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Lee KH, Harrison W, Chow KL, Lee M, Kerr AJ. Cardiogenic Shock Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: Outcomes and Predictors of Mortality (ANZACS-QI 73). Heart Lung Circ 2024; 33:450-459. [PMID: 38453606 DOI: 10.1016/j.hlc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 12/22/2023] [Accepted: 01/01/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND & AIMS Cardiogenic shock (CS) is a serious complication of acute myocardial infarction (MI) and is associated with significant mortality. We describe a contemporary, real-world cohort of patients with ST-elevation MI (STEMI) and CS, including 30-day mortality and clinically relevant predictors of mortality. METHODS All patients presenting with STEMI who were treated with percutaneous coronary intervention (PCI) in New Zealand (2016 to 2020) were identified from the Aotearoa New Zealand All Cardiology Services Quality Improvement (ANZACS-QI) registry and stratified based on their Killip class on arrival to the cardiac catheterisation laboratory. Primary outcome was 30-day all-cause mortality. Multivariable analysis was used to identify predictors of mortality prior to PCI and to develop a mortality scoring system. RESULTS In total, 6,649 patients were identified, including 192 (2.9%) Killip IV (CS) patients. Thirty-day mortality was 47.5% in patients with CS, 14.6% in those with heart failure without shock, and 3% in those without heart failure. Independent predictors of 30-day mortality for patients with CS were: estimated glomerular filtration rate <60 mL/min/1.73m2 (relative risk [RR] 1.89, 95% confidence interval [CI] 1.39-2.58), cardiac arrest (RR 1.54, 95% CI 1.15-2.06), diabetes (RR 1.31, 95% CI 1.01-1.70), female sex (RR 1.32, 95% CI 1.01-1.72), femoral arterial access (RR 1.42, 95% CI 1.06-1.90) and left main stem culprit (RR 2.16, 95% CI 1.65-2.84). A multivariable Shock score was developed which predicts 30-day mortality with good global discrimination (area under the curve 0.79, 95% CI 0.73-0.85). CONCLUSION In this national cohort, the 30-day mortality for STEMI patients presenting with CS treated with PCI remains high, at nearly 50%. The ANZACS-QI Shock score is a promising tool for mortality risk stratification prior to PCI but requires further validation.
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Affiliation(s)
- Kyu Hyun Lee
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand.
| | - Wil Harrison
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand
| | - Kok Lam Chow
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand
| | - Mildred Lee
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Andrew J Kerr
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand; Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
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2
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Arnold JH, Perl L, Assali A, Codner P, Greenberg G, Samara A, Porter A, Orvin K, Kornowski R, Vaknin Assa H. The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction. J Clin Med 2023; 12:6259. [PMID: 37834902 PMCID: PMC10573491 DOI: 10.3390/jcm12196259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/13/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality. METHODS STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE). RESULTS Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01). CONCLUSIONS CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.
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Affiliation(s)
- Joshua H. Arnold
- Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Abid Assali
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
- Department of Cardiology, Meir Medical Center, Kfar-Saba 4428164, Israel
| | - Pablo Codner
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Gabriel Greenberg
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Abid Samara
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Avital Porter
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Katia Orvin
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Hana Vaknin Assa
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
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3
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Schmitt A, Weidner K, Rusnak J, Ruka M, Egner-Walter S, Mashayekhi K, Tajti P, Ayoub M, Akin I, Behnes M, Schupp T. Age-related outcomes in patients with cardiogenic shock stratified by etiology. J Geriatr Cardiol 2023; 20:555-566. [PMID: 37675262 PMCID: PMC10477585 DOI: 10.26599/1671-5411.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND As a result of improved and novel treatment strategies, the spectrum of patients with cardiovascular disease is consistently changing. Overall, those patients are typically older and characterized by increased burden with comorbidities. Limited data on the prognostic impact of age in cardiogenic shock (CS) is available. Therefore, this study investigates the prognostic impact of age in patients with CS. METHODS From 2019 to 2021, consecutive patients with CS of any cause were included. The prognostic value of age (i.e., 60-80 years and > 80 years) was investigated for 30-day all-cause mortality. Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses were performed for statistics. Subsequent risk assessment was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). RESULTS 223 CS patients were included with a median age of 77 years (interquartile range: 69-82 years). No significant difference in 30-day all-cause mortality was observed for both age-groups (54.6% vs. 63.4%, log-rank P = 0.169; HR = 1.273, 95% CI: 0.886-1.831, P = 0.192). In contrast, when analyzing subgroups stratified by CS-etiology, AMI-related CS patients of the group > 80 years showed an increased risk of 30-day all-cause mortality (78.1% vs. 60.0%, log-rank P = 0.032; HR = 1.635, 95% CI: 1.000-2.673, P = 0.050), which was still evident after multivariable adjustment (HR = 2.072, 95% CI: 1.174-3.656, P = 0.012). CONCLUSIONS Age was not associated with 30-day all-cause mortality in patients with CS of mixed etiology. However, increasing age was shown to be a significant predictor of increased mortality-risk in the subgroup of patients presenting with AMI-CS.
