. We examined all completed, published, randomized trials of coronary stenting for AMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, rescue angioplasty, stenting, and balloon angioplasty. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus.

RESULTS

A total of 13 randomized trials were identified and analyzed involving 6922 patients (3460 or 50% randomized to stent and 3462 or 50% to balloon). Stenting was not associated with a significant reduction in 30-day (2.9% versus 3.0%, p=0.81) and 1-year mortality (5.1% versus 5.2%, p=0.81), as compared to balloon angioplasty. However, a significant relationship was observed between patient's risk profile and mortality benefits from coronary stenting at 30-day (beta -0.63 [-25.4; -2.45], p=0.022) and 1-year follow-up (beta -0.61 [-15.9; -0.76], p=0.034). Stenting was associated with benefits in terms of TVR at both 30-day (3.1% versus 5.1%, p<0.0001) and 6 to 12 months (11.3% versus 18.4%, p<0.0001) follow-up, without any difference in terms of reinfarction.

CONCLUSIONS

Among AMI patients undergoing primary angioplasty, coronary stent implantation, when anatomically and technically feasible, may be considered, in addition to benefits in terms of TVR, to reduce mortality in high-risk patients, who may be identified by the use of validated risk scores.

Effectiveness of glycoprotein IIb/IIIa inhibitor use during primary coronary angioplasty: results of propensity analysis using the New York State Percutaneous Coronary Intervention Reporting System

Patients undergoing primary angioplasty in clinical practice experience a higher risk for adverse events than those enrolled in clinical trials. Whether glycoprotein (GP) IIb/IIIa inhibitor use during primary angioplasty is both safe and effective in real life is unknown. Therefore, we examined the pattern of GP IIb/IIIa use and its effectiveness in a large population-based cohort of 7,321 patients who underwent primary angioplasty in New York State. Propensity analysis was used to account for the nonrandomized use of GP IIb/IIIa inhibitors. Overall, 78.5% of patients who underwent primary angioplasty received GP IIb/IIIa inhibitors. In-hospital mortality was significantly lower with GP IIb/IIIa use (3% vs 6.2%, p <0.0001) after adjustment for both propensity score (odds ratio 0.57, 95% confidence interval 0.44 to 0.74, p <0.0001) and the combination of propensity score and clinical characteristics (odds ratio 0.63, 95% confidence interval 0.45 to 0.88, p = 0.006). Patients with older age and higher Mayo Clinic Risk Score (MCRS) received GP IIb/IIIa inhibitors less often. However, stratified analysis of patients with low to moderate risk (MCRS <12) versus high risk (>or=12) demonstrated that GP IIb/IIIa use lowered risk of mortality both in low- to moderate-risk (1.39% vs 3.23%, p <0.0001) and high-risk patients (16.15% vs 22.41%, p = 0.03). In conclusion, adjunct GP IIb/IIIa inhibitor use during primary angioplasty is effective and associated with improved in-hospital survival rates.

[Cardiogenic shock after acute myocardial infarction]

Cardiogenic shock remains the major cause of death among patients with acute myocardial infarction. Besides supportive therapy there is clear evidence that revascularization of the infarct related artery should be performed as soon as possible with percutaneous transluminal coronary angioplasty. Placement of coronary stents and administration of platelet glycoprotein IIb/IIIa antagonists may further improve outcome. Intra-aortic balloon pumping should be integral part of this treatment strategy but is unfortunately underused in clinical practice. Routine bypass surgery for cardiogenic shock patients is deferred and restricted to selected patients.

Association of glycoprotein IIb/IIIa inhibitors and long-term survival following administration during percutaneous coronary intervention for acute myocardial infarction

OBJECTIVES

We sought to evaluate the impact of GP IIb/IIIa receptor blockers on long-term mortality in patients undergoing PCI for AMI.

BACKGROUND

Glycoprotein (GP) IIb/IIIa inhibitors are potent suppressors of platelet aggregation and when used during percutaneous coronary intervention (PCI) for the treatment of acute myocardial infarction (AMI) may improve short-term clinical outcomes, including survival. However, the impact of GP IIb/IIIa treatment during PCI for AMI on long-term survival is unknown.

