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Saleiro C, de Campos D, Ribeiro JM, Lopes J, Puga L, Sousa JP, Gomes ARM, Siserman A, Lourenço C, Gonçalves L. Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes. Rev Port Cardiol 2023; 42:113-120. [PMID: 36163139 DOI: 10.1016/j.repc.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/23/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Carolina Saleiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Diana de Campos
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana M Ribeiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - João Lopes
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luís Puga
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José P Sousa
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Rita M Gomes
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Alexandrina Siserman
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carolina Lourenço
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Gonçalves
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Research (ICBR), Coimbra, Portugal
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Myrda K, Gąsior M, Dudek D, Nawrotek B, Niedziela J, Wojakowski W, Gierlotka M, Grygier M, Stępińska J, Witkowski A, Lesiak M, Legutko J. One-Year Outcome of Glycoprotein IIb/IIIa Inhibitor Therapy in Patients with Myocardial Infarction-Related Cardiogenic Shock. J Clin Med 2021; 10:5059. [PMID: 34768577 PMCID: PMC8584341 DOI: 10.3390/jcm10215059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/21/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We aimed to evaluate the effect of intravenous glycoprotein IIb/IIIa receptor inhibitors (GPIs) on in-hospital survival and mortality during and at the 1-year follow-up in patients undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI) complicated by cardiogenic shock (CS), who were included in the Polish Registry of Acute Coronary Syndromes (PL-ACS). METHODS From 2003 to 2019, 466,566 MI patients were included in the PL-ACS registry. A total of 10,193 patients with CS received PCI on admission. Among them, GPIs were used in 3934 patients. RESULTS The patients treated with GPIs were younger, had lower systolic blood pressure on admission, required inotropes and intra-aortic balloon pump (IABP) support more frequently, and showed a lower efficacy of coronary angioplasty. In both groups, the same rates of in-hospital adverse events were observed. A lower mortality rate was reported in the group treated with GPIs 12 months after admission (54.9% vs. 57.9%, p = 0.002). Therapy with GPI was an independent factor reducing the risk of mortality in the 12-month follow-up. CONCLUSIONS The addition of GPIs to the standard pharmacotherapy combined with PCI in patients with MI and CS on admission reduced the risk of death in the 12-month follow-up period without increasing in-hospital adverse event rates.
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Affiliation(s)
- Krzysztof Myrda
- Silesian Center for Heart Diseases, 3rd Department of Cardiology, 41-800 Zabrze, Poland; (M.G.); (J.N.)
| | - Mariusz Gąsior
- Silesian Center for Heart Diseases, 3rd Department of Cardiology, 41-800 Zabrze, Poland; (M.G.); (J.N.)
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, 31-088 Kraków, Poland; (D.D.); (J.L.)
- GVM Care & Research, Maria Cecilia Hospital, Cotignola, 48033 Ravenna, Italy
| | - Bartłomiej Nawrotek
- Clinical Department of Interventional Cardiology, John Paul II Hospital, 31-202 Kraków, Poland;
| | - Jacek Niedziela
- Silesian Center for Heart Diseases, 3rd Department of Cardiology, 41-800 Zabrze, Poland; (M.G.); (J.N.)
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, 3rd Division of Cardiology, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Marek Gierlotka
- Department of Cardiology, Institute of Medicine, University of Opole, 45-040 Opole, Poland;
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (M.L.)
| | | | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-628 Warszawa, Poland;
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (M.L.)
| | - Jacek Legutko
- Institute of Cardiology, Jagiellonian University Medical College, 31-088 Kraków, Poland; (D.D.); (J.L.)
- Clinical Department of Interventional Cardiology, John Paul II Hospital, 31-202 Kraków, Poland;
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3
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Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression. J Intensive Care 2020; 8:85. [PMID: 33292610 PMCID: PMC7656750 DOI: 10.1186/s40560-020-00502-y] [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: 09/17/2020] [Accepted: 10/26/2020] [Indexed: 01/11/2023] Open
Abstract
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.
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Abstract
Approximately 10% of patients with acute myocardial infarction develop cardiogenic shock. Randomized studies have shown a significant improvement in survival with early revascularization, which now represents the most important cornerstone in the treatment of infarct-related cardiogenic shock. In the vast majority of cases, this is achieved by percutaneous coronary intervention (PCI). In cases of complex coronary anatomy or mechanical complications, the Heart Team should be consulted promptly. The randomized CULPRIT-SHOCK study showed a survival advantage for patients with multivessel coronary artery disease and a percutaneous revascularization strategy who were treated by culprit-lesion-only PCI compared with immediate multivessel PCI. There are currently few data on anticoagulation and antiplatelet therapy in cardiogenic shock as well as on active mechanical circulatory support in this setting.
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Affiliation(s)
- Anne Freund
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany. .,German Center for Cardiovascular Research (DZHK), Berlin, Deutschland.