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Affiliation(s)
- Alexander Schmitt
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum-Bad Oeynhausen, Bad Oeynhausen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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4
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Xiao X, Bloom JE, Andrew E, Dawson LP, Nehme Z, Stephenson M, Anderson D, Fernando H, Noaman S, Cox S, Chan W, Kaye DM, Smith K, Stub D. Age as a predictor of clinical outcomes and determinant of therapeutic measures for emergency medical services treated cardiogenic shock. J Geriatr Cardiol 2023; 20:1-10. [PMID: 36875161 PMCID: PMC9975487 DOI: 10.26599/1671-5411.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The impact of age on outcomes in cardiogenic shock (CS) is poorly described in the pre-hospital setting. We assessed the impact of age on outcomes of patients treated by emergency medical services (EMS). METHODS This population-based cohort study included consecutive adult patients with CS transported to hospital by EMS. Successfully linked patients were stratified into tertiles by age (18-63, 64-77, and > 77 years). Predictors of 30-day mortality were assessed through regression analyses. The primary outcome was 30-day all-cause mortality. RESULTS A total of 3523 patients with CS were successfully linked to state health records. The average age was 68 ± 16 years and 1398 (40%) were female. Older patients were more likely to have comorbidities including pre-existing coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, and cerebrovascular disease. The incidence of CS was significantly greater with increasing age (incidence rate per 100,000 person years 6.47 [95% CI: 6.1-6.8] in age 18-63 years, 34.34 [32.4-36.4] in age 64-77 years, 74.87 [70.6-79.3] in age > 77 years, P < 0.001). There was a step-wise increase in the rate of 30-day mortality with increasing age tertile. After adjustment, compared to the lowest age tertile, patients aged > 77 years had increased risk of 30-day mortality (adjusted hazard ratio = 2.26 [95% CI: 1.96-2.60]). Older patients were less likely to receive inpatient coronary angiography. CONCLUSION Older patients with EMS-treated CS have significantly higher rates of short-term mortality. The reduced rates of invasive interventions in older patients underscore the need for further development of systems of care to improve outcomes for this patient group.
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Affiliation(s)
- Xiaoman Xiao
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia
| | - Emily Andrew
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - Michael Stephenson
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - David Anderson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia
| | - Shelley Cox
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia
| | - Karen Smith
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
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5
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Cosentino N, Resta ML, Somaschini A, Campodonico J, D’Aleo G, Di Stefano G, Lucci C, Moltrasio M, Bonomi A, Cornara S, Demarchi A, De Ferrari G, Bartorelli AL, Marenzi G. ST-Segment Elevation Acute Myocardial Infarction Complicated by Cardiogenic Shock: Early Predictors of Very Long-Term Mortality. J Clin Med 2021; 10:2237. [PMID: 34064067 PMCID: PMC8196779 DOI: 10.3390/jcm10112237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/07/2021] [Accepted: 05/20/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is the leading cause of in-hospital mortality in ST-segment elevation myocardial infarction (STEMI). Only limited data are available on the long-term outcome of STEMI patients with CS undergoing contemporary treatment. We aimed to investigate long-term mortality and its predictors in STEMI patients with CS and to develop a risk score for long-term mortality prediction. METHODS AND RESULTS We retrospectively included 465 patients with STEMI complicated by CS and treated with primary angioplasty and intra-aortic balloon pump between 2005 and 2018. Long-term mortality, including both in-hospital mortality and all-cause mortality following discharge from the index hospitalization, was the primary endpoint. The long-term mortality (median follow-up 4 (2.0-5.2) years) was 60%, including in-hospital mortality (34%). At multivariate analysis, independent predictors of long-term mortality were age (HR 1.41, each 10-year increase), admission left ventricular ejection fraction (HR 1.51, each 10%-unit decrease) and creatinine (HR 1.28, each mg/dl increase), and acute kidney injury (HR 1.81). When these predictors were pooled together, the area under the curve (AUC) for long-term mortality was 0.80 (95% CI 0.75-0.84). Using the four variables, we developed a risk score with a mean (cross-validation analysis) AUC of 0.79. When the score was applied to in-hospital mortality, its AUC was 0.79, and 0.76 when the score was applied to all-cause mortality following discharge. CONCLUSIONS In STEMI patients with CS, the risk of death is still substantial in the years following the index event. A simple clinical score at the time of the index event accurately predicts long-term mortality risk.
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Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Marta L. Resta
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Alberto Somaschini
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Jeness Campodonico
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Giampaolo D’Aleo
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Giovanni Di Stefano
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Claudia Lucci
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Marco Moltrasio
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Alice Bonomi
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Stefano Cornara
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Andrea Demarchi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Gaetano De Ferrari
- Dipartimento di Scienze Mediche, Cardiologia Città della Salute e della Scienza, Università di Torino, 10126 Torino, Italy;
| | - Antonio L. Bartorelli
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
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6
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Marashly Q, Taleb I, Kyriakopoulos CP, Dranow E, Jones TL, Tandar A, Overton SD, Tonna JE, Stoddard K, Wever-Pinzon O, Kemeyou L, Koliopoulou AG, Shah KS, Nourian K, Richins TJ, Burnham TS, Welt FG, McKellar SH, Nativi-Nicolau J, Drakos SG. Predicting mortality in cardiogenic shock secondary to ACS requiring short-term mechanical circulatory support: The ACS-MCS score. Catheter Cardiovasc Interv 2021; 98:1275-1284. [PMID: 33682308 DOI: 10.1002/ccd.29581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify predictors of 30-day all-cause mortality for patients with cardiogenic shock secondary to acute coronary syndrome (ACS-CS) who require short-term mechanical circulatory support (ST-MCS). BACKGROUND ACS-CS mortality is high. ST-MCS is an attractive treatment option for hemodynamic support and stabilization of deteriorating patients. Mortality prediction modeling for ACS-CS patients requiring ST-MCS has not been well-defined. METHODS The Utah Cardiac Recovery (UCAR) Shock database was used to identify patients admitted with ACS-CS requiring ST-MCS devices between May 2008 and August 2018. Pre-ST-MCS clinical, laboratory, echocardiographic, and angiographic data were collected. The primary endpoint was 30-day all-cause mortality. A weighted score comprising of pre-ST-MCS variables independently associated with 30-day all-cause mortality was derived and internally validated. RESULTS A total of 159 patients (mean age, 61 years; 78% male) were included. Thirty-day all-cause mortality was 49%. Multivariable analysis resulted in four independent predictors of 30-day all-cause mortality: age, lactate, SCAI CS classification, and acute kidney injury. The model had good calibration and discrimination (area under the receiver operating characteristics curve 0.80). A predictive score (ranging 0-4) comprised of age ≥ 60 years, pre-ST-MCS lactate ≥2.5 mmol/L, AKI at time of ST-MCS implementation, and SCAI CS stage E effectively risk stratified our patient population. CONCLUSION The ACS-MCS score is a simple and practical predictive score to risk-stratify CS secondary to ACS patients based on their mortality risk. Effective mortality risk assessment for ACS-CS patients could have implications on patient selection for available therapeutic strategy options.
