Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?

Electrocardiographic patterns and clinical outcomes of acute coronary syndrome cardiogenic shock in patients undergoing percutaneous coronary intervention - A propensity score analysis

OBJECTIVES

To determine the influence of presenting electrocardiographic (ECG) changes on prognosis in acute coronary syndrome cardiogenic shock (ACS-CS) patients undergoing percutaneous coronary angiography (PCI).

BACKGROUND

The effect of initial ECG changes such as ST-elevation myocardial infarction (STEMI) versus non-STEMI among patients ACS-CS on prognosis remains unclear.

METHODS

We analysed data from consecutive patients with ACS-CS enrolled in the Victorian Cardiac Outcomes registry between 2014 and 2020. Inverse probability of treatment weighting analysis (IPTW) was used to assess the effect of ECG changes on 30-day mortality.

RESULTS

Of 1564 patients with ACS-CS who underwent PCI, 161 had non-STEMI and 1403 had STEMI on ECG. The mean age was 66 ± 13 years, and 74 % (1152) were males. Patients with non-STEMI compared to STEMI were older (70 ± 12 vs 65 ± 13 years), had higher rates of diabetes (34 % vs 21 %), prior coronary artery bypass graft surgery (14 % vs 3.3 %), peripheral arterial disease (10.6 % vs 4.1 %, p < 0.01), and lower baseline eGFR (53.8 [37.1, 75.4] vs 65.3 [46.3, 87.8] ml/min/1.73m2), all p ≤ 0.01. Non-STEMI patients were more likely to have a culprit left circumflex artery (29 % vs 20 %) and more often underwent multivessel percutaneous coronary intervention (30 % vs 20 %) but had lower rates of out-of-hospital cardiac arrest (21 % vs 39 %), all p ≤ 0.01. Propensity score analysis with IPTW confirmed that non-STEMI ECG was associated with lower odds for 30-day all-cause mortality (OR 0.47 [0.32, 0.69], p < 0.001), and 30-day major adverse cardiovascular and cerebrovascular events (OR 0.48 [0.33, 0.70]).

CONCLUSIONS

In patients undergoing PCI, Non-STEMI as compared to STEMI on index ECG was associated with approximately half the relative risk of both 30-day mortality and 30-day MACCE and could be a useful variable to integrate in ACS-CS risk scores.

Timing of angiography and outcomes in patients with non-ST-segment elevation myocardial infarction: Insights from the evaluation and management of patients with acute chest pain in China registry

Objective

Although an invasive strategy has been recommended within 24 h for patients with non-ST-segment elevation myocardial infarction (NSTEMI), the optimal timing of the invasive strategy remains controversial. We sought to investigate the association between the different timings of invasive strategies and clinical outcomes in patients with NSTEMI.

Materials and methods

Patients admitted with NSTEMI from the Evaluation and Management of Patients with Acute ChesT pain in China (EMPACT) registry between January 2016 and September 2017 were included. The primary outcomes were major adverse cardiac events (MACEs) within 30 days. Multivariable logistic regression was performed to assess independent risk factors for MACEs.

Results

A total of 969 patients with NSTEMI from the EMPACT Registry were eligible for this study. Coronary angiography (CAG) was performed in 501 patients [<24 h, n = 150 (15.5%); ≥ 24 h, n = 351 (36.2%)]. The rate of MACEs at 30 days in all patients was 9.2%, including 54 (5.6%) deaths. Patients who underwent CAG had a lower rate of MACEs and mortality than those who did not receive CAG (MACEs: 5.6% vs. 13.0%, P < 0.001; mortality: 1.6% vs. 9.8%, P < 0.001). Nonetheless, no statistically significant difference was found in the rates of MACEs and mortality between the early (< 24 h) and delayed (≥ 24 h) CAG groups. Older age (OR: 1.036, 95% CI: 1.007, 1.065, P = 0.014), and acute heart failure (OR: 2.431, 95% CI: 1.244, 4.749, P = 0.009) increased the risk of MACEs and protective factors were underwent CAG (OR: 0.427, 95% CI: 0.219, 0.832, P = 0.012) or PCI (OR: 0.376, 95% CI: 0.163, 0.868, P = 0.022). In the multilevel logistic regression, older age (OR: 0.944, 95% CI: 0.932, 0.957, P < 0.001), cardiogenic shock (OR: 0.233, 95% CI: 0.079, 0.629, P = 0.009), pulmonary moist rales (OR: 0.368, 95% CI: 0.197, 0.686, P = 0.002), and prior chronic kidney disease (OR: 0.070, 95% CI: 0.018, 0.273, P < 0.001) was negatively associated with CAG.

