Cardiogenic Shock Following Acute Myocardial Infarction: What's New?

Biventricular dysfunction predicts mortality in ST elevation myocardial infarction patients with cardiogenic shock

BACKGROUND

The incidence of mortality in patients with cardiogenic shock due to ST elevation myocardial infarction (STEMI) remains high even with prompt reperfusion therapy. Ventricular systolic dysfunction is the primary condition causing cardiogenic shock in STEMI. Studies have been widely conducted on the left ventricle (LV) and right ventricle (RV) systolic dysfunction related to mortality events. However, the parameters of biventricular systolic dysfunction predicting mortality as a stronger predictor of mortality are still unclear. Accordingly, we evaluated the predictor mortality value of biventricular systolic dysfunction in STEMI patients with cardiogenic shocks. Based on The Society for Cardiovascular Angiography and Intervention classification, we analyzed data from November 2021 to September 2023 at Dr. Sardjito General Hospital in Yogyakarta, Indonesia, using the Sardjito Cardiovascular Intensive Care (SCIENCE) registry with a retrospective cohort design. Multivariate logistic regression analysis was used to assess predictors of in-hospital mortality.

RESULTS

There were 1,059 subjects with a mean ± SD age of 59 ± 11 years, dominated by men (80.5%) who met the inclusion and exclusion criteria. Based on multivariate analysis, biventricular dysfunction (BVD) is a factor that significantly increases the risk of in-hospital mortality (Odds ratio [OR], 1.771: 95% confidence interval [CI] 1.113-2.819; p = 0.016). Other significant factors affecting mortality were renal failure (OR, 5.122; 95% CI 3.233-8.116; p < 0.001), percutaneous coronary intervention (PCI) (OR, 0.493; 95% CI 0.248-0.981; p = 0.044), and inotropic/vasopressor (OR, 6.876; 95% CI 4.583-10.315; p < 0.001).

CONCLUSIONS

Biventricular dysfunction significantly increases the risk of in-hospital mortality in STEMI patients with cardiogenic shock. Renal failure, PCI, and the requirement for inotropic or vasopressor drugs are also factors that influence in-hospital mortality.

Efficacy and safety of percutaneous mechanical circulatory support in patients with cardiogenic shock following acute myocardial infarction: A meta-analysis of randomized controlled trials

BACKGROUND

Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI) with high mortality rates. While mechanical circulatory support devices like intra-aortic balloon pump (IABP) and Impella are used to manage CS, their comparative effectiveness remains unclear. This meta-analysis aims to evaluate the safety and efficacy of Impella in the treatment of AMI-associated CS.

METHODS

A comprehensive literature search was performed across PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science. The primary efficacy endpoint was 6-month all-cause mortality. Secondary efficacy endpoints included 30-day mortality, major bleeding, limb ischemia, sepsis, and left ventricular ejection fraction. Pooled odds ratios (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated using the random-effects model via Revman version 5.4. Statistical significance was determined at P < .05.

RESULTS

Four RCTs with a total of 442 patients were included in this meta-analysis. The pooled analysis showed that the odds of 6-month all-cause mortality were significantly lower with Impella compared to standard of care (OR: 0.64, 95% CI: 0.43-0.95; P value: .03). However, 30-day mortality reported no statistically significant difference between the 2 groups (OR: 1.03; 95% CI: 0.43-2.48; P = .95). Our analysis found that the use of impella is associated with a statistically significant increase in the odds of major bleeding (OR: 3.61; 95% CI: 1.14-11.40; P = .03), limb ischemia (OR: 4.91; 95% CI: 1.37-17.59; P = .01), and sepsis (OR: 2.75; 95% CI: 1.25-6.08; P = .01). No statistical significance was found in left ventricular ejection fraction at follow-up between the 2 groups (SMD: -0.35; 95% CI: -0.78 to 0.07; P = .11).

CONCLUSION

Impella significantly reduces 6-month all-cause mortality in patients with CS following AMI compared to standard of care. However, this survival benefit is offset by a substantial increase in major bleeding, limb ischemia, and sepsis risks associated with Impella. Future large scale trials are needed to validate these findings and refine clinical guidelines for the optimal use of Impella in treating CS.

VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION REDUCES MYOCARDIAL AND MITOCHONDRIAL DAMAGE IN ACUTE MYOCARDIAL INFARCTION

ABSTRACT

Background: Myocardial infarction (MI) is a common cardiovascular disease with a high fatality rate once accompanied by cardiogenic shock. The efficacy of extracorporeal membrane oxygenation (ECMO) in treating MI is controversial. Methods: MI was induced by ligating the left anterior descending artery (LAD) in adult male rats. Groups were defined as follows: MI group, reperfusion for 90 min after 30 min of LAD occlusion; MI + ECMO group, reperfusion and ECMO were performed for 90 min immediately after 30 min of LAD occlusion; prolonged MI + ECMO group, ECMO was used immediately after 30 min of occlusion with persistent occlusion of the LAD for an additional 30 min, followed by 90 min of reperfusion. The myocardial infarct size and mitochondrial morphology and function data were collected and compared of each group. Results: The ECMO groups had a smaller myocardial infarct size and larger percentage ejection fraction. Compared with the prolonged MI + ECMO group, the immediate reperfusion group had a lower percentage of infarct size (63.28% vs. 17.97% vs. 31.22%, MI vs. MI + ECMO vs. prolonged MI + ECMO). Mitochondria isolated from the ischemic zone showed an intact mitochondrial structure, including fewer voids and broken cristae, and preserved activity of mitochondrial complex II and complex IV in ECMO groups. Conclusions: ECMO support in MI can reduce myocardial injury despite delayed coronary reperfusion.

Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock

BACKGROUND

Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes.

METHODS

Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017.

RESULTS

A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups.

CONCLUSIONS

Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.

Clinical use of cangrelor: a real world multicenter experience from South Italy Insights from the M.O.Ca. registry

BACKGROUND

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and oral P2Y12 inhibitor (P2Y12-I) represents the standard of care for patients with acute coronary syndromes (ACS) or with chronic coronary syndromes (CCS) treated with percutaneous coronary intervention (PCI). Cangrelor, the first intravenous P2Y12-I, is deemed to overcome the drawbacks of the oral administration; nevertheless real world data on this new drug are scanty. We sought to investigate routine clinical use of cangrelor in four interventional centers of Italy.

METHODS

We enrolled 241 consecutive patients (196 ACS, 45 CCS) treated with cangrelor during PCI. Drug administration modalities and in-hospital clinical outcomes were evaluated. A subanalysis in patients selected on the basis of the CHAMPION Phoenix trial inclusion/exclusion criteria (CHAMPION-like subpopulation) was also performed.

RESULTS

Cangrelor was mainly utilized in ACS patients, who presented poorer clinical conditions and higher bleeding risk. Cangrelor was given only in P2Y12-I naïve patients; switch to clopidogrel was always done at the end of the infusion, while ticagrelor or prasugrel were prevalently given 30 minutes before. In-hospital mortality was 10.0% and GUSTO moderate/severe bleeding was 2.5%. Bleeding data showed nevertheless to be in line with the CHAMPION Phoenix results in the "CHAMPION-like" subpopulation.

CONCLUSIONS

Cangrelor was predominantly used in ACS with modalities substantially in accord with the label indications. Poor clinical outcomes are due to the prevalent utilization in highly challenging clinical settings, nevertheless the rate of bleeding and stent thrombosis are in line with the randomized trials if analyzed in a subpopulation of comparable risk profile.