METHODS

Patients undergoing primary or rescue PCI for AMI within 24 hours of symptom onset with or without GP IIb/IIIa inhibitor treatment were identified from a multicenter PCI database. All cause mortality at a mean follow-up of 3 years was the primary end point.

RESULTS

Of the 269 patients treated with primary or rescue PCI for AMI, 107 (40%) received a GP IIb/IIIa antagonist. Patients treated with GP inhibitors were more likely to present with or develop heart failure (13% vs. 6.2%, P = 0.052). Left ventricular ejection fraction was reduced in those treated with GP IIb/IIIa antagonists (44% vs. 48%, P = 0.051). The extent of coronary artery disease did not differ between groups. Stent use was 80% in both groups. Procedural success was high and did not differ between groups. In-hospital mortality was low and did not differ between groups. The mortality at a mean follow-up of 3 years was 1.9% among patients treated with a GP IIb/IIIa antagonist and 15% for those who were not treated (log-rank P = 0.0005). Treatment with a GP IIb/IIIa antagonist was independently associated with a significant reduction in the hazard of long-term mortality (Hazard Ratio, 0.159; 95% Confidence Interval, 0.034-0.729; P = 0.018).

CONCLUSIONS

Treatment of patients undergoing PCI for AMI with GP IIb/IIIa antagonists appears to be associated with a profound reduction in late mortality.

Comparison of outcomes in acute myocardial infarction treated with coronary angioplasty alone versus coronary stent implantation

Randomized trials have demonstrated the superiority of primary angioplasty with stent implantation over balloon angioplasty alone in the treatment of acute myocardial infarction (AMI). However, it remains unknown whether the beneficial outcomes that are attained in clinical trials can be generalized to community-based practice. We conducted a retrospective cohort study of all patients who underwent primary angioplasty for AMI in New York State in 1998 and 1999. In total, 6,010 consecutive patients who presented within 23 hours of an AMI were identified for this analysis. In-hospital mortality was the primary end point. Stents were placed in 5,225 patients (87%). Patients who received stents were younger (61 vs 62 years, p = 0.011) and less often women (29% vs 33%, p = 0.018). Patients who received stents were less likely to have a history of hypertension (56% vs 61%, p = 0.013), diabetes (17% vs 24%, p <0.001), a creatinine level > or = 2.5 mg/dl (0.8% vs 2.0%, p = 0.002), 3-vessel coronary disease (14% vs 19%, p <0.001), and left main disease (2.4% vs 4.6%, p <0.001). Stent use was associated with significant decreases in length of stay (5.9 vs 8.1 day, p <0.001), major adverse cardiovascular events (4.1% vs 12%, p <0.001), and in-hospital mortality (3.5% vs 9.3%, p <0.001). After multivariate logistic regression analysis to adjust for differences in baseline characteristics, stent use was associated with a 50% decrease in risk of in-hospital mortality (odds ratio 0.474, 95% confidence interval 0.311 to 0.723, p = 0.001).

Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial

BACKGROUND

The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated the survival advantage of emergency revascularization versus initial medical stabilization in patients developing cardiogenic shock after acute myocardial infarction. The relative merits of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with shock have not been defined. The objective of this analysis was to compare the effects of PCI and CABG on 30-day and 1-year survival in the SHOCK trial.

METHODS AND RESULTS

Of the 302 trial patients, 128 with predominant left ventricular failure had emergency revascularization. The selection of revascularization procedures was individualized. Eighty-one patients (63.3%) had PCI, and 47 (36.7%) had CABG. The median time from randomization to intervention was 0.9 hours (interquartile range [IQR], 0.3 to 2.2 hours) for PCI and 2.7 hours (IQR, 1.3 to 5.5 hours) for CABG. Baseline demographics and hemodynamics were similar, except that there were more diabetics (48.9% versus 26.9%; P=0.02), 3-vessel disease (80.4% versus 60.3%; P=0.03), and left main coronary disease (41.3% versus 13.0%; P=0.001) in the CABG group. In the PCI group, 12.3% had 2-vessel and 2.5% had 3-vessel interventions. In the CABG group, 84.8% received > or =2 grafts, 52.2% received > or =3 grafts, and 87.2% were deemed completely revascularized. The survival rates were 55.6% in the PCI group compared with 57.4% in the CABG group at 30 days (P=0.86) and 51.9% compared with 46.8%, respectively, at 1 year (P=0.71).