Conclusion

This real-world cohort study of NSTEMI patients confirmed that the early invasive strategy did not reduce the incidence of MACEs and mortality within 30 days compared with the delayed invasive strategy in NSTEMI patients.

Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study

OBJECTIVE

To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States.

METHODS

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

RESULTS

In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased.

CONCLUSIONS

In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.

Clinical Outcomes According to ECG Presentations in Infarct-Related Cardiogenic Shock in the Culprit Lesion Only PCI vs Multivessel PCI in Cardiogenic Shock Trial

BACKGROUND

The impact of ECG presentations of acute myocardial infarction (AMI) in cardiogenic shock is unknown.

RESEARCH QUESTION

In myocardial infarction with cardiogenic shock, is there a difference in the outcomes and effect of revascularization strategies between non-ST-segment elevation myocardial infarction (NSTEMI) and left bundle branch block myocardial infarction (LBBBMI) vs ST-segment elevation myocardial infarction (STEMI)?

STUDY DESIGN AND METHODS

Cardiogenic shock patients from the CULPRIT-SHOCK trial with NSTEMI or LBBBMI were compared with STEMI patients for 30-day and 1-year all-cause mortality. The interaction between ECG presentation and the effect of revascularization strategies on outcomes was evaluated.

RESULTS

Of 665 cardiogenic shock patients analyzed, 55.9% demonstrated STEMI, 29.3% demonstrated NSTEMI, and 14.7% demonstrated LBBBMI. Patients differed in mean age (68.0 years in STEMI patients, 71.0 years in NSTEMI patients, and 73.5 years in LBBBMI patients; P = .015), cardiovascular risk factors, and angiographic severity. No difference was found in the 30-day risk of death between NSTEMI and STEMI patients (48.7% vs 43.0%; adjusted OR [aOR], 1.05; 95% CI, 0.66-1.67; P = .85), nor between LBBBMI and STEMI patients (59.2% vs 43.0%; aOR, 1.31; 95% CI, 0.73-2.34; P = .36). Although the univariate risk of death by 1 year was higher in NSTEMI and LBBBMI patients compared with STEMI patients, ECG presentation was not an independent risk factor of mortality after adjustment (NSTEMI vs STEMI: 56.4% vs 46.8%; aOR, 1.21; 95% CI, 0.76-1.92; P = .42; LBBBMI vs STEMI: 69.4% vs 46.8%; aOR, 1.59; 95% CI, 0.89-2.84; P = .12). ECG presentation did not modify the effect of the revascularization strategy on 30-day and 1-year mortality (P = .91 and P = .97 for interaction).

INTERPRETATION

In patients with cardiogenic shock, NSTEMI and LBBBMI presentations reflect higher-risk profiles than STEMI presentations, but are not independent risk factors of mortality. ECG presentations did not modify the treatment effect, supporting culprit-lesion-only percutaneous coronary intervention as the preferred strategy across the AMI spectrum.

Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry

Background

Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI).

Methods and Results

Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score.

Conclusions

Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study

AIM

We sought to describe the contemporary annual incidence of cardiogenic shock (CS) following acute myocardial infarction (AMICS), the proportion of patients developing CS following ST-elevation myocardial infarction (STEMI), and other temporal changes in AMICS in Denmark between 2010 and 2017.

METHODS AND RESULTS

Medical records of patients suspected of having AMICS during 2010-2017 were reviewed to identify consecutive patients with AMICS in a cohort corresponding to two-thirds of the Danish population. Due to changes in recruitment area over the study period, population-based incidence could only be calculated from 2012 to 2017. A total of 1716 patients with AMICS were identified and an increase in the annual incidence was observed, from a nadir 65.3 per million person-years in 2013 to 80.0 per million person-years in 2017 (P-value for trend < 0.001). This trend corresponded to an increase in patients with non-STEMI and a decrease in patients developing CS after STEMI (10.0-6.6%, P-value for trend < 0.001) Also, mean arterial blood pressure at the time of AMICS was lower (63 ± 11 mmHg to 61 ± 13 mmHg, P-value for trend = 0.001) and the frequency of patients with left ventricular ejection fraction ≤ 30% increased (61.8%-71.4%, P-value for trend = 0.004). The annual 30-day mortality during the study period remained unchanged at about 50%.

CONCLUSION

The incidence rate of AMICS increased in the Danish population between 2012 and 2017. Fewer patients with STEMI developed CS, and haemodynamic severity of CS increased during the study period; however, survival rates remained unchanged.

Revascularization Strategies for Non-ST-Elevation Myocardial Infarction

PURPOSE OF REVIEW

Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics.