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Deutschland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
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Gorog DA, Price S, Sibbing D, Baumbach A, Capodanno D, Gigante B, Halvorsen S, Huber K, Lettino M, Leonardi S, Morais J, Rubboli A, Siller-Matula JM, Storey RF, Vranckx P, Rocca B. 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). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:125-140. [PMID: 32049278 DOI: 10.1093/ehjcvp/pvaa009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Dirk Sibbing
- Ludwig-Maximilians-Universität, München, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Andreas Baumbach
- Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London, West Smithfield, London, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Danderyds Hospital, Danderyd, Sweden
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical School, Vienna, Austria
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio Leonardi
- Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Joao Morais
- Cardiology Division, Leiria Hospital Center, Pousos, Leiria, Portugal.,ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Marquis‐Gravel G, Zeitouni M, Kochar A, Jones WS, Sketch MH, Rao SV, Patel MR, Ohman EM. Technical consideration in acute myocardial infarction with cardiogenic shock: A review of antithrombotic and PCI therapies. Catheter Cardiovasc Interv 2019; 95:924-931. [DOI: 10.1002/ccd.28455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/15/2019] [Accepted: 08/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Guillaume Marquis‐Gravel
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | | | - Ajar Kochar
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - W. Schuyler Jones
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Michael H. Sketch
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Sunil V. Rao
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - E. Magnus Ohman
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
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Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y 12 inhibition from the IABP-SHOCK II trial. Resuscitation 2019; 137:205-212. [PMID: 30790690 DOI: 10.1016/j.resuscitation.2019.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
AIMS Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor. METHODS AND RESULTS We retrospectively identified 136 CS patients treated with cangrelor. Patients were 1:1 matched to CS patients from the IABP-SHOCK II trial not receiving cangrelor by age, sex, cardiac arrest, type of myocardial infarction, culprit lesion, glycoprotein IIb/IIIa inhibitor, and oral P2Y12-receptor inhibitor and followed-up for 12 months. The study cohort consisted of 88 matched pairs. Thirty-day and 12-month mortality was 29.5% and 34.1% in cangrelor-treated patients and 36.4% and 47.1% in control group (P = 0.34 and P = 0.08, respectively). The rate of definite acute stent thrombosis was 2.3% in both groups. Moderate and severe bleeding events occurred in 21.6% in the cangrelor and 19.3% in the control group (P = 0.71). Patients treated with cangrelor more frequently experienced ≥1 TIMI flow grade improvement during PCI (92.9% vs. 81.2%, P = 0.02). CONCLUSION Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y12 inhibitors in CS patients undergoing PCI. The use of cangrelor in CS offers a potentially safe and effective antiplatelet option and should be evaluated in randomized trials.
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Vaduganathan M, Qamar A, Badreldin HA, Faxon DP, Bhatt DL. Reply: Cangrelor or Abciximab as First Choice in Cardiogenic Shock. JACC Cardiovasc Interv 2019; 10:2468-2469. [PMID: 29217013 DOI: 10.1016/j.jcin.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 11/18/2022]
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Nuding S, Werdan K, Prondzinsky R. Optimal course of treatment in acute cardiogenic shock complicating myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:99-112. [PMID: 29310471 DOI: 10.1080/14779072.2018.1425141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Sebastian Nuding
- a Department of Medicine III , University Hospital Halle (Saale) , Halle (Saale) , Germany
| | - Karl Werdan
- a Department of Medicine III , University Hospital Halle (Saale) , Halle (Saale) , Germany
| | - Roland Prondzinsky
- b Department of Medicine I , Carl-von-Basedow Hospital Merseburg , Germany
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 958] [Impact Index Per Article: 136.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Joseph J, Patterson T, Arri S, McConkey H, Redwood SR. Primary Angioplasty For Patients in Cardiogenic Shock: Optimal Management. Interv Cardiol 2016; 11:39-43. [PMID: 29588703 DOI: 10.15420/icr.2016.11.1.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cardiogenic shock complicates approximately 5-10 % of all MI events and remains the most common cause of death among MI cases. Over the past few decades, the mortality rate associated with cardiogenic shock has decreased with the introduction of early revascularisation, although there are limited data for patients with triple-vessel disease and left main stem disease. In more recent years, there have been a number of advances in the mechanical circulatory support devices that can help improve the haemodynamics of patients in cardiogenic shock. Despite these advances, together with progress in the use of inotropes and vasopressors, cardiogenic shock remains associated with high morbidity and mortality rates. This review will outline the management of cardiogenic shock complicating acute MI with a smajor focus on revascularisation techniques and the use of mechanical circulatory support devices.