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Affiliation(s)
- Qussay Marashly
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christos P Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elizabeth Dranow
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tara L Jones
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Anwar Tandar
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sean D Overton
- Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kathleen Stoddard
- Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Line Kemeyou
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Antigone G Koliopoulou
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kevin S Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kimiya Nourian
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tyler J Richins
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tyson S Burnham
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Frederick G Welt
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stephen H McKellar
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
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7
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Ran P, Yang JQ, Li J, Li G, Wang Y, Qiu J, Zhong Q, Wang Y, Wei XB, Huang JL, Siu CW, Zhou YL, Zhao D, Yu DQ, Chen JY. A risk score to predict in-hospital mortality in patients with acute coronary syndrome at early medical contact: results from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:167. [PMID: 33569469 PMCID: PMC7867931 DOI: 10.21037/atm-21-31] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background A number of models have been built to evaluate risk in patients with acute coronary syndrome (ACS). However, accurate prediction of mortality at early medical contact is difficult. This study sought to develop and validate a risk score to predict in-hospital mortality among patients with ACS using variables available at early medical contact. Methods A total of 62,546 unselected ACS patients from 150 tertiary hospitals who were admitted between 2014 and 2017 and enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, were randomly assigned (at a ratio of 7:3) to a training dataset (n=43,774) and a validation dataset (n=18,772). Based on the identified predictors which were available prior to any blood test, a new point-based risk score for in-hospital death, CCC-ACS score, was derived and validated. The CCC-ACS score was then compared with Global Registry of Acute Coronary Events (GRACE) risk score. Results The in-hospital mortality rate was 1.9% in both the training and validation datasets. The CCC-ACS score, a new point-based risk score, was developed to predict in-hospital mortality using 7 variables that were available before any blood test including age, systolic blood pressure, cardiac arrest, insulin-treated diabetes mellitus, history of heart failure, severe clinical conditions (acute heart failure or cardiogenic shock), and electrocardiographic ST-segment deviation. This new risk score had an area under the curve (AUC) of 0.84 (P=0.10 for Hosmer-Lemeshow goodness-of-fit test) in the training dataset and 0.85 (P=0.13 for Hosmer-Lemeshow goodness-of-fit test) in the validation dataset. The CCC-ACS score was comparable to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of in-hospital death in the validation dataset. Conclusions The newly developed CCC-ACS score, which utilizes factors that are acquirable at early medical contact, may be able to stratify the risk of in-hospital death in patients with ACS. Clinical trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.
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Affiliation(s)
- Peng Ran
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jun-Qing Yang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guang Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yan Wang
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Jia Qiu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qi Zhong
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yu Wang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xue-Biao Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie-Leng Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Ying-Ling Zhou
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dan-Qing Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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8
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Sharma YP, Krishnappa D, Kanabar K, Kasinadhuni G, Sharma R, Kishore K, Mehrotra S, Santosh K, Gupta A, Panda P. Clinical characteristics and outcome in patients with a delayed presentation after ST-elevation myocardial infarction and complicated by cardiogenic shock. Indian Heart J 2019; 71:387-393. [PMID: 32035521 PMCID: PMC7013184 DOI: 10.1016/j.ihj.2019.11.256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Delayed presentation after ST-elevation myocardial infarction (STEMI) and complicated by cardiogenic shock (CS-STEMI) is commonly encountered in developing countries and is a challenging scenario because of a delay in revascularization resulting in infarction of a large amount of the myocardium. We aimed to assess the clinical characteristics, angiographic profile, and predictors of outcome in patients with a delayed presentation after CS-STEMI. METHODS A total of 147 patients with CS-STEMI with time to appropriate medical care ≥12 h after symptom onset were prospectively recruited at a tertiary referral center. RESULTS The median time to appropriate care was 24 h (interquartile range 18-48 h). The mean age was 58.7 ± 11.1 years. Left ventricular pump failure was the leading cause of shock (67.3%), whereas mechanical complications accounted for 14.9% and right ventricular infarction for 13.6% of cases. The overall in-hospital mortality was 42.9%. Acute kidney injury [Odds ratio (OR) 8.04; 95% confidence intervals (CI) 3.08-20.92], ventricular tachycardia (OR 7.04; CI 2.09-23.63), mechanical complications (OR 6.46; CI 1.80-23.13), and anterior infarction (OR 3.18; CI 1.01-9.97) were independently associated with an increased risk of mortality. Coronary angiogram (56.5%) revealed single-vessel disease (45.8%) as the most common finding. Percutaneous coronary intervention was performed in 53 patients (36%), at a median of 36 h (interquartile range 30-72) after symptom onset. CONCLUSION Patients with a delayed presentation after CS-STEMI were younger and more likely to have single-vessel disease. We found a high in-hospital mortality of 42.9%. Appropriate randomized studies are required to evaluate the optimal treatment strategies in these patients.