RECENT FINDINGS

The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.

Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.

Cardiogenic Shock

Cardiogenic shock (CS) is a physiologic state in which cardiac pump function is inadequate to perfuse the tissues. If CS is not rapidly recognized and treated, tissue hypoperfusion can quickly lead to organ dysfunction and patient death. Evaluation of patients with suspected CS should include an electrocardiogram, chest radiograph, laboratory studies, and bedside echocardiogram. Initial resuscitation is directed toward restoring cardiac output and tissue perfusion. Mechanical circulatory support is indicated for patients with CS who do not respond to pharmacologic therapy. Ultimately, these patients should undergo emergent reperfusion therapy with either percutaneous coronary intervention or coronary artery bypass grafting.

Predictive value of the baseline electrocardiogram ST-segment pattern in cardiogenic shock: Results from the CardShock Study

BACKGROUND

The most common aetiology of cardiogenic shock (CS) is acute coronary syndrome (ACS), but even up to 20%-50% of CS is caused by other disorders. ST-segment deviations in the electrocardiogram (ECG) have been investigated in patients with ACS-related CS, but not in those with other CS aetiologies. We set out to explore the prevalence of different ST-segment patterns and their associations with the CS aetiology, clinical findings and 90-day mortality.

METHODS

We analysed the baseline ECG of 196 patients who were included in a multinational prospective study of CS. The patients were divided into 3 groups: (a) ST-segment elevation (STE). (b) ST-segment depression (STDEP). (c) No ST-segment deviation or ST-segment impossible to analyse (NSTD). A subgroup analysis of the ACS patients was conducted.

RESULTS

ST-segment deviations were present in 80% of the patients: 52% had STE and 29% had STDEP. STE was associated with the ACS aetiology, but one-fourth of the STDEP patients had aetiology other than ACS. The overall 90-day mortality was 41%: in STE 47%, STDEP 36% and NSTD 33%. In the multivariate mortality analysis, only STE predicted mortality (HR 1.74, CI₉₅ 1.07-2.84). In the ACS subgroup, the patients were equally effectively revascularized, and no differences in the survival were noted between the study groups.

CONCLUSION

ST-segment elevation is associated with the ACS aetiology and high mortality in the unselected CS population. If STE is not present, other aetiologies must be considered. When effectively revascularized, the prognosis is similar regardless of the ST-segment pattern in ACS-related CS.

Risk Stratification and in Hospital Morality in Patients Presenting with Acute Coronary Syndrome (ACS) in Bahrain

Background:

Risk factors and short-term mortality in patients presented with Acute Coronary Syndrome (ACS) in Bahrain has not been evaluated before.

Aim:

In this prospective observational study, we aim to determine the clinical risk profiles of patients with ACS in Bahrain and describe the incidence, pattern of presentation and predictors of in-hospital clinical outcomes after admission.

Methods:

Patients with ACS were prospectively enrolled over a 12 month period. The rate of incidence of risk factors in patients was compared with 635 non-cardiac patient admissions that matched for age and gender. Multiple logistic regression analysis was used to predict poor outcomes in patients with ACS. The variables were ages >65 years, body mass index (BMI) >28 kg/m², GRACE (Global Registry of Acute Coronary Events) score >170, history of diabetes mellitus (DM), systolic hypertension >180 mmHg, level of creatinine >160 μmol/l and Heart Rate (HR) on admission >90 bpm, serum troponin rise and ST segment elevation on the ECG.

Results:

Patients with ACS (n=635) were enrolled consecutively. Mean age was 61.3 ± 13.2 years, with 417 (65.6%) male. Mean age for patients with ST-segment elevation myocardial infarction (STEMI, n=156) compared with non-STEMI (NSTEMI, n=158) and unstable angina (UA, n=321) was 56.5± 12.8 vs 62.5±14.0 years respectively. In-hospital mortality was 5.1%, 3.1% and 2.5% for patients with STEMI, NSTEMI, and UA, respectively. In STEMI patients, thrombolytic therapy was performed in 88 (56.5%) patients and 68 (43.5%) had primary coronary angioplasty (PCI). The predictive value of different clinical variables for in-hospital mortality and cardiac events in the study were: 2.8 for GRACE score >170, 3.1 for DM, 2.2 for SBP >180 mmHg, 1.4 for age >65 years, 1.8 for BMI >28, 1.7 for creatinine >160 μmol/L, 2.1 for HR >90 bpm, 2.2 for positive serum troponin and 2.3 for ST elevation.