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Affiliation(s)
- Jubin Joseph
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Tiffany Patterson
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Satpal Arri
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Hannah McConkey
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Simon R Redwood
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
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Park JS, Cha KS, Lee DS, Shin D, Lee HW, Oh JH, Kim JS, Choi JH, Park YH, Lee HC, Kim JH, Chun KJ, Hong TJ, Jeong MH, Ahn Y, Chae SC, Kim YJ. Culprit or multivessel revascularisation in ST-elevation myocardial infarction with cardiogenic shock. Heart 2015; 101:1225-32. [DOI: 10.1136/heartjnl-2014-307220] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/18/2015] [Indexed: 11/04/2022] Open
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13
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Van Herck JL, Claeys MJ, De Paep R, Van Herck PL, Vrints CJ, Jorens PG. Management of cardiogenic shock complicating acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 4:278-97. [DOI: 10.1177/2048872614568294] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 12/23/2014] [Indexed: 01/10/2023]
Affiliation(s)
- Jozef L Van Herck
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Marc J Claeys
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Rudi De Paep
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Paul L Van Herck
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Christiaan J Vrints
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Philippe G Jorens
- Department of Intensive Care Medicine and Cardiology, Antwerp University Hospital, University of Antwerp, Belgium
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De Felice F, Tomassini F, Fiorilli R, Gagnor A, Parma A, Cerrato E, Musto C, Nazzaro MS, Varbella F, Violini R. Effect of Abciximab Therapy in Patients Undergoing Coronary Angioplasty for Acute ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock. Circ J 2015; 79:1568-74. [DOI: 10.1253/circj.cj-15-0053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | - Antonio Parma
- Interventional Cardiology Unit, S. Camillo Forlanini Hospital
| | | | - Carmine Musto
- Interventional Cardiology Unit, S. Camillo Forlanini Hospital
| | | | | | - Roberto Violini
- Interventional Cardiology Unit, S. Camillo Forlanini Hospital
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15
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Birkhead J, Weston C, Timmis A, Chen R. The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:344-52. [PMID: 25202024 DOI: 10.1177/2048872614549733] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND In acute coronary syndrome, the use of intravenous insulin infusions (IVII) to control hyperglycaemia is based on limited evidence of survival benefit. AIMS To compare 7 day survival for patients receiving IVII compared with those receiving routine care to control admission hyperglycaemia (>=11 mmol/l) in acute coronary syndrome. METHODS AND RESULTS We used matched propensity analysis to examine observational data from the MINAP database between 2008 and 2012. We matched 5974 pairs of patients. We separately examined outcomes for ST elevation (STEMI) and non ST segment elevation (NSTEMI) infarctions, and those without known diabetes and those with type 2 diabetes. Survival benefit from the use of IVII was seen only in patients with STEMI not known to have diabetes at admission (adjusted hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.64-0.92), p=0.005). Those with STEMI and existing type 2 diabetes who received IVII showed similar outcomes to routine care (HR 0.99 (95% CI 0.80-1.23), p=0.931). In patients with NSTEMI IVII was associated with significantly worse adjusted 7 day survival outcome than routine care, regardless of diabetes status; for those without known diabetes, HR 1.50 (95% CI 1.04-2.16), p=0.029, and for those with type 2 diabetes, HR 1.35 (95% CI 1.08-1.70), p=0.010. CONCLUSION As used in current clinical practice to treat hyperglycaemia in acute coronary syndromes, IVII appears to be of benefit only for patients with STEMI who are not known to have diabetes. IVII is associated with adverse early outcomes in patients with NSTEMI.
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Affiliation(s)
- John Birkhead
- National Institute for Cardiovascular Outcomes Research, UK
| | | | - Adam Timmis
- NIHR Biomedical Research Unit, Barts Health NHS Trust, UK
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Wadke R, Sanborn TA. Cardiogenic Shock: Background, Shock Trial/Registry, Evolving Data, Changing Survival, Best Medical Therapy. Interv Cardiol Clin 2013; 2:397-406. [PMID: 28582101 DOI: 10.1016/j.iccl.2013.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cardiogenic shock remains associated with unacceptably high mortality, but recent improvements with early revascularization, continued support with pharmacologic agents, and use of an intra-aortic balloon pump have led to improvements in the rate of mortality. Timely intervention with cardiac surgery in patients with mechanical complications, 3-vessel disease, and left main disease is beneficial. Continued research and ever-improving understanding of this once deadly condition have helped further in improving prognosis. Cutting-edge technologies, such as myocyte cell implantation and the use of a cooling system, will help in pushing the boundaries farther.
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Affiliation(s)
- Rahul Wadke
- Hospitalist Division, Department of Internal Medicine, Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Timothy A Sanborn
- Head Cardiology Division, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building, Third Floor, Evanston, IL 60201, USA
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Mylotte D, Morice MC, Eltchaninoff H, Garot J, Louvard Y, Lefèvre T, Garot P. Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization. JACC Cardiovasc Interv 2013; 6:115-25. [PMID: 23352816 DOI: 10.1016/j.jcin.2012.10.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 10/12/2012] [Accepted: 10/26/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This study sought to assess the impact of multivessel (MV) primary percutaneous coronary intervention (PCI) on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) and resuscitated cardiac arrest (CA). BACKGROUND The safety and efficacy of MV primary PCI in patients with STEMI and refractory CS is unknown. METHODS We conducted a multicenter prospective observational study of consecutive STEMI patients presenting to 5 French centers. Patients were classified as having single-vessel (SVD) or multivessel (MVD) coronary disease, and underwent culprit-only or MV primary PCI. Baseline characteristics and 6-month survival were compared. RESULTS Among 11,530 STEMI patients, 266 had resuscitated CA and CS. Patients with SVD (36.5%) had increased 6-month survival compared to those with MVD (29.6% vs. 42.3%, p = 0.032). Baseline characteristics were similar in those with MVD undergoing culprit-only (60.9%) or MV (39.1%) primary PCI. However, 6-month survival was significantly greater in patients who underwent MV PCI (43.9% vs. 20.4%, p = 0.0017). This survival advantage was mediated by a reduction in the composite of recurrent CA and death due to shock (p = 0.024) in MV PCI patients. In those with MVD, culprit artery PCI success (hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.41 to 0.96, p = 0.030) and MV primary PCI (HR: 0.57; 95% CI: 0.38 to 0.84, p = 0.005) were associated with increased 6-month survival. CONCLUSIONS The results of this study suggest that in STEMI patients with MVD presenting with CS and CA, MV primary PCI may improve clinical outcome. Randomized trials are required to verify these results.
