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Hori Y, Sakakura K, Jinnouchi H, Taniguchi Y, Tsukui T, Hatori M, Kasahara T, Watanabe Y, Yamamoto K, Seguchi M, Fujita H. Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Heart Vessels 2024; 39:665-672. [PMID: 38498204 DOI: 10.1007/s00380-024-02382-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 02/28/2024] [Indexed: 03/20/2024]
Abstract
Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.
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Affiliation(s)
- Yoichi Hori
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan.
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Masashi Hatori
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Taku Kasahara
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Yusuke Watanabe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
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Shah T, Kapadia S, Lansky AJ, Grines CL. ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes. Curr Cardiol Rep 2022; 24:529-540. [PMID: 35286662 DOI: 10.1007/s11886-022-01676-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men. RECENT FINDINGS This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.
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Affiliation(s)
- Tayyab Shah
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA.
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ST-Elevation Myocardial Infarction Outcomes: A United States Nationwide Emergency Departments Cohort Study. J Emerg Med 2022; 62:306-315. [PMID: 35058097 DOI: 10.1016/j.jemermed.2021.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/18/2021] [Accepted: 10/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Literature regarding trends in incidence and mortality of ST-elevation myocardial infarction (STEMI) in emergency departments (EDs) is limited. OBJECTIVE To study the trends of incidence and mortality of STEMI. METHODS Using the National Emergency Department Sample database in the United States, we identified all ED encounters for patients presenting with STEMI using International Classification of Diseases codes. A linear p-trend was used to assess the trends. RESULTS Out of the 973 million ED encounters represented, 641,762 (65/100,000; mean age 69 [59-81] years, 35.8% female) adult patients were recorded with STEMI. Among the major complications associated with STEMI, a total of 49,401 (7.7%) had cardiac complications, which included acute heart failure (n = 9361, 1.6%), ventricular tachycardia or fibrillation (n = 12,267, 1.91%), conduction block (n = 20,165, 3.1%), and cardiogenic shock (n = 7608, 1.2%). There were 5675 (0.9%) patients recorded with cerebrovascular events, which included acute ischemic stroke among 5205 (0.8%) patients and 470 (0.1%) with transient ischemic attack. Acute kidney injury was recorded for 10,082 (1.6%) patients. The trend for incidence of STEMI in the ED had decreased from 7.76/10,000 in 2011 to 4.07/10,000 in 2018 (linear p-trend 0.0006). However, the yearly mortality of STEMI related to ED encounters had remained relatively steady: 7.56% in 2011 to 7.50% in 2018 (linear p-trend 0.2364). CONCLUSION Despite the fact that the number of patients presenting to the ED with STEMI has been decreasing, the mortality trends have remained steady. Further research of in-hospital STEMI may yield opportunities to reduce the risk of complications, improve patient outcomes and decrease health care burden.
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Shah T, Lansky AJ, Grines CL, O'Neill WW, Moses JW, Chieffo A, Kapur NK, Chou J. Mechanical Circulatory Support in Myocardial Infarction Complicated by Cardiogenic Shock: Impact of Sex and Timing. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100002. [PMID: 39130134 PMCID: PMC11307664 DOI: 10.1016/j.jscai.2021.100002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 10/29/2021] [Accepted: 11/11/2021] [Indexed: 08/13/2024]
Abstract
Background Sex differences in presentation, treatment, and outcomes persist in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS). Sex-based outcomes of patients with AMICS undergoing percutaneous coronary intervention (PCI) with percutaneous left ventricular assist device (pLVAD) support are poorly defined. Methods From January 2017 to August 2019, consecutive patients undergoing PCI who received Impella support within 48 hours of myocardial infarction were enrolled in the prospective RECOVER III postmarket registry. In-hospital survival and predictors of mortality were compared by sex. Results A total of 358 patients (276 men and 82 women) were included. Women had lower baseline mean arterial pressure and shorter duration of pLVAD support compared with men. In-hospital adverse events were similar in women and men, including mortality (54% versus 46%, P = .25), major bleeding (11% versus 10%, P = .83), and vascular complications requiring surgery (8.5% versus 4%, P = .10). Women had better survival with pre-PCI versus post-PCI pLVAD implantation (59% versus 34%, P = .03), whereas survival in men was similar regardless of pre- versus post-PCI pLVAD support (56% versus 50%, P = .39). The number of inotrope/vasopressor use pre-pLVAD was the strongest predictor of mortality in women (OR 3.03, P = .01) but not in men (OR 1.18, P = .25). Conclusions Survival of patients with AMICS treated with PCI and Impella support was 52% at hospital discharge and was similar for women and men. Women with AMICS may derive greater benefit from early pLVAD support prior to escalation of inotrope/vasopressors and had no evidence of increased risk of access-related complications.