Conclusion:

Patients with STEMI compared with NSTEMI and UA were of younger age. There was higher in-hospital mortality in STEMI compared with NSTEMI and UA patients. The most significant predictors of death or cardiac events on admission in ACS were DM, GRACE Score >170, systolic hypertension >180 mmHg, positive serum troponin and HR >90 bpm.

Acute myocardial infarction and lesion location in the left circumflex artery: importance of coronary artery dominance

AIMS

Due to the limitations of 12-lead ECG, occlusions of the left circumflex artery (LCX) are more likely to present as non-ST-elevation acute coronary syndrome (NSTEACS) compared with other coronary arteries. We aimed to study mortality in patients with LCX lesions and to assess the importance of coronary artery dominance on triage of these patients.

METHODS AND RESULTS

From the Eastern Danish Heart Registry, 3,632 NSTEACS and 3,907 ST-elevation myocardial infarction (STEMI) consecutive, single-vessel disease patients were included. LCX was the culprit in 25% of NSTEACS and 14% of STEMIs (p<0.001). LCX lesions presented predominantly as STEMI in left dominant coronary arteries compared with NSTEACS (46% vs. 30%, p<0.001). Higher 30-day mortality was found in LCX-STEMI compared with LCX-NSTEACS (HR 7.9, 95% CI: 3.2-19.7, p<0.001) with no difference in long-term mortality (HR 0.9, 95% CI: 0.7-1.2, p=0.5). LCX-NSTEACS were not associated with higher mortality compared with other NSTEACS lesions.

CONCLUSIONS

The 12-lead ECG seems sufficient for triage of patients with LCX lesions as a majority of patients with a large LCX due to a dominant left coronary artery present as STEMI. Patients with LCX-NSTEACS do not have higher mortality compared with patients with LCX-STEMI or NSTEACS with lesions in other coronary territories.

Early Invasive Strategy for Unstable Angina: a New Meta-Analysis of Old Clinical Trials

Randomized controlled trials (RCTs) were conflicting to support whether unstable angina versus non-ST-elevation myocardial infarction (UA/NSTEMI) patients best undergo early invasive or a conservative revascularization strategy. RCTs with cardiac biomarkers, in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1975-2013 were reviewed considering all cause mortality, recurrent non-fatal myocardial infarction (MI) and their combination. Follow-up lasted from 6-24 months and the use of routine invasive strategy up to its end was associated with a significantly lower composite of all-cause mortality and recurrent non-fatal MI (Relative Risk [RR] 0.79; 95% confidence interval [CI], 0.70-0.90) in UA/NSTEMI. In NSTEMI, by the invasive strategy, there was no benefit (RR 1.19; 95% CI, 1.03-1.38). In the shorter time period, from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the combined end-point among UA/NSTEMI (RR 1.29; 95% CI, 1.05-1.58) and NSTEMI (RR 1.82; 95% CI, 1.34-2.48) patients. Therefore, in trials recruiting a large number of UA patients, by routine invasive strategy the largest benefit was seen, whereas in NSTEMI patients death and non-fatal MI were not lowered. Routine invasive treatment in UA patients is accordingly supported by the present study.

Trends in Coronary Angiography, Revascularization, and Outcomes of Cardiogenic Shock Complicating Non-ST-Elevation Myocardial Infarction

Early revascularization is the mainstay of treatment for cardiogenic shock (CS) complicating acute myocardial infarction. However, data on the contemporary trends in management and outcomes of CS complicating non-ST-elevation myocardial infarction (NSTEMI) are limited. We used the 2006 to 2012 Nationwide Inpatient Sample databases to identify patients aged ≥ 18 years with NSTEMI with or without CS. Temporal trends and differences in coronary angiography, revascularization, and outcomes were analyzed. Of 2,191,772 patients with NSTEMI, 53,800 (2.5%) had a diagnosis of CS. From 2006 to 2012, coronary angiography rates increased from 53.6% to 60.4% in patients with NSTEMI with CS (ptrend <0.001). Among patients who underwent coronary angiography, revascularization rates were significantly higher in patients with CS versus without CS (72.5% vs 62.6%, p <0.001). Patients with NSTEMI with CS had significantly higher risk-adjusted in-hospital mortality (odds ratio 10.09, 95% confidence interval 9.88 to 10.32) as compared to those without CS. In patients with CS, an invasive strategy was associated with lower risk-adjusted in-hospital mortality (odds ratio 0.43, 95% confidence interval 0.42 to 0.45). Risk-adjusted in-hospital mortality, length of stay, and total hospital costs decreased over the study period in patients with and without CS (ptrend <0.001). In conclusion, we observed an increasing trend in coronary angiography and decreasing trend in in-hospital mortality, length of stay, and total hospital costs in patients with NSTEMI with and without CS. Despite these positive trends, overall coronary angiography and revascularization rates remain less than optimal and in-hospital mortality unacceptably high in patients with NSTEMI and CS.