CONCLUSIONS

Among SHOCK trial patients randomized to emergency revascularization, those treated with CABG had a greater prevalence of diabetes and worse coronary disease than those treated with PCI. However, survival rates were similar. Emergency CABG is an important component of an optimal treatment strategy in patients with cardiogenic shock, and should be considered a complementary treatment option in patients with extensive coronary disease.

Management of cardiogenic shock attributable to acute myocardial infarction in the reperfusion era

Cardiogenic shock is the leading cause of death among patients hospitalized with acute myocardial infarction. It is defined as tissue hypoperfusion resulting from ventricular pump failure in the presence of adequate intravascular volume. Rapid assessment and triage of patients presenting in cardiogenic shock followed by appropriate institution of supportive therapies including vasopressor and inotropic agents, mechanical ventilatory support, and intra-aortic balloon pump counterpulsation are critical for effective management of these patients. However, emergency percutaneous coronary intervention or coronary artery bypass graft surgery is required to decrease mortality rates. Novel approaches, including inhibition of nitric oxide synthase and new mechanical support devices, may further decrease mortality rates, which remain high despite reperfusion therapy.

Heart failure and shock complicating acute coronary syndromes

Heart failure (HF) complicating acute coronary syndromes (ACS) is a heterogeneous clinical syndrome characterized by varying degrees of pulmonary congestion, and in its severest form, by profound organ hypoperfusion (cardiogenic shock). The occurrence of HF in patients with ACS has long been recognized as a strong predictor of increased morbidity and mortality. As such, there is increased interest in better understanding the epidemiology and management of this common clinical syndrome. This manuscript reviews recent insights from work in this area, including recent important trials evaluating the impact of renin-angiotensin system inhibition, early beta-blockade, and aggressive reperfusion strategies.

Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score

OBJECTIVES

We sought to develop a simple risk score for predicting mortality after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

BACKGROUND

Accurate risk stratification after primary PCI is important. Previous risk scores after reperfusion therapy have incorporated clinical +/- angiographic variables but have not considered baseline left ventricular function. Moreover, prior studies have not been validated against independent databases or studies.

METHODS

The databases from the two largest multicenter, randomized AMI trials of primary PCI were utilized for score derivation (the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications [CADILLAC] trial, n = 2,082) and subsequent validation (the Stent-Primary Angioplasty in Myocardial Infarction [Stent-PAMI] trial, n = 900). Logistic regression and the jackknife procedure were used to select correlates of one-year mortality that were subsequently weighted and integrated into an integer scoring system.

RESULTS

Seven variables selected from the initial multivariate model were weighted proportionally to their respective odds ratio for one-year mortality (age >65 years [2 points], Killip class 2/3 [3 points], baseline left ventricular ejection fraction <40% [4 points], anemia [2 points], renal insufficiency [3 points], triple-vessel disease [2 points], and post-procedural Thrombolysis In Myocardial Infarction flow grade [2 points]). Three strata of risk were defined (low risk, score 0 to 2; intermediate risk, score 3 to 5; and high risk, score >/=6) with excellent prognostic accuracy for survival in the derivation and validation sets (c statistics = 0.83 and 0.81 for 30-day mortality and 0.79 and 0.78 for 1-year mortality, respectively).

CONCLUSIONS

In AMI patients treated with primary PCI, seven risk factors readily available at the time of intervention accurately predict short- and long-term mortality. Of note, measurement of baseline left ventricular function is the single most powerful predictor of survival and should be incorporated into risk score models.

[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]

OBJECTIVE

To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI).

METHODS

Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004.

RESULTS

The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004).

CONCLUSION

In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty

BACKGROUND

Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines.

AIM

To evaluate the in-hospital and 30-day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS.

METHODS AND RESULTS

Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co-morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In-hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non-cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48 hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age 75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0-1.24, P=0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95-1.0, P=0.05), were independent predictors of all cause mortality at 30 days.