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Affiliation(s)
- Yash Paul Sharma
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Darshan Krishnappa
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Kewal Kanabar
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Ganesh Kasinadhuni
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rakesh Sharma
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Kamal Kishore
- Department of Biostatistics, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Saurabh Mehrotra
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Krishna Santosh
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Ankur Gupta
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Prashant Panda
- Department of Cardiology, Advanced Cardiac Centre (ACC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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9
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Moraes PIM, Alves CR, Souza MT, Kawakami SE, Goncalves I, Barbosa AHP, Moreno AC, Caixeta AM, Carvalho AC. Cardiogenic shock after ST elevation myocardial infarction and IABP-SHOCK II risk score validation in a cohort treated with pharmacoinvasive strategy. Open Heart 2019; 6:e001069. [PMID: 31413846 PMCID: PMC6667936 DOI: 10.1136/openhrt-2019-001069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 11/04/2022] Open
Abstract
Objective To validate the Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) score in patients with cardiogenic shock after ST elevation myocardial infarction (STEMI) treated with pharmacoinvasive strategy (PhIS) and to analyse the influence of ischaemia time on different risk strata. Methods We analysed 2143 patients with STEMI who underwent reperfusion with tenecteplase in primary health services between May 2010 and April 2017 and were transferred to a tertiary hospital for cardiac catheterisation and continuity of care. Those who evolved to cardiogenic shock were scored as low (0-2), moderate (3-4) or high (5-9) risk of death in 30 days and pairwise-log-rank test was used to compare strata. Time intervals between symptoms onset and lytic (pain-to-needle) and fibrinolytic-catheterisation were also compared. Results Cardiogenic shock occurred in 212 (9.9%) individuals. The 30-day mortality using the IABP-SHOCK II score was 26.6% for low-risk (n=94), 53.2% for moderate-risk (n=62) and 76% for high-risk (n=25) analysed patients (p<0.001). Validation of the score showed good discrimination for death, area under the curve of 0.73 (CI: 0.66 to 0.81; p<0.001). The median intervals of pain-to-needle and fibrinolytic-catheterisation showed no association with the group stratification (220 vs 251 vs 200 min; p=0.22 and 390 vs 435 vs 315 min; p=0.18, respectively). Conclusions In patients with cardiogenic shock after STEMI treated with PhIS, risk stratification using IABP-SHOCK II score was adequate. There was no influence of pain-to-needle and fibrinolytic-catheterisation times on the ability to the score model stratification.
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Affiliation(s)
- Pedro Ivo M Moraes
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Claudia Rodrigues Alves
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Tulio Souza
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Suzi Emiko Kawakami
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Iran Goncalves
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Antonio Celio Moreno
- Department of Cardiology, Hospital do Servidor Público Municipal, Sao Paulo, Brazil
| | - Adriano Mendes Caixeta
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil.,Department of Cardiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Antonio Carlos Carvalho
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
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10
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Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J 2019; 40:2671-2683. [DOI: 10.1093/eurheartj/ehz363] [Citation(s) in RCA: 234] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/17/2019] [Accepted: 05/11/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortality remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment.
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Affiliation(s)
- Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | - E Magnus Ohman
- Duke Heart Center, Duke University Medical Center, Box 3126 DUMC, Durham, NC 27710, USA
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Medizinische Klinik B, Bremserstraße 79, D-67063 Ludwigshafen, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
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11
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Raja DC, Chopra A, Subban V, Maharajan R, Anandhan H, Vasu N, Farook J, Paramasivam R, Narayanan S, Uthayakumaran K, Pakshirajan B, Victor S, Solirajaram R, Krishnamoorthy J, Janakiraman E, Pandurangi UM, Kalidoss L, Mullasari AS. Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI-A tertiary care center experience. Indian Heart J 2018; 70 Suppl 3:S259-S264. [PMID: 30595270 PMCID: PMC6309147 DOI: 10.1016/j.ihj.2018.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/21/2018] [Accepted: 03/23/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. MATERIALS AND METHODOLGY During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). RESULTS Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR=0.99, 0.99-1; p=0.02), left ventricular ejection fraction (LVEF) (OR=0.90, 0.82-0.98; p=0.02), need for cardio-pulmonary resuscitation (OR=0.12, 0.24-0.66; p=0.01), and post PCI TIMI flows (OR=0.08, 0.02-0.29; p<0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. CONCLUSION Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.
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Affiliation(s)
- Deep Chandh Raja
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Aashish Chopra
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Vijayakumar Subban
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Rashmi Maharajan
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Harini Anandhan
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Nandhakumar Vasu
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Jawahar Farook
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Ramachandran Paramasivam
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Srinivasan Narayanan
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | | | - Balaji Pakshirajan
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Suma Victor
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Ramkumar Solirajaram
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Jaishankar Krishnamoorthy
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Ezhilan Janakiraman
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Ulhas M Pandurangi
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Latchumanadhas Kalidoss
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India
| | - Ajit Sankaradas Mullasari
- Department of Cardiology, Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India.
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12
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Abstract
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.
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Affiliation(s)
- Deepak Acharya
- From the Section of Advanced Heart Failure, Mechanical Circulatory Support, and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL
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13
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Pöss J, Köster J, Fuernau G, Eitel I, de Waha S, Ouarrak T, Lassus J, Harjola VP, Zeymer U, Thiele H, Desch S. Risk Stratification for Patients in Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2017; 69:1913-1920. [DOI: 10.1016/j.jacc.2017.02.027] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/19/2017] [Accepted: 02/06/2017] [Indexed: 01/08/2023]
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14
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Prognostic Analysis for Cardiogenic Shock in Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8530539. [PMID: 28251160 PMCID: PMC5303841 DOI: 10.1155/2017/8530539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
Abstract
Cardiogenic shock (CS) is uncommon in patients suffering from acute myocardial infarction (AMI). Long-term outcome and adverse predictors for outcomes in AMI patients with CS receiving percutaneous coronary interventions (PCI) are unclear. A total of 482 AMI patients who received PCI were collected, including 53 CS and 429 non-CS. Predictors for AMI patients with CS including recurrent MI, cardiovascular (CV) mortality, all-cause mortality, and repeated-PCI were analyzed. The CS group had a lower central systolic pressure and central diastolic pressure (both P < 0.001). AMI patients with hypertension history were less prone to develop CS (P < 0.001). Calcium channel blockers and statins were less frequently used by the CS group than the non-CS group (both P < 0.05) after discharge. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, CV mortality, and all-cause mortality were higher in the CS group than the non-CS group (all P < 0.005). For patients with CS, stroke history was a predictor of recurrent MI (P = 0.036). CS, age, SYNTAX score, and diabetes were predictors of CV mortality (all P < 0.05). CS, age, SYNTAX score, and stroke history were predictors for all-cause mortality (all P < 0.05). CS, age, and current smoking were predictors for repeated-PCI (all P < 0.05).