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Affiliation(s)
- Tayyab Shah
- Yale School of Medicine, New Haven, Connecticut
| | | | - Cindy L. Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | | | - Jeffrey W. Moses
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Navin K. Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
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Singh H, Mehta RH, O'Neill W, Kapur NK, Lalonde T, Ohman M, Ghiu I, Chen-Hsing Y, Dutcheshen K, Schreiber T, Rosman H, Kaki A. Clinical features and outcomes in patients with cardiogenic shock complicating acute myocardial infarction: early vs recent experience with impella. Am Heart J 2021; 238:66-74. [PMID: 33848505 DOI: 10.1016/j.ahj.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.
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Biventricular Impella (Bi-Pella) in Refractory Cardiogenic Shock: The First Case from the Middle East. Case Rep Med 2021; 2021:6676339. [PMID: 34335787 PMCID: PMC8324370 DOI: 10.1155/2021/6676339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/08/2021] [Indexed: 11/17/2022] Open
Abstract
Cardiogenic shock (CS) associated with biventricular failure (BiVF) carries significant in-hospital morbidity and mortality. We describe here the successful use of percutaneous biventricular Impella (Bi-Pella) for cardiogenic shock secondary to acute biventricular myocardial infarctions (AMI-CS), as guided by parameters such as mixed venous oxygen saturation (SvO2), pulmonary artery pulsatility index (PAPi), central venous pressure (CVP), and cardiac power output (CPO). We aim to highlight the promising outcomes of timely implanted biventricular Impella in (AMI-CS).
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Hatori M, Sakakura K, Taniguchi Y, Jinnouchi H, Tsukui T, Yamamoto K, Seguchi M, Wada H, Fujita H. Factors Associated with In-Hospital Death in Patients with Killip Class 3 Acute Myocardial Infarction. Int Heart J 2021; 62:756-763. [PMID: 34276022 DOI: 10.1536/ihj.21-078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The clinical outcomes in acute myocardial infarction (AMI) patients with Killip class 3 are often inconsistent with those in the literature, and the factors associated with poor outcomes have not been sufficiently investigated. The purpose of this study was to identify factors associated with in-hospital death in AMI patients with Killip class 3. We included 205 AMI patients with Killip class 3, and divided them into a survived group (n = 189) and in-hospital death group (n = 16). The primary objective was to identify factors associated with in-hospital death using multivariate analysis. Age was significantly younger in the survived group than in the in-hospital death group (73.1 ± 11.2 versus 83.2 ± 6.2 years, P < 0.001). Systolic blood pressure (SBP) was significantly higher in the survived group than in the in-hospital death group (150.0 ± 31.2 versus 124.8 ± 25.3 mmHg, P = 0.002). The prevalence of TIMI thrombus grade ≥ 2 was significantly greater in the in-hospital death group than in the survived group (56.3 versus 22.2%, P = 0.005). In multivariate logistic regression analysis, in-hospital death was significantly associated with age [odds ratio (OR) 1.168, 95% confidence interval (CI) 1.061-1.287, P = 0.002] and TIMI thrombus grade ≥ 2 (versus ≤ 1: OR 5.743, 95% CI 1.717-19.214, P = 0.005), and inversely associated with SBP on admission (per 10 mmHg increase: OR 0.764, 95% CI 0.613-0.953, P = 0.017). In conclusion, in-hospital death was associated with age and coronary thrombus burden, and was inversely associated with SBP on admission in patients with Killip class 3. It may be important to recognize these high risk features to improve the clinical outcomes of patients with Killip class 3.