CONCLUSION

Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.

Impact of stents and abciximab on survival from cardiogenic shock treated with percutaneous coronary intervention

This retrospective observational review compares patient characteristics and in-hospital and long-term outcomes of cohorts of patients undergoing percutaneous coronary intervention (PCI) for cardiogenic shock complicating acute myocardial infarction (MI) prior to the use of stents (as well as glycoprotein IIb/IIIa inhibitor and dual-antiplatelet therapy) with PCI in the stent era. Cardiogenic shock remains the leading cause of hospital mortality from acute MI. This is a report of consecutive patients with cardiogenic shock complicating acute MI, without mechanical complication, referred for emergency catheterization to a single operator at two consecutive Veterans Affairs medical centers over a 15-year period (1988 to August 2003). PCI was attempted in all 93 cases: 44 consecutive patients in the present era and 49 consecutive patients in the stent era. Patients with comparable extent of coronary disease, more ST elevation myocardial infarction, multiple areas of infarction, and greater comorbidity underwent PCI in the stent era. Nevertheless, PCI in the stent era was associated with higher rates of acute success and improved in-hospital survival. Kaplan-Meier curves and log-rank testing showed highly significant improvement in overall survival (P < 0.0001). Logistic regression of in-hospital survival demonstrated that stent use (colinear with glycoprotein IIb/IIIa use and dual-antiplatelet therapy) was significantly associated with survival in a model adjusting for extent of coronary disease and comorbidities (P = 0.007). Stents and abciximab have been associated with improved acute angiographic and procedural success of PCI for cardiogenic shock, leading to improved survival.

Efficacy and safety of abciximab on acute myocardial infarction treated with percutaneous coronary interventions: a meta-analysis of randomized, controlled trials

OBJECTIVE

To evaluate the efficacy and safety of abciximab following acute myocardial infarction (AMI) treated with percutaneous coronary interventions.

METHODS

A meta-analysis of randomized controlled trials of platelet glycoprotein IIb/IIIa inhibitor abciximab as adjunctive therapy to percutaneous coronary interventions for AMI was performed. Main outcomes measured were: (1) mortality, (2) reinfarction, (3) target vessel revascularization (TVR), (4) major cardiac events (MACE) that were a composite endpoint of death, reinfarction, and TVR, and (5) major bleeding.

RESULTS

Six trials randomized 3755 patients who were followed for a mean of 5.5 months. Compared with the control, abciximab significantly reduced mortality (OR 0.70, 95% CI 0.50-0.97), TVR (0.79, 95% CI 0.65-0.96) and MACE (0.76, 95% CI 0.65-0.90). Reduction on TVR and MACE was confirmed in stent patients, but not in balloon angioplasty patients. Abciximab was associated with an increased risk of major bleeding (OR 1.39, 95% CI 1.03-1.87), but bleeding was observed only with a 100U/kg heparin bolus followed by a maintenance infusion (OR 1.89, 95% CI 1.10-3.28) and not with a bolus of 70U/kg (OR 1.22, 95% CI 0.85-1.73).

CONCLUSIONS

Abciximab, as adjunctive therapy to percutaneous coronary interventions, reduces mortality, TVR and MACE following AMI. The reduction of clinical outcomes occurs with stent implantation but not with balloon angioplasty. A 70U/kg heparin bolus must be used to avoid major bleeding.

Pressure response to vasopressors and mortality after direct angioplasty for cardiogenic shock

BACKGROUND

There is very little known about the relationship between pre-intervention arterial pressure response to vasopressor therapy (PRV) and death rate, after primary angioplasty for immediate cardiogenic shock (CS) complicating acute myocardial infarction (AMI).

METHODS

We examined data from 32 consecutive cases, admitted to our department within 12 h after the onset of MI and in CS, treated with direct PTCA, from May 1995 to March 2001. Intravenous administration of dobutamine and vasopressor agents was required in all patients before intervention.