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15
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Chen KC, Yin WH, Young MS, Wei J. In-Hospital Tele-ECG Triage and Interventional Cardiologist Activation of the Infarct Team for STEMI Patients is Associated with Improved Late Clinical Outcomes. ACTA CARDIOLOGICA SINICA 2016; 32:428-38. [PMID: 27471356 DOI: 10.6515/acs20150731c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Due to recent advances, door-to-balloon time (D2BT) has been reduced significantly for patients with ST-segment elevation myocardial infarction (STEMI). However, whether this reduction can be translated into a concrete mortality or morbidity benefit is still the subject of controversy. We conducted a before-and-after study to determine the impact of in-hospital tele-electrocardiography (ECG) triage and interventional cardiologist activation of the infarct team on D2BT and long-term clinical outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). METHODS A total of 272 consecutive patients with acute STEMI undergoing PPCI were enrolled in our study, comprising 102 tele-ECG patients and 170 conventional triage patients. Major adverse cardiovascular and cerebral vascular events (MACCE), including death, recurrent nonfatal MI, nonfatal stroke, and angina-driven target vessel revascularization were recorded during a 3-year follow-up. RESULTS The median D2BT of the tele-ECG group was significantly shorter than control group (79 minutes vs. 109 minutes, p < 0.001). The tele-ECG triage group had a higher percentage of patients reaching the D2BT goal (< 90 minutes) (78% vs. 55%; p < 0.001). The MACCE rate was significantly lower in the Tele-ECG versus the control group (23.5% vs. 38.2%, p = 0.012). Tele-ECG group had a lower mortality rate which did not reached statistical significance (2% vs. 5.9%, p = 0.102). In multivariable Cox proportional hazards analyses, the implementation of tele-ECG triage (HR = 0.43, p = 0.003) and the presence of moderate or severe mitral regurgitation at presentation (HR = 1.87, p = 0.029) were discovered as independently associated with MACCE. CONCLUSIONS In-hospital tele-ECG triage and interventional cardiologist activation can shorten D2BT and is associated with improved late clinical outcomes during a 3-year follow-up in STEMI patients undergoing PPCI.
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Affiliation(s)
- Kuan-Chun Chen
- Division of Cardiology; ; Heart Center, Cheng Hsin General Hospital; ; Institute of Emergency and Critical Care Medicine
| | - Wei-Hsian Yin
- Division of Cardiology; ; Heart Center, Cheng Hsin General Hospital; ; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital
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16
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Abstract
Cardiogenic shock is the leading cause of morbidity and mortality in patients presenting with acute coronary syndrome. Although early reperfusion strategies are essential to the management of these critically ill patients, additional treatment plans are often needed to stabilize and treat the patient before reperfusion may be possible. This article discusses pharmacologic and surgical interventions, their indications and contraindications, management strategies, and treatment algorithms.
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Affiliation(s)
- Joshua B Moskovitz
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA.
| | - Zachary D Levy
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA
| | - Todd L Slesinger
- Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, 300 Community Drive, Hempstead, NY 11030, USA
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17
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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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18
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Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Lauer B, Böhm M, Ebelt H, Schneider S, Werdan K, Schuler G. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet 2013; 382:1638-45. [PMID: 24011548 DOI: 10.1016/s0140-6736(13)61783-3] [Citation(s) in RCA: 629] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In current international guidelines the recommendation for intra-aortic balloon pump (IABP) use has been downgraded in cardiogenic shock complicating acute myocardial infarction on the basis of registry data. In the largest randomised trial (IABP-SHOCK II), IABP support did not reduce 30 day mortality compared with control. However, previous trials in cardiogenic shock showed a mortality benefit only at extended follow-up. The present analysis therefore reports 6 and 12 month results. METHODS The IABP-SHOCK II trial was a randomised, open-label, multicentre trial. Patients with cardiogenic shock complicating acute myocardial infarction who were undergoing early revascularisation and optimum medical therapy were randomly assigned (1:1) to IABP versus control via a central web-based system. The primary efficacy endpoint was 30 day all-cause mortality, but 6 and 12 month follow-up was done in addition to quality-of-life assessment for all survivors with the Euroqol-5D questionnaire. A masked central committee adjudicated clinical outcomes. Patients and investigators were not masked to treatment allocation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00491036. FINDINGS Between June 16, 2009, and March 3, 2012, 600 patients were assigned to IABP (n=301) or control (n=299). Of 595 patients completing 12 month follow-up, 155 (52%) of 299 patients in the IABP group and 152 (51%) of 296 patients in the control group had died (relative risk [RR] 1·01, 95% CI 0·86-1·18, p=0·91). There were no significant differences in reinfarction (RR 2·60, 95% CI 0·95-7·10, p=0·05), recurrent revascularisation (0·91, 0·58-1·41, p=0·77), or stroke (1·50, 0·25-8·84, p=1·00). For survivors, quality-of-life measures including mobility, self-care, usual activities, pain or discomfort, and anxiety or depression did not differ significantly between study groups. INTERPRETATION In patients undergoing early revascularisation for myocardial infarction complicated by cardiogenic shock, IABP did not reduce 12 month all-cause mortality. FUNDING German Research Foundation; German Heart Research Foundation; German Cardiac Society; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte; University of Leipzig--Heart Centre; Maquet Cardiopulmonary; Teleflex Medical.
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Affiliation(s)
- Holger Thiele
- University of Leipzig-Heart Centre, Leipzig, Germany.