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Affiliation(s)
- Masashi Hatori
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
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Otaal PS, Shah A, Batta A, Sood A, Pal A. Clinical and Angiographic Prophesy of Hemodynamic Status in Patients with Acute Anterior Wall ST-Segment-Elevation Myocardial Infarction and Totally Occluded Left Anterior Descending Artery. Integr Blood Press Control 2021; 14:89-97. [PMID: 34168494 PMCID: PMC8219224 DOI: 10.2147/ibpc.s315050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Left anterior descending artery (LAD) is the most common occluded vessel in a patient presenting with acute anterior wall ST-segment elevated myocardial infarction (STEMI). Acute occlusion of LAD usually results in hemodynamic compromise. However, some patients maintain hemodynamic stability despite its proximal occlusion. As the factors associated with hemodynamic status in such patients are poorly understood, our study sought to determine the clinical and angiographic parameters associated with hemodynamic stability in these patients. Methods In this prospective observational study, 60 consecutive patients of acute anterior wall STEMI with completely occluded LAD on coronary angiography were included. Various clinical and angiographic parameters associated with hemodynamic status were evaluated. Results Of the 60 patients, 30 patients each were included in the hemodynamically stable (group I) and hemodynamically unstable group (group II). The mean age of the patients in group I and group II was 51.07±13.78 years and 55.47±11.69 years, respectively. The hemodynamically unstable group had a significantly higher number of patients with diabetes mellitus, elevated Troponin T level, and lower left ventricular ejection fraction as compared to the stable group (p<0.05). In contrast, 11 (36.7%) patients in the hemodynamically stable group had rich collaterals compared to 4 (13.3%) patients in the hemodynamically unstable group. The difference was statistically significant (p=0.037). Conclusion The present study showed that the presence of diabetes, severe LV systolic dysfunction, elevated Troponin-T level, and poor collaterals were associated with hemodynamic instability, whereas the presence of better collaterals predicted hemodynamic stability in patients presenting with anterior wall STEMI and total LAD occlusion.
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Affiliation(s)
- Parminder Singh Otaal
- Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Shah
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Akash Batta
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arnab Pal
- Department of Biochemistry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings. Int J Angiol 2021; 30:67-75. [PMID: 34025097 DOI: 10.1055/s-0041-1723944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.
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Affiliation(s)
- Rod Partow-Navid
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Narut Prasitlumkum
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ashish Mukherjee
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ramdas G Pai
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
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Fefer P. In Non-STEMI, Go for the Culprit. Chest 2021; 159:1319-1320. [PMID: 34021988 DOI: 10.1016/j.chest.2020.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/29/2020] [Indexed: 10/21/2022] Open
Affiliation(s)
- Paul Fefer
- Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.
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11
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Mitral Valve Surgery for Papillary Muscle Rupture: Outcomes in 1342 Patients From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2020; 110:1975-1981. [DOI: 10.1016/j.athoracsur.2020.03.097] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/02/2020] [Accepted: 03/25/2020] [Indexed: 11/19/2022]
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Cormican DS, Sonny A, Crowley J, Sheu R, Sun T, Gibson CM, Núñez-Gil IJ, Ramakrishna H. Acute Myocardial Infarction Complicated by Cardiogenic Shock: Analysis of the Position Statement From the European Society of Cardiology Acute Cardiovascular Care Association, With Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:3098-3104. [PMID: 33234469 DOI: 10.1053/j.jvca.2020.10.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/28/2022]
Abstract
Effective management of cardiogenic shock (CS) is hampered by a lack of evidence-based information. This is a high-mortality condition, without clear, evidence-based guidelines for perioperative management, specifically-a lack of target endpoints for treatment (e.g.: mean arterial pressure or oxygenation), utility of regional care systems or the benefits of palliative care. The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) recently published a position statement that aimed to offer contemporary guidance on the diagnosis and treatment of acute myocardial infarction (AMI) complicated by CS. Herein, we review this complex clinical topic and review the ACCA statement on AMI associated with CS, with a focus on relevance to perioperative management.