RESULTS

Ten patients, after vasopressor therapy, showed a significant improvement in systolic arterial pressure, invasively measured, (>90 mmHg, responders) before undergoing PTCA. Responders were younger and with less impaired pre-procedural LVEF (39.6%+/-10.7 vs. 30.9%+/-8.4, P=0.02). After direct PTCA responders showed an improved final TIMI flow (2.8+/-0.6 vs. 2.2+/-0.7, P=0.04) and blush grade (1.9+/-0.9 vs. 1+/-1, P=0.03). The mortality rate was lower in responders compared with non-responders both in hospital (20% vs. 68%, P=0.02) and at 3.5 years of follow-up (30% vs. 73%, P=0.049). After adjustment by multivariate analysis older age and lower blush grade correlated with in hospital death, while age remained the only predictor of late death.

CONCLUSIONS

PRV was not an independent predictor of death after direct PTCA for CS. The association of no PRV with older age and lower post procedural blush grade may explain the difference in mortality rates between responders and non-responders.

Outcomes with changes in prescribing of glycoprotein IIb/IIIa inhibitors in PCI

BACKGROUND

Glycoprotein IIb/IIIa receptor antagonists have been shown to have an impact on the outcomes of death/myocardial infarction (MI) in patients undergoing percutaneous coronary intervention. At our institution, tirofiban has largely replaced abciximab in an attempt to decrease costs.

OBJECTIVE

To assess the impact of this change on patient outcomes in the absence of head-to-head trials.

METHODS

Medical records were reviewed and telephone follow-ups were conducted on patients receiving tirofiban (n = 83) at our facility between February and November 1999. Death/MI at 30 days and 6 months after infusion were recorded. Safety and length of stay (LOS) were also assessed. These data were compared using chi2 analysis with results obtained from a previous review of abciximab use (n = 83) collected between May 1997 and November 1998.

RESULTS

There was no difference in the baseline incidence of (1) cardiovascular risk factors, (2) prior revascularization, (3) prior MI, (4) the number of vessels with atherosclerotic disease assessed by angiography, and (5) the number of vessels receiving procedures. Death/MI trended to be worse with tirofiban versus abciximab at our institution at 30 days (4.8% abciximab vs. 12% tirofiban; p = 0.163) and 6 months (6% abciximab vs. 18.1% tirofiban; p = 0.032). Bleeding and median LOS (3 d abciximab vs. 3 d tirofiban) were not different. Despite an increase in pharmacy cost, the use of abciximab provided these outcomes without an increase in total hospital cost.

CONCLUSIONS

The perceived economically driven change in medication selection from abciximab to tirofiban may not have been appropriate based on the negative trends seen in this review. To maintain optimal patient outcomes, this change should be reevaluated.

Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial

OBJECTIVES

We examined the clinical, angiographic, and procedural characteristics determining survival after percutaneous coronary intervention (PCI) for cardiogenic shock.

BACKGROUND

The SHOCK (SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?) trial prospectively enrolled patients with shock complicating acute myocardial infarction (MI). Patients were randomized to a strategy of early revascularization or initial medical stabilization.

METHODS

Patients randomized to early revascularization underwent PCI or bypass surgery on the basis of predefined clinical criteria. Patients randomized to early revascularization who underwent PCI and had angiographic films available for analysis are the subject of this report (n = 82).

RESULTS

The median time from MI to PCI was 11 h. The majority of patients had occluded culprit arteries (Thrombolysis In Myocardial Infarction [TIMI] grade 0 or 1 flow in 62%) and multivessel disease (81%). One-year mortality in PCI patients was 50%. Mortality was 39% if PCI was successful but 85% if unsuccessful (p < 0.001). Mortality was 38% if TIMI flow grade 3 was achieved, 55% with TIMI grade 2 flow, and 100% with TIMI grade 0 or 1 flow (p < 0.001). Mortality was 67% if severe mitral regurgitation was documented. Independent correlates of mortality were as follows: increasing age (p < 0.001), lower systolic blood pressure (p = 0.009), increasing time from randomization to PCI (p = 0.019), lower post-PCI TIMI flow (0/1 vs. 2/3) (p < 0.001), and multivessel PCI (p = 0.040).