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Affiliation(s)
- Darren Mylotte
- Institut Cardiovasculaire Paris Sud, Institut Hospitalier Jacques Cartier, Massy, and Hôpital Claude Galien, Quincy, France.
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Subban V, Gnanaraj A, Gomathi B, Janakiraman E, Pandurangi U, Kalidoss L, Ajit SM. Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction-a single centre experience. Indian Heart J 2012; 64:152-8. [PMID: 22572491 DOI: 10.1016/s0019-4832(12)60052-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Mortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 - 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS. METHODS Forty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival. RESULTS There were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12-72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status. CONCLUSION Mortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1724] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 896] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s00390-011-0284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hussain F, Philipp RK, Ducas RA, Elliott J, Džavík V, Jassal DS, Tam JW, Roberts D, Garber PJ, Ducas J. The ability to achieve complete revascularization is associated with improved in-hospital survival in cardiogenic shock due to myocardial infarction: Manitoba cardiogenic shock registry investigators. Catheter Cardiovasc Interv 2011; 78:540-8. [DOI: 10.1002/ccd.23006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 01/20/2011] [Indexed: 11/08/2022]
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Tousek P, Rokyta R, Tesarova J, Pudil R, Belohlavek J, Stasek J, Rohac F, Widimsky P. Routine upfront abciximab versus standard periprocedural therapy in patients undergoing primary percutaneous coronary intervention for cardiogenic shock: The PRAGUE-7 Study. An open randomized multicentre study. ACTA ACUST UNITED AC 2011; 13:116-22. [DOI: 10.3109/17482941.2011.567282] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Comparison of invasive and non-invasive treatment strategies in older patients with acute myocardial infarction complicated by cardiogenic shock (from the Polish Registry of Acute Coronary Syndromes - PL-ACS). Am J Cardiol 2011; 107:30-6. [PMID: 21146682 DOI: 10.1016/j.amjcard.2010.08.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Revised: 08/11/2010] [Accepted: 08/11/2010] [Indexed: 11/20/2022]
Abstract
Cardiogenic shock (CS) continues to be the most important factor affecting the mortality rate of patients with acute myocardial infarctions (AMIs). However, controversy regarding the optimal treatment of older patients with AMIs complicated by CS still exists. The aim of this study was to compare the results of invasive (coronary angiography during index hospitalization) and noninvasive treatment strategies in patients aged ≥ 75 years with AMIs complicated by CS, defined as systolic blood pressure <90 mm Hg or need for hemodynamic support and end-organ hypoperfusion. A multicenter Polish registry that included data on patients with acute coronary syndromes was examined to identify patients with AMIs treated from October 2003 to May 2007. A total of 97,531 patients with AMIs were hospitalized, and 5.5% of those patients (n = 5,390) had CS on admission, including 1,976 patients aged ≥ 75 years (509 treated invasively and 1,467 treated noninvasively). In-hospital mortality was 55.4% in patients treated invasively and 69.9% in patients treated noninvasively (p <0.0001). After 6 months, the mortality rate was 65.8% in the invasive group and 80.5% in the noninvasive group (p <0.0001). Propensity score analysis, in which 499 patients of each group were analyzed after being matched for demographic and clinical data, confirmed the early and long-term benefits of the invasive strategy. In conclusion, applying the invasive strategy to patients with AMIs complicated by CS reduced in-hospital and 6-month mortality in patients aged ≥ 75 years.