Intracoronary electrocardiogram ST-segment elevation in patients with non-ST-segment elevation myocardial infarction and its association with culprit lesion location and myocardial injury

AIMS

An intracoronary electrocardiogram (IC-ECG) is a sensitive method to detect local myocardial ischaemia. We investigated the prevalence of IC-ECG ST-segment elevation (STE) with respect to culprit lesion location in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and its relationship with elevated levels of cardiac biomarkers.

METHODS AND RESULTS

We examined 87 NSTEMI patients who underwent IC-ECG recording by locating the insulated polymer-coated guidewire distal to the culprit lesion before percutaneous coronary intervention (PCI). Cardiac biomarkers were serially examined. IC-ECG STE was observed in 24 patients (27.6%) before PCI, and was significantly more frequent in patients with LCx culprit lesions (LAD vs. LCx vs. RCA, 12.1% vs. 53.3% vs. 16.7%; p<0.001). Peak cardiac troponin I (cTnI) values were associated with IC-ECG STE, ejection fraction (EF), cTnI values on admission, and type B2/C lesions. In multivariate analysis, IC-ECG STE (odds ratio [OR], 5.04; 95% confidence intervals [CI]: 1.51-16.85; p=0.009), and EF (OR, 0.95; 95% CI: 0.90-1.00; p=0.043) were predictors of greater peak cTnI values.

CONCLUSIONS

IC-ECG STE was not uncommon in NSTEMI patients, particularly those with LCx culprit lesions. IC-ECG monitoring before PCI may help identify NSTEMI patients with high risk of greater myocardial injury.

Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR

BACKGROUND

Cardiogenic shock is a deadly complication of an acute myocardial infarction (MI). We sought to characterize differences in patient features, treatments, and outcomes of cardiogenic shock by MI classification: ST-segment-elevation MI (STEMI) versus non-ST-segment elevation MI (NSTEMI).

METHODS AND RESULTS

We compared differences in care by the shock status of 235 541 patients with STEMI and NSTEMI treated at 392 US hospitals from 2007 to 2011. Cardiogenic shock occurred in 12.2% of patients with STEMI versus 4.3% of patients with NSTEMI. Compared with STEMI shock, NSTEMI shock was more likely in patients who were older and predominantly women; had diabetes mellitus, hypertension, previous heart failure, MI, or peripheral arterial disease; and who received coronary artery bypass grafting (11.6% versus 21.2%; P<0.0001) but less likely to have received percutaneous coronary intervention (84.2% versus 35.3%; P<0.0001). Compared with patients with STEMI presenting with shock at admission, patients with NSTEMI presenting with shock had longer delays to percutaneous coronary intervention (1.2 versus 3.2 hours) and coronary artery bypass grafting (7.9 versus 55.9 hours). Cardiogenic shock in patients with STEMI was associated with a lower mortality risk (33.1% shock versus 2.0% no shock; adjusted odds ratio, 14.1; 95% confidence interval, 13.0-15.4; interaction P value <0.0001) compared with patients with NSTEMI (40.8% shock versus 2.3% no shock, odds ratio, 19.0; 95% confidence interval, 17.1-21.2).

CONCLUSIONS

Cardiogenic shock is associated with high mortality in patients with STEMI and NSTEMI. However, urgent revascularization is more commonly pursued in patients with STEMI presenting with shock than in patients with NSTEMI. More research is needed to improve the outcomes for patients with MI presenting with shock, particularly those presenting with NSTEMI.

Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improve survival of patients with acute myocardial infarction complicated by profound cardiogenic shock

PURPOSE

The aim of this study was to evaluate the impact of extracorporeal membrane oxygenation (ECMO) assistance on the clinical outcome of patients with acute myocardial infarction (AMI) that is complicated by profound cardiogenic shock (CS) who received primary percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

We collected patients from January 2004 through December 2006 (stage 1); 25 patients who presented with AMI and received primary PCI and had profound CS were enrolled in the study. Intraaortic balloon counterpulsation (IABP) was the only modality for extracorporeal support in our hospital. From January 2007 through December 2009 (stage 2), 33 patients who presented with AMI and received primary PCI and had profound CS were enrolled; for this stage; both intra-aortic balloon counter-pulsation and ECMO support were available in our facility.