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Affiliation(s)
- Daniel S Cormican
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Jerome Crowley
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Terri Sun
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | | | - Iván J Núñez-Gil
- Interventional Cardiology. Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Concerning trends in cardiogenic shock-related admissions among United States cannabis users. IJC HEART & VASCULATURE 2020; 30:100614. [PMID: 32817882 PMCID: PMC7424209 DOI: 10.1016/j.ijcha.2020.100614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 12/03/2022]
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Daly M, Long B, Koyfman A, Lentz S. Identifying cardiogenic shock in the emergency department. Am J Emerg Med 2020; 38:2425-2433. [PMID: 33039227 DOI: 10.1016/j.ajem.2020.09.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early. OBJECTIVE This review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician. DISCUSSION The most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound. CONCLUSIONS The emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.
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Affiliation(s)
- Madison Daly
- Division of Emergency Medicine, The University of Vermont Medical Center, United States of America
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, United States of America
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, The University of Vermont Larner College of Medicine, United States of America.
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Smilowitz NR, Alviar CL, Katz SD, Hochman JS. Coronary artery bypass grafting versus percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock. Am Heart J 2020; 226:255-263. [PMID: 32278440 PMCID: PMC7442583 DOI: 10.1016/j.ahj.2020.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Myocardial infarction (MI) complicated by cardiogenic shock (CS) is associated with high mortality. Early coronary revascularization improves survival, but the optimal mode of revascularization remains uncertain. We sought to characterize practice patterns and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with MI complicated by CS. METHODS Patients hospitalized for MI with CS between 2002 and 2014 were identified from the United States National Inpatient Sample. Trends in management were evaluated over time. Propensity score matching was performed to identify cohorts with similar baseline characteristics and MI presentations who underwent PCI and CABG. The primary outcome was in-hospital all-cause mortality. RESULTS A total of 386,811 hospitalizations for MI with CS were identified; 67% were STEMI. Overall, 62.4% of patients underwent revascularization, with PCI in 44.9%, CABG in 14.1%, and a hybrid approach in 3.4%. Coronary revascularization for MI and CS increased over time, from 51.5% in 2002 to 67.4% in 2014 (P for trend < .001). Patients who underwent CABG were more likely to have diabetes mellitus (35.5% vs. 29.2%, P < .001) and less likely to present with STEMI (48.7% vs. 80.9%, P < .001) than those who underwent PCI. CABG (without PCI) was associated with lower mortality than PCI (without CABG) overall (18.9% vs. 29.0%, P < .001) and in a propensity-matched subgroup of 19,882 patients (19.0% vs. 27.0%, P < .001). CONCLUSIONS CABG was associated with lower in-hospital mortality than PCI among patients with MI complicated by CS. Due to the likelihood of residual confounding, a randomized trial of PCI versus CABG in patients with MI, CS, and multi-vessel coronary disease is warranted.
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Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, NY.