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Kouz R, Kouz S, Schampaert E, Rinfret S, Tardif JC, Nguyen M, Eisenberg M, Harvey R, Afilalo M, Lauzon C, Dery JP, Mansour S, Huynh T. Effectiveness and safety of glycoprotein IIb/IIIa inhibitors in patients with myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis of observational studies. Int J Cardiol 2010; 153:249-55. [PMID: 20971515 DOI: 10.1016/j.ijcard.2010.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Revised: 06/13/2010] [Accepted: 08/08/2010] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Meta-analyses of randomized controlled trials (RCT) showed that glycoprotein IIb/IIIa inhibitors (GPI) are associated with reduced adverse events following primary percutaneous coronary revascularization (PCI). However, the external validity of RCTs is generally limited due to their restricted inclusion of patients. The objective of this study is to evaluate the effectiveness and safety of GPI, as adjuvant therapy for primary PCI in real-life patients with myocardial infarction with ST segment elevation (STEMI) from the general population. METHODS We identified all published peer-reviewed observational studies enrolling STEMI patients who underwent primary PCI. We performed random-effect meta-analyses to determine the association of GPI with major adverse events. RESULTS A total of 11 studies, enrolling 12,253 patients, were retained for this meta-analysis. GPI was associated with approximately 53% reduction in short-term mortality (odds ratio (OR): 0.47, 95% confidence intervals (CI): 0.32-0.68). There was a 62% reduction in long-term mortality associated with GPI (OR: 0.38, 95% CI: 0.30-0.50). GPI was associated with a 62% reduction in 30-day re-infarction (OR: 0.38, 95% CI: 0.24-0.60) and 42% reduction in 30-day repeat PCI (OR: 0.58, 95% CI: 0.36-0.94). A non-significant increase in major bleeding with GPI was observed with an OR of 1.55 (95% CI: 0.92-2.62). CONCLUSIONS GPI is associated with significant reductions in short-term mortality, re-infarction and repeat PCI, long-term mortality and an inconclusive increase in major bleeding. These results provide evidence for the safety and effectiveness of GPI as adjuvant therapy for primary PCI in real-life STEMI patients.
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Thiele H, Allam B, Chatellier G, Schuler G, Lafont A. Shock in acute myocardial infarction: the Cape Horn for trials? Eur Heart J 2010; 31:1828-35. [PMID: 20610640 DOI: 10.1093/eurheartj/ehq220] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Holger Thiele
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Strümpellstrasse 39, Leipzig, Germany.
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Mehta RH, Lopes RD, Ballotta A, Frigiola A, Sketch MH, Bossone E, Bates ER. Percutaneous coronary intervention or coronary artery bypass surgery for cardiogenic shock and multivessel coronary artery disease? Am Heart J 2010; 159:141-7. [PMID: 20102880 DOI: 10.1016/j.ahj.2009.10.035] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 10/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite advances in treatment of cardiogenic shock (CS), the incidence of this serious complication of acute ST-elevation myocardial infarction (STEMI) has stayed relatively constant, and rates of mortality, although somewhat improved in recent decades, remain dauntingly high. Although both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are used in patients with CS with multivessel coronary disease, the optimal revascularization strategy in this setting remains unknown. METHODS We conducted a literature search and review of English language publications on CS in multiple online medical databases. Studies were included if they were (1) randomized controlled trials or observational cohort studies, (2) single-center or multicenter reports, (3) prospective or retrospective studies, and (4) contained information on PCI and CABG. Non-English language studies were excluded. RESULTS Our search retrieved no published findings from randomized clinical trials, and only 4 observational reports evaluating PCI versus CABG. Our review of the limited available data suggests similar mortality rates with CABG and PCI in patients with STEMI and multivessel coronary disease complicated by CS. CONCLUSIONS Limited data from observational studies in patients with CS and multivessel disease suggest that CABG should be considered a complementary reperfusion strategy to PCI and may be preferred, especially when complete revascularization with PCI is not possible. Our data highlight the need for large randomized trials to further evaluate the relative benefit of PCI versus CABG in patients with multivessel coronary disease and CS using contemporary surgical and percutaneous techniques.
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De Luca G, Gibson CM, Huber K, Zeymer U, Dudek D, Cutlip D, Bellandi F, Noc M, Emre A, Zorman S, Gabriel HM, Maioli M, Rakowski T, Gyöngyösi M, Van't Hof AWJ. Association between advanced Killip class at presentation and impaired myocardial perfusion among patients with ST-segment elevation myocardial infarction treated with primary angioplasty and adjunctive glycoprotein IIb-IIIa inhibitors. Am Heart J 2009; 158:416-21. [PMID: 19699865 DOI: 10.1016/j.ahj.2009.06.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2009] [Accepted: 06/05/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although primary angioplasty has been shown to improve survival as compared with thrombolysis, the outcome is still unsatisfactory in subsets of patients such as those with signs of heart failure at presentation. In fact, although primary angioplasty is able to restore TIMI 3 flow in most patients, suboptimal myocardial reperfusion is observed in a relatively large proportion of patients. The aim of this study was to investigate among patients with ST-segment elevation myocardial infarction undergoing primary angioplasty the association between heart failure at presentation and myocardial perfusion and its implications in terms of survival. METHODS Our population is represented by patients undergoing primary angioplasty who are included in the EGYPT database. Congestive heart failure was defined as Killip class >1 at admission. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. RESULTS Detailed data on Killip class at presentation were available in 1,427 of 1,662 patients (86% of the initial population) who represent the final population of this study. Killip class was associated with myocardial perfusion, distal embolization, enzymatic infarct size, predischarge ejection fraction, and 1-year mortality rate. Myocardial blush was an independent predictor of 1-year mortality (hazard ratio 7.44, 95% CI 1.82-30.4, P = .005) in patients with advanced Killip class at presentation. CONCLUSIONS Our study shows that patients with heart failure complicating ST-segment elevation myocardial infarction have impaired myocardial perfusion, which accounts for the poor outcome observed in these patients. Further efforts should be aimed at improving myocardial perfusion, beyond epicardial recanalization, to further improve the outcome of these high-risk patients.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, "Maggiore della Carità" Hospital, Eastern Piedmont University, Novara, Italy.