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Wu X, Yang D, Zhao Y, Lu C, Wang Y. Effectiveness of percutaneous coronary intervention within 12 hours to 28 days of ST-elevation myocardial infarction in a real-world Chinese population. PLoS One 2013; 8:e58382. [PMID: 23554888 PMCID: PMC3595272 DOI: 10.1371/journal.pone.0058382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/04/2013] [Indexed: 11/24/2022] Open
Abstract
Objectives Percutaneous coronary intervention( PCI) for ST-elevation myocardial infarction (STEMI) has been widely accepted for patient who come within 12 hours, but for those who come to the hospital late (12 hours to 28 days) the long-term data and possible predictors are limited regarding ‘hard’ endpoints in ‘real world’. Methods The registry data of all 5523 consecutive patients admitted due to an incident STEMI (12 hours to 28 days) in our center were analyzed. Patients were divided into 3 age groups (age<65; age = 65–74; age ≥75) and two therapeutic groups including conservative and PCI group. The primary endpoints included 30-day mortality and 1-year mortality. Results The clinical characteristics include female gender; history of diabetes mellitus, previous myocardial infarction, cerebral vascular disease, chronic renal failure, atrial fibrillation, hypertension, anemia, gastric bleeding; presentation of ventricular tachycardia/ventricular fibrillation, pneumonia, heart failure, multiple organ failure and cardiogenic shock. The ratio of all the above factors increased with the age getting older (all p<0.05), while that of the PCI decreased significantly with ageing (53.9%, 36.3% and 21.7%). Except hypertension, all the other factors were less seen in the PCI group than in the conservative group (p<0.01). Pooled estimates, based on type of therapy and age groups, PCI resulted in significantly lower 30-day and 1-year mortality. Cox analysis showed the positive predictors for 30 days and 1 year mortality were heart failure, cerebral vascular disease, chronic renal failure, ventricular tachycardia/ventricular fibrillation, age, female, gastric intestinal bleeding, cardiogenic shock, multiple organ failure, while PCI was a negative predictor. ROCs analysis showed AUCs were always higher for PCI group. Conclusions The elderly have more comorbidities and higher rates of mortality, mandating thorough evaluation before acceptance for PCI. PCI between 12 hours to 28 days in all ages of patients including the elderly with STEMI is significantly more effective than conservative therapy.
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Affiliation(s)
- Xingli Wu
- Institute of Geriatric Cardiology, China PLA General Hospital, Beijing, China.
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De Felice F, Fiorilli R, Parma A, Musto C, Nazzaro MS, Confessore P, Scappaticci M, Violini R. One-year clinical outcome of patients treated with or without abciximab in rescue coronary angioplasty. Int J Cardiol 2013; 163:294-298. [PMID: 21703701 DOI: 10.1016/j.ijcard.2011.06.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/23/2011] [Accepted: 06/06/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The clinical results of abciximab administration during rescue angioplasty (PCI) are poorly investigated. METHODS We evaluated the outcome of 406 consecutive patients undergoing rescue PCI treated with (n=218) or without (n=188) abciximab and a clopidogrel loading dose of 300 mg. The end point was the incidence of major cardiac adverse events (MACE) defined as death, recurrent acute myocardial infarction (AMI) and target vessel revascularization at 30 days and 1 year. The predictors of MACE were also investigated. RESULTS No differences were found in MACE between the groups treated with or without abciximab at 30 days (15 and 20, p=0.67) and 1 year (23 and 29, p=0.85). Stepwise logistic regression analysis identified: cardiogenic shock (Odds Ratio [OR]=17.8, 95% confidence interval [CI] 5-99, p=0.0001), age (OR=1.099, 95% CI 1.04-1.15, p=0.0001), TIMI flow 0-1 after procedure (OR=5.51, 95% CI 1.72-17.6, p=0.004) as independent predictors of MACE at 30 days. Cox proportional hazards model identified: cardiogenic shock (adjusted hazard ratio [HR]=3.83, 95% confidence interval [CI] 1.76-8.35, p=0.01), age (HR=3.7, 95% CI 1.75-8.3, p=0.01), TIMI flow 0-1 after procedure (HR=1.04, 95% CI 1.01-1.07, p=0.001 as predictors of MACE at 1 year). After propensity score adjustments the predictors of MACE did not change. CONCLUSION There were no differences in MACE at 30 days and 1 year in patients treated with or without abciximab during rescue PCI after a clopidogrel loading dose of 300 mg. Cardiogenic shock, age and TIMI flow 0 and 1 after PCI were predictors of MACE.
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Affiliation(s)
- Francesco De Felice
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy.
| | - Rosario Fiorilli
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Antonio Parma
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Carmine Musto
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Marco Stefano Nazzaro
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Pierpaolo Confessore
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Massimiliano Scappaticci
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
| | - Roberto Violini
- UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense n 87, 00152 Roma, Italy
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Salahuddin S, Bhargava B. Cardiogenic shock in acute coronary syndromes-miles to go? Indian Heart J 2012; 64:159-61. [PMID: 22572492 DOI: 10.1016/s0019-4832(12)60053-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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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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Westaby S, Kharbanda R, Banning AP. Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy. Nat Rev Cardiol 2011; 9:158-71. [PMID: 22182955 DOI: 10.1038/nrcardio.2011.194] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ischemic cardiogenic shock is a complex, self-perpetuating pathological process that frequently causes death irrespective of medical therapy. Early definition of coronary anatomy is a pivotal step towards survival. Those destined to develop shock are likely to have three-vessel or left main stem disease with previously impaired left ventricular function. Early reperfusion of the occluded artery can limit infarct size, but ischemia-reperfusion injury or the 'no-reflow' phenomenon can preclude improvement in myocardial contractility. Emergence of shock depends upon the volume of ischemic myocardium, stroke volume, and peripheral vascular resistance. If cytokine release triggers the systemic inflammatory response, systemic vascular resistance falls and inadequate coronary perfusion pressure heralds the downward spiral. Survival depends on early recognition of shock, followed by aggressive targeted treatment of left, right, or biventricular failure. The goal is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial pressure, which is achieved with inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption, and extended ischemia. The value of intra-aortic balloon counter-pulsation is now questioned in patients with advanced shock. When mean arterial pressure is <55 mmHg with serum lactate >11 mmol/l, death is likely and mechanical circulatory support becomes the only chance for survival.
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Affiliation(s)
- Stephen Westaby
- Departments of Cardiothoracic Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK.