RESULTS

A Kaplan-Meier survival analysis displayed significantly improved survival for patients in stage 2 (P = .001; 1-year survival in stage 1 vs 2; 24% vs 63.64%). Patients presenting with either STEMI (ST segment elevation myocardial infarction) or NSTEMI (Non-ST segment elevation myocardial infarction) benefited from ECMO-assisted PCI (P < .05). In stage 1, patients with refractory ventricular tachycardia/ventricular fibrillation had a very low survival rate; however, in stage 2, the survival rate of patients with and without refractory ventricular tachycardia/ventricular fibrillation was similar (P = .316).

CONCLUSION

Extracorporeal membrane oxygenation-assisted PCI for patients with AMI that is complicated by profound CS may improve the 30-day and 1-year survival rates.

Routine invasive versus conservative management in non-ST-elevation acute coronary syndromes

Coronary angiography as part of the management of non-ST-segment-elevation acute coronary syndrome (ACS) patients has several advantages but also carries some risks if done routinely. The advantage of a planned early invasive approach in moderate to high-risk patients appears to be clear and is recommended by guidelines. This is often not mirrored by real world practice; however, only about 50% to 70% of ACS patients do undergo a diagnostic catheterization. In addition, the optimal timing of an angiography or intervention in relation to contemporary antithrombotic regimens remains unclear. In this paper, the current evidence for routine invasive management as well as the timing of catheterization in non-ST-ACS is reviewed.

A review of cardiogenic shock in acute myocardial infarction

Cardiogenic shock continues to be the most common cause of death in patients hospitalized with acute myocardial infarction. It has also been frequently associated with ST-segment elevation myocardial infarction (STEMI) and patients with co-morbidities. Cardiogenic shock presents with low systolic blood pressure and clinical signs of hypoperfusion. Rapid diagnosis and supportive therapy in the form of medications, airway support and intra-aortic balloon counterpulsation is required. Initial stabilization can be followed by reperfusion by fibrinolytic therapy, emergent percutaneous intervention (PCI) or coronary artery bypass grafting (CABG). The latter two have been found to decrease mortality in the long term. Research is being carried out on the role of inflammatory mediators in the clinical manifestation of cardiogenic shock. Mechanical support devices also show promise in the future.

Predictors and in-hospital outcomes of cardiogenic shock on admission in patients with acute coronary syndromes admitted to hospitals without on-site invasive facilities

BACKGROUND

The purpose was to identify predictors of cardiogenic shock (CS) on admission and to asses associations between CS and real-life management patterns and outcomes in unselected cohort of acute coronary syndrome (ACS) patients admitted to hospitals without onsite invasive facilities.

METHODS

Data concerning in-hospital management and mortality of 56 (4.3%) patients with and 1257 (95.7%) without CS on hospital admission was assessed.

RESULTS

Prior myocardial infarction, prior heart failure symptoms, age, and diabetes mellitus were independently associated with increased risk of CS on admission. A total of 23.8% patients were transferred for invasive treatment during index hospital stay and the frequency of transfer was similar among patients with and without CS on admission (21.4% versus 23.9%; P = 0.75), but in the STEMI subgroup, patients with shock were transported less frequently (21.4% versus 43.8%; P = 0.0027). CS patients were less likely to receive guideline-recommended therapies including antiplatelet drugs, statins, and beta-blockers. In-hospital mortality was lower in non-shock patients (6.2% versus 63.6%; P < 0.001) and CS on admission was an independent predictor of in-hospital death.

CONCLUSIONS

CS on admission is an important determinant of treatment strategy selection and is associated with unfavorable prognosis of ACS patients admitted to hospitals without on-site invasive facilities.

Critical care aspects in the management of patients with acute coronary syndromes

The spectrum of acute coronary syndromes (ACS) includes several clinical complexes that frequently cause critical instability in affected patients. This article focuses on several critical care aspects of these unstable ACS patients. The management of cardiogenic shock can be particularly challenging because the mechanical defects are varied in cause, severity, and specific treatment. Complications of fibrinolytic therapy are potentially deadly and arrhythmias are relatively common in the ACS patients. Discussions on the management of these problems should help the emergency physician more effectively to treat critically ill patients with ACS.

The evaluation and management of cardiogenic shock

Cardiogenic shock (CS) continues to be the leading cause of death in patients who present to the hospital with acute myocardial infarction (AMI). Mortality in patients with AMI complicated by CS remains extremely high, with 1-month mortality rates ranging from 40% to 60%. Although pump failure is the dominant etiologic feature of CS after AMI, the inflammatory system has been implicated in its pathogenesis. The dominant therapy for treatment of CS is early mechanical revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. Supportive measures such as intravenous vasopressors or intra-aortic balloon counterpulsation can complement the benefit of definitive revascularization. Newer therapies are directed at mitigating the inflammatory response or supporting cardiovascular function until either patient recovery or until other destination therapy is available. The strategies in this critical pathway outline the general approach in treating CS after AMI at our institution.