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Lee KW, Norell MS. Cardiogenic shock complicating myocardial infarction and outcome following percutaneous coronary intervention. ACTA ACUST UNITED AC 2009; 10:131-43. [DOI: 10.1080/17482940801983006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Survival of Elderly Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2009; 2:146-52. [DOI: 10.1016/j.jcin.2008.11.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 10/14/2008] [Accepted: 11/07/2008] [Indexed: 11/20/2022]
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Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R, Hochman JS. Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease. Ann Thorac Surg 2008; 86:29-34. [PMID: 18573394 DOI: 10.1016/j.athoracsur.2008.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 03/05/2008] [Accepted: 03/07/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown. METHODS The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators. RESULTS The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p <or= 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival. CONCLUSIONS Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, CA 90095-171715, USA.
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De Luca G, Suryapranata H, Stone GW, Antoniucci D, Biondi-Zoccai G, Kastrati A, Chiariello M, Marino P. Coronary stenting versus balloon angioplasty for acute myocardial infarction: A meta-regression analysis of randomized trials. Int J Cardiol 2008; 126:37-44. [PMID: 17544528 DOI: 10.1016/j.ijcard.2007.03.112] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Revised: 02/21/2007] [Accepted: 03/28/2007] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Maggiore della Carità Hospital, Eastern Piedmont University, C.So Mazzini, 18, 24100 Novara, Italy.
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Brodie BR. What anti-thrombotic therapy is best with primary PCI for acute ST elevation myocardial infarction: How should the HORIZONS trial change current practice? Catheter Cardiovasc Interv 2008; 71:816-21. [DOI: 10.1002/ccd.21518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
The treatment of cardiogenic shock complicating the acute coronary syndromes consists of medical therapy, percutaneous revascularization procedures, cardiac surgery, and the implantation of devices. Medical therapy is limited to different positive inotropic and vasoactive drugs, without any firm evidence of survival benefit using these drugs. Several new pharmacologic compounds are at different stages of clinical research, but are not yet routinely approved for the treatment of cardiogenic shock. The only evidence-based therapy with proven survival benefit is timely revascularization. Intra-aortic balloon pump counterpulsation maintains its central role as supportive treatment in cardiogenic shock patients. Anecdotal evidence is available about the use of ventricular assist devices, cardiac resynchronization therapy, and emergent heart transplantation.
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Affiliation(s)
- Zaza Iakobishvili
- Intensive Cardiac Care Unit, Department of Cardiology, Rabin Medical Center, Beilinson Campus, 39 Jabotinsky Street, Petah Tikva, Israel 49100
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Srinivas VS, Skeif B, Negassa A, Bang JY, Shaqra H, Monrad ES. 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. Am J Cardiol 2007; 99:482-5. [PMID: 17293189 DOI: 10.1016/j.amjcard.2006.08.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 08/24/2006] [Accepted: 08/24/2006] [Indexed: 11/19/2022]
Abstract
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.
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Usman MHU, Shah MA, ul-Islam T, Adenwalla HN, Rahman F, Baqir M, Altaf M, Venkataraman R, Cherayil M, Berger S. Abciximab and fatal pulmonary hemorrhage. Heart Lung 2006; 35:423-6. [PMID: 17137944 DOI: 10.1016/j.hrtlng.2006.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2004] [Accepted: 06/06/2006] [Indexed: 11/17/2022]
Abstract
Abciximab, a platelet glycoprotein IIb/IIIa receptor blocker, is a well-known agent in percutaneous coronary intervention because of its antiplatelet, antithrombotic effects, which allow for good outcome. Major bleeding is a well-recognized complication of abciximab therapy, and pulmonary hemorrhage, although infrequent, is a serious, under-recognized, and often fatal complication. We describe a case of fatal pulmonary hemorrhage in a young woman who presented with acute myocardial infarction and cardiogenic shock and was treated with abciximab in conjunction with percutaneous coronary intervention. The possibility of diffuse pulmonary hemorrhage should be strongly suspected in the presence of hypoxemia, infiltrates on chest radiography, and a decrease in hemoglobin. Awareness about this complication of abciximab therapy on the part of physicians and health care professionals is strongly warranted. Therapy that may be used if diagnosis is promptly made includes bronchoscopic-guided balloon tamponade or iced saline lavage. These therapeutic interventions are still in the developmental stage, and to date there are no trials to document their efficacy and survival benefit.