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Comparison of one-year outcome of patients aged <75 years versus ≥75 years undergoing "rescue" percutaneous coronary intervention. Am J Cardiol 2011; 108:1075-80. [PMID: 21791331 DOI: 10.1016/j.amjcard.2011.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 05/31/2011] [Accepted: 06/02/2011] [Indexed: 11/20/2022]
Abstract
The influence of age on the clinical results after rescue angioplasty (percutaneous coronary intervention [PCI]) has been poorly investigated. In the present study, we evaluated the outcome of 514 consecutive patients undergoing rescue PCI who were divided into 2 groups according to age: <75 years (n = 469) and ≥75 years (n = 45). The primary end point of the study was the incidence of death at 1 year of follow-up. The secondary end point was the 1-year incidence of major cardiac adverse events (MACE) defined as a composite of death, recurrent acute myocardial infarction, and target vessel revascularization. The predictors of death and MACE at 1 year were also investigated. At 1 year of follow-up, the <75-year-old group had a significantly lower incidence of death (7% vs 24%, p = 0.0001) and MACE (14% vs 28%, p = 0.01) compared to the ≥75-year-old group. The Cox proportional hazards model identified age (adjusted hazard ratio 0.2665, 95% confidence interval 0.1285 to 0.5524, p = 0.0004), cardiogenic shock (hazard ratio 0.1057, 95% confidence interval 0.0528 to 0.2117, p <0.000001), Thrombolysis In Myocardial Infarction flow grade 2 to 3 after PCI versus 0 to 1 (hazard ratio 3.8380, 95% confidence interval 1.7781 to 8.2843, p = 0.0006), multi- versus single-vessel disease (hazard ratio 0.3716, 95% confidence interval 0.1896 to 0.7284, p = 0.0039) as independent predictors of survival at 1 year of follow-up. In conclusion, at 1 year of follow-up after rescue PCI, the patients aged ≥75 years had a greater incidence of death and MACE compared to patients aged <75 years. Age, cardiogenic shock, Thrombolysis In Myocardial Infarction flow grade 0-1 after PCI, and multivessel coronary disease were predictors of survival and freedom from MACE at 1 year of follow-up.
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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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De Felice F, Fiorilli R, Parma A, Musto C, Nazzaro MS, Stefanini GG, Caferri G, Violini R. Comparison of one-year cardiac events with drug-eluting versus bare metal stent implantation in rescue coronary angioplasty. Am J Cardiol 2011; 107:210-4. [PMID: 21129713 DOI: 10.1016/j.amjcard.2010.08.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Revised: 08/29/2010] [Accepted: 08/31/2010] [Indexed: 10/18/2022]
Abstract
Rescue percutaneous coronary intervention (PCI) with bare metal stent (BMS) implantation is useful in patients with acute myocardial infarction (AMI) and failed thrombolysis. Drug-eluting stent (DESs) are more effective in reducing restenosis compared to BMS. No data are available comparing the clinical outcomes between the 2 types of stents nor has information ever been provided about the predictors of events in patients treated with rescue PCI in the current era. The aims of the present study were to evaluate the outcomes of patients undergoing rescue PCI with DES implantation compared to BMS implantation and to determine the independent predictors of events during 1 year of follow-up. The study population consisted of 311 consecutive patients with ST-segment elevation AMI and evidence of failed fibrinolysis undergoing successful revascularization with DES (n = 134) or BMS (n = 177) implantation. The end point of the present study was the incidence of major adverse cardiac events (MACE) defined as death, recurrent AMI, and target vessel revascularization. No differences were found in the number of MACE at 1 year of follow-up between the DES and BMS groups (n = 10 and 19, respectively, p = 0.29). The Cox proportional hazards model identified cardiogenic shock (adjusted hazard ratio 7.05, 95% confidence interval 2.08 to 23.9, p = 0.001), age (hazard ratio 1.51, 95% CI 1.09 to 2.08, p = 0.011), and final minimal lumen diameter (hazard ratio 0.42, 95% confidence interval 0.21 to 0.83, p = 0.013) as independent predictors of MACE at 1 year of follow-up. After propensity score adjustments, the predictors did not change. In conclusion, we found no differences between DESs and BMSs with respect to MACE at 1 year of follow-up in patients with AMI treated with rescue PCI. Cardiogenic shock, age, and final minimal luminal diameter were identified as predictors of MACE.
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Sleeper LA, Reynolds HR, White HD, Webb JG, Džavík V, Hochman JS. A severity scoring system for risk assessment of patients with cardiogenic shock: a report from the SHOCK Trial and Registry. Am Heart J 2010; 160:443-50. [PMID: 20826251 DOI: 10.1016/j.ahj.2010.06.024] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 06/16/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND Early revascularization (ERV) is beneficial in the management of cardiogenic shock (CS) complicating myocardial infarction. The severity of CS varies widely, and identification of independent risk factors for outcome is needed. The effect of ERV on mortality in different risk strata is also unknown. We created a severity scoring system for CS and used it to examine the potential benefit of ERV in different risk strata using data from the SHOCK Trial and Registry. METHODS Data from 1,217 patients (294 from the randomized trial and 923 from the registry) with CS due to pump failure were included in a Stage 1 severity scoring system using clinical variables. A Stage 2 scoring system was developed using data from 872 patients who had invasive hemodynamic measurements. The outcome was in-hospital mortality at 30 days. RESULTS In-hospital mortality at 30 days was 57%. Multivariable modeling identified 8 risk factors (Stage 1): age, shock on admission, clinical evidence of end-organ hypoperfusion, anoxic brain damage, systolic blood pressure, prior coronary artery bypass grafting, noninferior myocardial infarction, and creatinine > or = 1.9 mg/dL (c-statistic = 0.74). Mortality ranged from 22% to 88% by score category. The ERV benefit was greatest in moderate- to high-risk patients (P = .02). The Stage 2 model based on patients with pulmonary artery catheterization included age, end-organ hypoperfusion, anoxic brain damage, stroke work, and left ventricular ejection fraction <28% (c-statistic = 0.76). In this cohort, the effect of ERV did not vary by risk stratum. CONCLUSIONS Simple clinical predictors provide good discrimination of mortality risk in CS complicating myocardial infarction. Early revascularization is associated with improved survival across a broad range of risk strata.