Cardiogenic shock

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

More aggressive pharmacological treatment may improve clinical outcome in patients with non-ST-elevation acute coronary syndromes treated conservatively

INTRODUCTION

Increased adherence to guideline-recommended therapies, especially early invasive strategy introduction may improve clinical outcome in patients with non-ST-elevation acute coronary syndromes. The aim of this study was to assess the impact of more aggressive pharmacological treatment and application of current guidelines in everyday clinical practice in hospitals without on-site invasive facility, with a special focus on its influence on in-hospital mortality in non-ST-elevation acute coronary syndromes patients.

METHODS

We identified 807 non-ST-elevation acute coronary syndromes patients treated conservatively in the 29 hospitals participating in the Malopolska Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. For all patients, pharmacotherapy index based on the use of pharmacological treatment regimen during hospital stay was assessed. Each patient received 1 point for each of the following guideline-recommended drugs used: aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitor, low-molecular-weight heparin, beta-blocker, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, statin - range of points from 0 to 7.

RESULTS

The in-hospital mortality decreased with increase of pharmacotherapy index (0 points - 80.0%, 1 point - 36.4%, 2 points - 17.4%, 3 points - 7.6%, 4 points - 5.6%, 5 points - 1.7%, 6 points - 0.0%; P<0.0001, total mortality-5.3%). Independent predictors of in-hospital death were cardiogenic shock, thrombolysis in myocardial infarction (TIMI) risk score, renal insufficiency and pharmacotherapy index.

CONCLUSIONS

Our findings support the need for more aggressive pharmacological treatment of patients with non-ST-elevation acute coronary syndromes remaining in community hospitals for conservative treatment. Broader implementation of current guidelines and more frequent invasive treatment could improve the outcomes of non-ST-elevation acute coronary syndromes patients.

Cardiogenic shock: treatment

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.

Update on the management of cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock. Particular attention is given to pharmacologic advances.

RECENT FINDINGS

Cardiogenic shock continues to occur in 5-10% of patients who suffer a myocardial infarction and the mortality remains over 50% in most studies. Treatment preference is referral to a cardiac center capable of reperfusion using multiple therapies. While no delay in reperfusion is acceptable, emphasis on implementing supportive treatment such as vasopressors, inotropes, and fluids remains critical. There is a wide variance in treatment standards despite established guidelines. Overall mortality from cardiogenic shock has decreased but the incidence remains unchanged.

SUMMARY

Emerging pharmacological interventions designed to counteract the underlying proinflammatory pathophysiologic mechanisms may, in combination with early revascularization, result in improved patient outcomes, but there is no magic bullet on the horizon. Attention to the timeliness of transport and treatment of patients with a focus on revascularization is required for cardiogenic shock patients.

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

BACKGROUND

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

METHODS

Using the National Hospital Discharge Survey data from 1979 to 2003, we measured trends in the incidence of AMI complicated by cardiogenic shock, the use of percutaneous transluminal coronary angioplasty (PTCA), and the inhospital death.

RESULTS

Age-adjusted hospitalization rates (per 100,000 populations) in 1979 and 2003, respectively, were 213 and 261 for AMI, and 8.6 and 4.3 for AMI complicated by cardiogenic shock. Among patients with AMI, the proportion with cardiogenic shock was 3.9% (n = 17,000) in 1979 and 1.7% (n = 13,000) in 2003. Patients with acute myocardial infarction with cardiogenic shock, compared with those without cardiogenic shock, were more likely to be women (48% vs 43%, P < .0001), more likely to have anterior wall AMI (33% vs 14%, P < .0001), and had much higher inhospital mortality (43% vs 7%, P < .0001). Over the years, among AMI complicated by cardiogenic shock, PTCA use increased substantially from 0% to 28%. During this period, inhospital death decreased from 84% to 43%. After adjustment for age, sex, location of AMI, health insurance, and survey year, PTCA use was significantly associated with decreased inhospital deaths among patients with AMI with cardiogenic shock.

CONCLUSIONS

Although hospitalization for AMI has increased over the past 25 years, the hospitalization rate of AMI complicated by cardiogenic shock has decreased by 50%. At the same time, PTCA use and hospital survival have increased substantially among cardiogenic shock patients.

