Acute Myocardial Infarction Complicated by Cardiogenic Shock: Analysis of the Position Statement From the European Society of Cardiology Acute Cardiovascular Care Association, With Perioperative Implications

Rap1GAP exacerbates myocardial infarction by regulating the AMPK/SIRT1/NF-κB signaling pathway

Rap1 GTPase-activating protein (Rap1GAP) is an important tumor suppressor. The purpose of this study was to investigate the role of Rap1GAP in myocardial infarction (MI) and its potential mechanism. Left anterior descending coronary artery ligation was performed on cardiac-specific Rap1GAP conditional knockout (Rap1GAP-CKO) mice and control mice with MI. Seven days after MI, Rap1GAP expression in the hearts of control mice peaked, the expression of proapoptotic markers (Bax and cleaved caspase-3) increased, the expression of antiapoptotic factors (Bcl-2) decreased, and the expression of the inflammatory factors IL-6 and TNF-α increased; thus, apoptosis occurred, inflammation, infarct size, and left ventricular dysfunction increased, while the heart changes caused by MI were alleviated in Rap1GAP-CKO mice. Mouse heart tissue was obtained for transcriptome sequencing, and gene set enrichment analysis (GSEA) was used to analyze Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. We found that Rap1GAP was associated with the AMPK and NF-κB signaling pathways and that Rap1GAP inhibited AMPK/SIRT1 and activated the NF-κB signaling pathway in model animals. Similar results were observed in primary rat myocardial cells subjected to oxygen-glucose deprivation (OGD) to induce ischemia and hypoxia. Activating AMPK with the AMPK activator 5-aminoimidazole-4-carboxamide ribonucleoside (AICAR) reversed the damage caused by Rap1GAP overexpression in cardiomyocytes. In addition, the coimmunoprecipitation results showed that exogenous Rap1GAP interacted with AMPK. Rap1GAP was verified to regulate the AMPK SIRT1/NF-κB signaling pathway and exacerbate the damage to myocardial cells caused by ischemia and hypoxia. In conclusion, our results suggest that Rap1GAP promotes MI by modulating the AMPK/SIRT1/NF-κB signaling pathway and that Rap1GAP may be a therapeutic target for MI treatment in the future.

Dopamine versus norepinephrine as the first-line vasopressor in the treatment of cardiogenic shock

BACKGROUND

Only a few observational studies using small patient samples and one subgroup analysis have compared norepinephrine and dopamine for the treatment of cardiogenic shock (CS). The objective of the present study was to investigate whether the use of norepinephrine was associated with improvements in clinical outcomes in CS patients compared to dopamine.

METHODS

We retrospectively reviewed hospital medical records of patients who were admitted to cardiac intensive care unit from 2012 to 2018. We included 520 patients with CS in this analysis. The primary outcome was in-hospital mortality, and serial hemodynamic data were also assessed.

RESULTS

As a first-line vasopressor, dopamine was used in 156 patients (30%) and norepinephrine in 364 patients (70%). Overall, the norepinephrine group had significantly higher severity of shock, arrest at presentation, vital signs, and lactic acid than did the dopamine group at the time of vasopressor initiation. Nevertheless, in the norepinephrine group, additional vasopressor was required in 123 patients (33.8%), which was a significantly smaller percentage than the 92 patients (56.4%) in the dopamine group who required additional vasopressor (p < 0.001). There was no significant difference in in-hospital mortality between the two groups (26.9% and 31.9%, respectively, p = 0.26). In addition, the incidence of arrhythmia was not different between the two groups (atrial fibrillation, 12.2% vs. 15.7%, p = 0.30; ventricular tachyarrhythmia, 19.9% vs. 25.3%, p = 0.18).

CONCLUSIONS

The use of norepinephrine as a first-line vasopressor was not associated with reductions of in-hospital mortality or arrythmia but could reduce use of additional vasopressors in CS patients.

Cardiogenic Shock Does Not Portend Poor Long-Term Survival in Patients Undergoing Primary Percutaneous Coronary Intervention

Although a strong association of cardiogenic shock (CS) with in-hospital mortality in patients with acute coronary syndrome (ACS) is well established, less attention has been paid to its prognostic influence on long-term outcome. We evaluated the impact of CS in 1173 patients undergoing primary percutaneous coronary interventions between 1997 and 2009. Patients were followed up until the primary study endpoint (cardiovascular mortality) was reached. Within the entire study population, 112 (10.4%) patients presented with CS at admission. After initial survival, CS had no impact on mortality (non-CS: 23.5% vs. CS: 24.0%; p = 0.923), with an adjusted hazard ratio of 1.18 (95% CI: 0.77–1.81; p = 0.457). CS patients ≥ 55 years (p = 0.021) with moderately or severely impaired left ventricular function (LVF; p = 0.039) and chronic kidney disease (CKD; p = 0.013) had increased risk of cardiovascular mortality during follow-up. The present investigation extends currently available evidence that cardiovascular survival in CS is comparable with non-CS patients after the acute event. CS patients over 55 years presenting with impaired LVF and CKD at the time of ACS are at increased risk for long-term mortality and could benefit from personalized secondary prevention.

Cardiac Magnetic Resonance Assessment of the Protective Effect of Remote Ischemic Postconditioning on Coronary Microcirculation after Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction

This study intends to evaluate the characteristics of coronary microcirculatory function in patients with myocardial infarction undergoing reperfusion and its predictive value in assessing cardiac function, myocardial activity, recovery of ventricular wall motion after infarction, and distant myocardial remodeling by cardiac magnetic resonance technique (CMRI). Materials and Methods. The 293 cases of patients with myocardial infarction treated in our hospital from August 2017 to August 2021 were selected as the subjects of this retrospective study, 13 cases were shed due to transfer and moving, and the rest were divided into 140 cases each in the emergency and elective groups according to emergency percutaneous coronary intervention (PCI) and elective PCI. The patients' myocardial infarct volume ventricular volume, microcirculatory obstruction volume ventricular volume, microcirculatory obstruction volume/myocardial infarct volume, and LVEF, combined with BP and troponin T, were analysed by CMR for comparative analysis, hemodynamic, and cardiac function index differences. Results. The hemodynamics (CO, CI, SV, SI, LVSW1, and LCW) measured at different times were significantly different between the two groups; patients in the emergency group had significantly lower EDV and ESV than the elective group at 7-10 d postoperatively; and EDV, ESV, and LVEF improved in both groups after 3 months, while EDV, ESV, and LVEF improved significantly better in the emergency group than in the elective group, and the difference was statistically significant (P < 0.05). The myocardial infarct quality, VSM score, and ventricular wall motion abnormality score were significantly lower in the emergency group than in the elective group from 7 to 10 d after PCI; myocardial infarct quality, VSM score, and ventricular wall motion abnormality score improved in both groups at 3 months after PCI; and the degree of improvement of myocardial infarct quality and VSM score was significantly better in the emergency group than in the elective group (P < 0.05). Conclusion. Acute myocardial infarction patients with significant effect of emergency PCI treatment can be on their postmyocardial infarction left ventricular function, and in the treatment of coronary heart disease, myocardial infarction diagnosis has a certain reference value.