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Affiliation(s)
- M Haris U Usman
- Department of Internal Medicine, Drexel University College of Medicine, Darby, Pennsylvania, USA
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Geppert A, Dorninger A, Delle-Karth G, Zorn G, Heinz G, Huber K. Plasma concentrations of interleukin-6, organ failure, vasopressor support, and successful coronary revascularization in predicting 30-day mortality of patients with cardiogenic shock complicating acute myocardial infarction. Crit Care Med 2006; 34:2035-42. [PMID: 16775569 DOI: 10.1097/01.ccm.0000228919.33620.d9] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Inflammation may play an important role in the pathogenesis, persistence, and prognosis of cardiogenic shock. We analyzed whether elevated plasma concentrations of inflammatory markers are independently associated with an adverse prognosis (increased 30-day mortality rate) in patients with cardiogenic shock. DESIGN Retrospective study. SETTING Single-center study, eight-bed intensive care unit at a university hospital. PATIENTS Retrospective study on stored plasma samples from 38 patients with cardiogenic shock complicating acute myocardial infarction. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-day nonsurvivors (n = 23, 61%) had been less frequently successfully revascularized, exhibited more frequently renal failure, needed higher vasopressor doses, and presented with significantly higher interleukin-6 plasma concentrations on intensive care unit admission than 30-day survivors. Univariate hazard ratios (95% confidence interval) for 30-day mortality were 1.49 (1.24-1.80) for every 50 pg/mL increase in the interleukin-6 plasma concentration (p = .00003), 1.06 (1.02-1.10) for every 0.1 microg x kg x min increase in the total vasopressor dose (p = .007), 1.14 (1.04-1.25) for every mmol/L increase in serum lactate (p = .006), 2.47 (1.06-5.73) for acute renal failure (p = .036), and 0.34 (0.14-0.82) for successful revascularization (p = .016). However, interleukin-6 plasma concentrations were correlated with vasopressor need and were significantly higher in patients with acute renal failure and in patients without or unsuccessful revascularization. In a multivariate Cox-proportional hazard model, interleukin-6 was the only significant predictor of 30-day mortality with a hazard ratio of 1.42 (1.12-1.80, p = .004). Accordingly, interleukin-6 concentrations > or =200 pg/mL (the point of maximum interest by receiver operating characteristic analysis with a specificity of 87% and a sensitivity of 74%) were associated with a significantly increased 30-day mortality rate in both patients with and patients without successful revascularization. CONCLUSIONS Interleukin-6 concentrations are an independent predictor of 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock.
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Affiliation(s)
- Alexander Geppert
- Intensive Care Unit, Third Department of Medicine with Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna
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41
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De Luca G, Ernst N, van 't Hof AWJ, Ottervanger JP, Hoorntje JCA, Gosselink ATM, Dambrink JHE, de Boer MJ, Suryapranata H. Predictors and clinical implications of early reinfarction after primary angioplasty for ST-segment elevation myocardial infarction. Am Heart J 2006; 151:1256-9. [PMID: 16781232 DOI: 10.1016/j.ahj.2005.06.047] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2005] [Accepted: 06/28/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recurrent infarction after fibrinolytic therapy has been shown to be associated with increased mortality. The aim of this study was to analyze predictors and outcome of reinfarction in a consecutive series of patients undergoing primary angioplasty. METHODS Our population is represented by a total of 1955 patients with ST-segment elevation myocardial infarction treated by primary angioplasty between 1997 to 2002. All clinical, angiographic, and follow-up data were prospectively collected. Early reinfarction was defined when two clinical criteria were satisfied within 30 days after the procedure: (1) recurrent ischemic symptoms for >15 minutes after resolution of symptoms from initial MI; (2) new ST-T-wave changes or new Q waves; (3) reelevation in creatine kinase (CK) or CK-MB to higher levels than normal (or by another 20% if already higher than normal). RESULTS Early reinfarction was observed in 75 (3.8%) patients. At multivariate analysis, advanced Killip class (P = .002), poor preprocedural TIMI flow (P = .014), administration of IIb-IIIa inhibitors (P = .02), and diabetes (P = .038) were independent predictors of 30-day reinfarction. A total of 107 (5.6%) patients had died. Early reinfarction was associated with a significantly higher mortality (22.7% vs 4.9%, P < .001), even after adjustment for confounding factors (blood pressure, diabetes, Killip class, preprocedural TIMI flow, coronary stenting, multivessel disease, anterior infarct location, preprocedural stenosis, and administration of IIb-IIIa inhibitors) (HR 3.32, 95% CI 1.88-5.84, P < .0001). CONCLUSIONS This study showed that, among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction, advanced Killip class at presentation, poor preprocedural TIMI flow, the use of IIb-IIIa inhibitors, and diabetes are independently associated with 30-day reinfarction. Early reinfarction is an independent predictor of 1-year mortality.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands
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Berger JS, Brown DL. Association of glycoprotein IIb/IIIa inhibitors and long-term survival following administration during percutaneous coronary intervention for acute myocardial infarction. J Thromb Thrombolysis 2006; 21:229-34. [PMID: 16683214 DOI: 10.1007/s11239-006-5706-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey S Berger
- Department of Medicine (Cardiovascular Medicine), Duke University, Durham, NC, USA
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Berger JS, Fridman V, Brown DL. Comparison of outcomes in acute myocardial infarction treated with coronary angioplasty alone versus coronary stent implantation. Am J Cardiol 2006; 97:977-80. [PMID: 16563899 DOI: 10.1016/j.amjcard.2005.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Revised: 10/31/2005] [Accepted: 10/31/2005] [Indexed: 11/15/2022]
Abstract
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).