Clinical profile, contemporary management and one-year mortality in patients with severe acute heart failure syndromes: The EFICA study

BACKGROUND

Little is known about the epidemiology of acute decompensated heart failure (ADHF) in patients admitted to intensive and coronary care units (ICU/CCU). Observational data may improve disease management and guide the design of clinical trials.

AIMS

EFICA is an observational study of the clinical profile, management and survival of ADHF patients admitted to ICU/CCU.

METHODS

The study included 599 patients admitted to 60 ICU/CCUs across France. Relevant data was recorded during hospitalisation. Survival was assessed at 4 weeks and 1 year.

RESULTS

The main cause of ADHF was ischaemic heart disease (61%); 29% of patients had cardiogenic shock. Mortality was 27.4% at 4 weeks and 46.5% at 1 year, increasing to 43.2% and 62.5%, respectively, when including pre-admission deaths. Shock patients had the highest [57.8% vs. 15.2% without shock (p < 0.001)] and patients with hypertension and pulmonary oedema had the lowest 4-week mortality: (7%). Pre-admission NYHA class III-IV heart failure, not initial clinical presentation, influenced 1-year mortality.

CONCLUSION

ADHF is a heterogeneous syndrome. Based on initial clinical presentation, three entities with distinct features and outcome may be described: cardiogenic shock, pulmonary oedema with hypertension, and 'decompensated' chronic heart failure. This should be taken into account in future observational studies, guidelines and clinical trials.

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.

Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.

Akute Herzinsuffizienz und kardiogener Schock

Irrespective of improved medical and interventional therapeutic options, mortality among patients with acute heart failure and cardiogenic shock has remained disappointingly high. Early diagnosis and rapid initiation of basic treatment measures to improve hemodynamics and metabolism are of vital importance until causal therapy, e. g. revascularization, is initiated. Due to the principal difficulty to set up larger clinical trials, in patients with cardiogenic shock empirical rather than firm evidence supports the various treatment and management strategies currently in use. Continuous hemodynamic monitoring to tailor fluid therapy, new drugs, and prognostic markers have been developed for the treatment and monitoring of cardiogenic shock, all of which await testing in larger-scale studies. Ongoing challenges remain the right ventricular pump failure or hemodynamically compromising arrhythmia which may be either cause or consequence of cardiogenic shock.

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.

Management strategies for cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock remains the most serious complication of acute MI, with an incidence of 6 to 8% and a 30-day mortality rate that remains close to 50%. While cardiogenic shock is due primarily to left ventricular failure, other causes such as acute mitral regurgitation and ventricular septal rupture must always be considered as emergency surgery may be life saving. The purpose of this review is to summarize recent advances in the care of these critically ill patients including the consideration of etiology and pathophysiology as well as the influence of age and adjunctive therapies.

RECENT FINDINGS

Early revascularization is now an American College of Cardiology/American Heart Association guideline class 1 indication for percutaneous coronary intervention (PCI) particularly for younger patients in cardiogenic shock. Recent studies suggest there may also be a benefit in elderly patients with cardiogenic shock.

SUMMARY

Prompt triage of all patients in cardiogenic shock for early angiography, intra-aortic balloon pump counterpulsation, and early revascularization with PCI or bypass surgery is now the preferred management strategy.

Outcomes of elderly patients with cardiogenic shock treated with early percutaneous revascularization

BACKGROUND

Subgroup analysis from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial indicated that patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) who were > or =75 years old did not benefit from early revascularization and may have been harmed; their mortality rate at 30 days was 75%. The applicability of this subset analysis from a select patient population enrolled in a randomized trial to the general population is unclear.

METHODS

At the Mayo Clinic between 1991 and 2000, we evaluated the outcome of all patients > or =75 years old with CS caused by MI who underwent urgent percutaneous coronary intervention (PCI).

RESULTS

The study included 61 patients with a mean age of 79.5 +/- 3 years; 21% of these patients had a history of prior coronary artery bypass grafting (CABG), 41% had had a prior MI, 28% had diabetes mellitus, and 18% had a history of a cerebrovascular accident (CVA). PCI was performed 8.0 +/- 7.2 hours after onset of MI. Angiographic success (<50% residual stenosis) was achieved in 91% of the lesions that were dilated. In hospital outcomes included death (44%), CABG (1.6%), and CVA (4.9%). The 30-day mortality rate was 47%. The estimated survival rate 1 year after discharge (Kaplan Meier method) was 75%.

CONCLUSIONS

These data confirm a high early mortality rate among patients > or =75 years old with MI complicated by CS, but suggest that among patients referred for angiography, outcomes may be better than previously believed when early revascularization is performed. In this population, 56% of patients survived to be discharged from the hospital, and of the hospital survivors, 75% were alive at 1 year.