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Gao Y, Tong GX, Zhang XW, Leng JH, Jin JF, Wang NF, Yang JM. Interleukin-18 Levels on Admission Are Associated With Mid-Term Adverse Clinical Events in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Int Heart J 2010; 51:75-81. [DOI: 10.1536/ihj.51.75] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yan Gao
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Guo-xin Tong
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Xing-wei Zhang
- Department of Cardiology, The Affiliated Hospital of Hangzhou Normal University and The Second Municipal Hospital
| | - Jian-hang Leng
- Department of Clinical Laboratory Medicine, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Jian-fen Jin
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Ning-fu Wang
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Jian-min Yang
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
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Valente S, Lazzeri C, Chiostri M, Sori A, Giglioli C, Salvadori C, Gensini GF. Time of onset and outcome of cardiogenic shock in acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2008; 9:1235-40. [DOI: 10.2459/jcm.0b013e3283168a27] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kunadian B, Vijayalakshmi K, Dunning J, Sutton AGC, Muir DF, Wright RA, Hall JA, de Belder MA. Rescue angioplasty after failed fibrinolysis foracute myocardial infarction: Predictors of a failed procedure and 1-year mortality. Catheter Cardiovasc Interv 2008; 71:138-45. [DOI: 10.1002/ccd.21273] [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: 11/10/2022]
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Shiraishi J, Kohno Y, Sawada T, Takeda M, Arihara M, Hyogo M, Yagi T, Shima T, Okada T, Nakamura T, Matoba S, Yamada H, Shirayama T, Kitamura M, Furukawa K, Matsubara H, The AMI-Kyoto Multi-Center Risk Study Group. Predictors of In-Hospital Outcome After Primary Percutaneous Coronary Intervention for Recurrent Myocardial Infarction. Circ J 2008; 72:1225-9. [DOI: 10.1253/circj.72.1225] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jun Shiraishi
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Yoshio Kohno
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Takahisa Sawada
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
| | - Mitsuo Takeda
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Masayasu Arihara
- Department of Emergency Medicine, Kyoto First Red Cross Hospital
| | - Masayuki Hyogo
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Takakazu Yagi
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Takatomo Shima
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Takashi Okada
- Department of Cardiology, Kyoto First Red Cross Hospital
| | - Takeshi Nakamura
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
| | - Satoaki Matoba
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
| | - Hiroyuki Yamada
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
| | - Takeshi Shirayama
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
| | | | | | - Hiroaki Matsubara
- Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine
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Zhang M, Li J, Cai YM, Ma H, Xiao JM, Liu J, Zhao L, Guo T, Han MH. A risk-predictive score for cardiogenic shock after acute myocardial infarction in Chinese patients. Clin Cardiol 2007; 30:171-6. [PMID: 17443658 PMCID: PMC6652954 DOI: 10.1002/clc.20063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Cardiogenic shock after acute myocardial infarction (AMI) remains a poor prognosis. Although numerous studies discussed the predictors of cardiogenic shock complicating AMI, the data in Chinese patients is still absent. The goal of this study is to develop a risk-predictive score for cardiogenic shock after AMI, among Chinese patients, so as to guide clinicians to prevent cardiogenic shock. METHODS Patients with ST-segment elevated AMI were provided by two Chinese hospitals from 1994 to 2004. Baseline characteristics of each case were documented. Multivariable logistic regression modeling techniques were used to develop a model to predict the occurrence of cardiogenic shock within 72 h after admission. On the basis of the coefficients in the model, a risk score was developed for the probability of cardiogenic shock. To test its viability, another population, which was consistent with the original population, confirmed the scoring. RESULTS Among 2,077 patients, 184 cases developed cardiogenic shock within 72 h. Age, gender, BMI, killip class, MI location, multivessel disease, previous MI, family history of CAD, and thrombolytic therapy were strong predictors for shock after AMI. A risk-predictive score for shock was developed. It predicted cardiogenic shock accurately in another Chinese population. CONCLUSIONS A predictive model is developed in Chinese patients with AMI for the first time. It is based on some simple parameters, which can be easily obtained by clinicians. The risk score derived from the model can predict cardiogenic shock accurately.
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Affiliation(s)
- Min Zhang
- Department of Cardiology, The First Affiliated Hospital of Kunming University of Medical Sciences, Kunming, Yunnan 650032, PR China.
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Predictors of in-hospital mortality after percutaneous coronary intervention for cardiogenic shock. Int J Cardiol 2006; 114:176-82. [PMID: 16737749 DOI: 10.1016/j.ijcard.2006.01.024] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 12/09/2005] [Accepted: 01/08/2006] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The mortality of patients with cardiogenic shock (CS) complicating ST elevation acute myocardial infarction (STEMI) remains high, despite early revascularization. Current knowledge of predictors of death is limited. BACKGROUND The pathophysiologic understanding of CS after acute myocardial infarction has shifted from a mere hemodynamic disorder to a more complex approach including imbalance in metabolic functions. METHODS In 45 consecutive patients (71.4+/-13 years) with CS complicating STEMI treated with primary percutaneous coronary intervention (PCI) serum levels of lactate, glucose and uric acid on coronary care unit (CCU) admission were measured. The end-point was in-hospital death. RESULTS The following parameters, on CCU admission, were univariate predictors of in-hospital mortality: serum glucose >200 mg/dl (OR=11.3, p=0.002), serum creatinine >1.5 mg/dl (OR=12.7, p=0.003), uric acid >6.5 mg/dl (OR=6.7, p=0.016), lactate >6.5 mmol/l (OR=54, p<0.0001), age > or =75 years (OR=8.5, p=0.002), history of hypertension (OR=8.3, p=0.003) and TIMI flow post PCI < or = 2 (OR=12.9, p=0.02). At multivariate analysis, after adjustment for sex, age, hypertension and diabetes, lactate >6.5 mmol/l and TIMI flow post PCI < or = 2 were still independent predictors of in-hospital mortality (OR=295, p=0.01; OR=19.5, p=0.04, respectively). CONCLUSIONS Hyperlactatemia, hyperglycemia and increased levels of uric acid on CCU admission are univariate predictors of in-hospital death. Moreover, at multivariate analysis, hyperlactatemia (>6.5 mmol/l) is an independent indicator of in-hospital death in CS patients complicating STEMI.
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