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Affiliation(s)
- Jeffrey S Berger
- The Department of Medicine (Cardiovascular Medicine), State University of New York-Stony Brook School of Medicine, Stony Brook, New York
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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White HD, Assmann SF, Sanborn TA, Jacobs AK, Webb JG, Sleeper LA, Wong CK, Stewart JT, Aylward PEG, Wong SC, Hochman JS. 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. Circulation 2006; 112:1992-2001. [PMID: 16186436 DOI: 10.1161/circulationaha.105.540948] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland 1030, New Zealand.
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46
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Dawkins KD, Gershlick T, de Belder M, Chauhan A, Venn G, Schofield P, Smith D, Watkins J, Gray HH. Percutaneous coronary intervention: recommendations for good practice and training. Heart 2006; 91 Suppl 6:vi1-27. [PMID: 16365340 PMCID: PMC1876395 DOI: 10.1136/hrt.2005.061457] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.
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Affiliation(s)
- K D Dawkins
- British Cardiovascular Intervention Society, London, UK.
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Müller-Werdan U, Buerke M, Christoph A, Flieger R, Loppnow H, Prondzinsky R, Reith S, Schmidt H, Werdan K. Schock. KLINISCHE KARDIOLOGIE 2006. [PMCID: PMC7143837 DOI: 10.1007/3-540-29425-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Duvernoy CS, Bates ER. Management of cardiogenic shock attributable to acute myocardial infarction in the reperfusion era. J Intensive Care Med 2005; 20:188-98. [PMID: 16061902 DOI: 10.1177/0885066605276802] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Claire S Duvernoy
- Division of Cardiovascular Medicine and Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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De Luca G, Suryapranata H, Grimaldi R, Chiariello M. Coronary stenting and abciximab in primary angioplasty for ST-segment-elevation myocardial infarction. QJM 2005; 98:633-41. [PMID: 16040669 DOI: 10.1093/qjmed/hci097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Advances in anti-platelet therapy and improvement of stent deployment techniques have improved the safety and efficacy of stenting in the setting of ST-segment-elevation myocardial infarction (STEMI). However, in randomized trials, routine coronary stenting does not reduce mortality and re-infarction, compared to balloon angioplasty. Further, the benefits in target vessel revascularization seem to be reduced when applied to unselected patients with STEMI. Direct stenting represents an attractive strategy with potential benefits in terms of myocardial perfusion. Future large randomized trials are needed to evaluate whether this strategy has a significant impact on outcome, and to provide a cost-benefit analysis of the unrestricted use of drug-eluting stents in this high-risk subset of patients. The additional use of abciximab reduces mortality in primary angioplasty. Since the feasibility of long-distance transportation has been shown in several randomized trials, early pharmacological pre-treatment may confer further advantages by early recanalization and shorter ischaemic time, particularly in high-risk patients. Further randomized trials are needed to clarify the potential benefits from early abciximab administration and the potential role of small molecules in primary angioplasty for STEMI.
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Affiliation(s)
- G De Luca
- Division of Cardiology, Isala Klinieken, De Weezenlanden Hospital, Groot Wezenland, 20, 8011 JW, Zwolle, The Netherlands
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50
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De Luca G, van 't Hof AWJ, Ottervanger JP, Hoorntje JCA, Gosselink ATM, Dambrink JHE, Zijlstra F, de Boer MJ, Suryapranata H. Unsuccessful reperfusion in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Am Heart J 2005; 150:557-62. [PMID: 16169340 DOI: 10.1016/j.ahj.2004.10.044] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Accepted: 10/18/2004] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several studies have shown that patency of the epicardial vessel does not guarantee optimal myocardial perfusion in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify clinical and angiographic correlates of unsuccessful reperfusion by the use of myocardial blush grade in a large consecutive cohort of STEMI patients. METHODS Our population is represented by a total of 1,548 consecutive patients with STEMI treated by primary angioplasty at our institution. All clinical and angiographic data were prospectively collected. Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow with myocardial blush grades 2 to 3. RESULTS Poor myocardial reperfusion was observed in 358 patients (23.1%) and was associated with a significantly larger infarct size (1838 [350-3387] vs 1187 [607-2257], P < .0001) and lower ejection fraction (41 [31-48.2] vs 65 [36.5-52.5] P < .0001). At multivariate analysis, preprocedural TIMI flow 0 to 1, anterior infarction, ischemic time, postprocedural residual stenosis, advanced Killip class at presentation, and age were identified as independent predictors of poor myocardial reperfusion. At 1-year follow-up, a total of 92 patients (5.9%) had died. At multivariate analysis, including clinical and angiographic variables, unsuccessful reperfusion was an independent predictor of 1-year mortality (relative risk 3.11, 95% CI 1.99-4.87, P < .0001). CONCLUSIONS The prevalence of poor myocardial reperfusion is relatively high in patients undergoing primary angioplasty for STEMI, with a significant impact on 1-year mortality. Preprocedural TIMI flow, anterior infarction, ischemic time, Killip class at presentation, and age were independently associated with unsuccessful reperfusion. Future research should be focused on these high-risk patients, and treatment strategies should be developed to improve myocardial perfusion and clinical outcome.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken De Weezenlanden Hospital, 8011 JW Zwolle, The Netherlands
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