CONCLUSIONS

Restoration of coronary blood flow is a major predictor of survival in cardiogenic shock. Benefit appears to extend beyond the generally accepted 12-h post-infarction window. Surgery should be considered in shock patients with severe mitral insufficiency or multivessel disease not amenable to relatively complete percutaneous revascularization.

Glycoprotein IIb/IIIa receptor inhibitors in percutaneous coronary intervention and acute coronary syndrome

OBJECTIVE

To review the contemporary role of the glycoprotein (GYP) IIb/IIIa receptor inhibitors abciximab, eptifibatide, and tirofiban in patients undergoing percutaneous coronary intervention (PCI) and those with an acute coronary syndrome (ACS), and to provide an algorithm based on currently available evidence for specific agents.

DATA SOURCES

Primary articles were identified by a MEDLINE search (1966-January 2003); references cited in these articles provided additional resources.

STUDY SELECTION AND DATA EXTRACTION

All of the articles identified from data sources were considered for relevant information; this article primarily addresses large, controlled or comparative studies, and meta-analyses.

DATA SYNTHESIS

The role of GYP IIb/IIIa inhibitors in patients undergoing PCI and those with ACS has progressed markedly. To date, abciximab has the most robust data in patients undergoing PCI, particularly high-risk individuals. In PCI patients with lower risk (e.g., elective stenting), eptifibatide is a reasonable first-line option. Data do not support tirofiban for routine use in patients undergoing PCI. For individuals with signs and symptoms of ACS, specifically unstable angina or non-ST-segment elevation myocardial infarction (MI), eptifibatide or tirofiban is recommended in high-risk patients when a conservative approach is used (PCI is not planned). Abciximab is not recommended in this situation. In patients with ST-segment elevation MI (STEMI), abciximab is the only GYP IIb/IIIa inhibitor evaluated in large, well-designed investigations. For medical management in combination with a fibrinolytic agent, the role of abciximab remains unclear. For patients undergoing primary PCI for the management of STEMI, the available evidence supports the use of abciximab, albeit further investigation is warranted.

CONCLUSIONS

The role of GYP IIb/IIIa inhibitors in clinical cardiology continues to evolve. Choice of the agent depends on situation of use, patient-specific characteristics and risk stratification, and, in the case of ACS, chosen management strategy (medical management or intervention).

Reperfusion in acute myocardial infarction: current concepts

Myocardial reperfusion is the treatment of choice in acute myocardial infarction. Pharmacological thrombolysis restores coronary artery patency in about two thirds of patients with acute myocardial infarction. However, mechanical reperfusion with primary angioplasty and stenting achieves higher patency rates with less complications, especially in high-risk patients. Adjunctive pharmacotherapy and new device technology may improve the outcome of primary angioplasty. Facilitated angioplasty using a combination of half-dose thrombolysis, platelet glycoprotein IIb/IIIa antagonists, and early intervention, appears to be a promising strategy for the treatment of acute myocardial infarction in the modern era. The efficacy and safety of this approach are currently evaluated in several ongoing trials.

Revascularization, stenting, and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.

Administration of glycoprotein IIb-IIIa inhibitors in patients with ST-segment elevation myocardial infarction

Patients with ST-segment elevation acute myocardial infarction require immediate reperfusion therapy. Reperfusion therapy can be provided by either pharmacologic or mechanical means. Pharmacologic reperfusion therapy consists of administering fibrinolytics, whereas mechanical reperfusion consists of performing percutaneous intervention, usually with stent placement. Each approach has been shown to decrease mortality, but each has disadvantages in establishing flow in the infarct-related artery. Regardless of the approach, during an acute myocardial infarction, activation and externalization of glycoprotein (GP) IIb-IIIa receptors occur on the surface of platelets. The GP IIb-IIIa inhibitors block the binding of fibrinogen to these platelet receptors. These inhibitors have been investigated in combination with both reperfusion strategies. The goal of adding GP IIb-IIIa inhibitor therapy to either reperfusion approach is to obtain better early, complete, and sustained reperfusion. Subsequently, this should lead to better clinical outcomes for patients with ST-segment elevation acute myocardial infarction. Although no mortality benefit has been seen with the addition of GP IIb-IIIa inhibitor therapy, ischemic complications have been reduced significantly.