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Judith S Hochman
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY
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Rubini Gimenez M, Zeymer U, Desch S, de Waha-Thiele S, Ouarrak T, Poess J, Meyer-Saraei R, Schneider S, Fuernau G, Stepinska J, Huber K, Windecker S, Montalescot G, Savonitto S, Jeger RV, Thiele H. Sex-Specific Management in Patients With Acute Myocardial Infarction and Cardiogenic Shock: A Substudy of the CULPRIT-SHOCK Trial. Circ Cardiovasc Interv 2020; 13:e008537. [PMID: 32151161 DOI: 10.1161/circinterventions.119.008537] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Women are more likely to suffer and die from cardiogenic shock (CS) as the most severe complication of acute myocardial infarction. Data concerning optimal management for women with CS are scarce. Aim of this study was to better define characteristics of women experiencing CS and to the influence of sex on different treatment strategies. METHODS In the CULPRIT-SHOCK trial (The Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), patients with CS complicating acute myocardial infarction and multivessel coronary artery disease were randomly assigned to one of the following revascularization strategies: either percutaneous coronary intervention of the culprit-lesion-only or immediate multivessel percutaneous coronary intervention. Primary end point was composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days. We investigated sex-specific differences in general and according to the revascularization strategies. RESULTS Among all 686 randomized patients included in the analysis, 24% were women. Women were older and had more often diabetes mellitus and renal insufficiency, whereas they had less often history of previous acute myocardial infarction and smoking. After 30 days, the primary clinical end point was not significantly different between groups (56% women versus 49% men; odds ratio, 1.29 [95% CI, 0.91-1.84]; P=0.15). There was no interaction between sex and coronary revascularization strategy regarding mortality and renal failure (Pinteraction=0.11). The primary end point occurred in 56% of women treated by the culprit-lesion-only strategy versus 42% men, whereas 55% of women and 55% of men in the multivessel percutaneous coronary intervention group. CONCLUSIONS Although women presented with a different risk profile, mortality and renal replacement were similar to men. Sex did not influence mortality and renal failure according to the different coronary revascularization strategies. Based on these data, women and men presenting with CS complicating acute myocardial infarction and multivessel coronary artery disease should not be treated differently. However, further randomized trials powered to address potential sex-specific differences in CS are still necessary. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01927549.
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Affiliation(s)
- Maria Rubini Gimenez
- From the Department of Internal Medicine/Cardiology, Heart Center Leipzig, Germany (M.R.G., S.D., H.T.).,Cardiology Department, University Hospital Basel, Switzerland (M.R.G., R.V.J.)
| | | | - Steffen Desch
- From the Department of Internal Medicine/Cardiology, Heart Center Leipzig, Germany (M.R.G., S.D., H.T.).,German Center for Cardiovascular Research, Berlin, Germany (S.D., R.M.-S., G.F.)
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/ Angiology/Intensive Care Medicine, University Heart Center Lübeck, Germany (S.d.W.-T., J.P., R.M.-S., G.F.)
| | - Taoufik Ouarrak
- Institut für Herzinfarktforschung, Ludwigshafen, Germany (T.O., S.S.)
| | - Janine Poess
- Department of Internal Medicine/Cardiology/ Angiology/Intensive Care Medicine, University Heart Center Lübeck, Germany (S.d.W.-T., J.P., R.M.-S., G.F.)
| | - Roza Meyer-Saraei
- German Center for Cardiovascular Research, Berlin, Germany (S.D., R.M.-S., G.F.).,Department of Internal Medicine/Cardiology/ Angiology/Intensive Care Medicine, University Heart Center Lübeck, Germany (S.d.W.-T., J.P., R.M.-S., G.F.)
| | - Steffen Schneider
- Institut für Herzinfarktforschung, Ludwigshafen, Germany (T.O., S.S.)
| | - Georg Fuernau
- German Center for Cardiovascular Research, Berlin, Germany (S.D., R.M.-S., G.F.).,Department of Internal Medicine/Cardiology/ Angiology/Intensive Care Medicine, University Heart Center Lübeck, Germany (S.d.W.-T., J.P., R.M.-S., G.F.)
| | | | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical School, Vienna, Austria (K.H.)
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (S.W.)
| | - Gilles Montalescot
- Department of Cardiology, Sorbonne Université, Institut de Cardiologie (AP-HP), hôpital Pitié Salpêtrière, Paris, France (G.M.)
| | | | - Raban V Jeger
- Cardiology Department, University Hospital Basel, Switzerland (M.R.G., R.V.J.)
| | - Holger Thiele
- From the Department of Internal Medicine/Cardiology, Heart Center Leipzig, Germany (M.R.G., S.D., H.T.)
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18
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Sud K, Haddadin F, Tsutsui RS, Parashar A, Bandyopadhyay D, Ellis SG, Tuzcu EM, Kapadia S. Readmissions in ST-Elevation Myocardial Infarction and Cardiogenic Shock (from Nationwide Readmission Database). Am J Cardiol 2019; 124:1841-1850. [PMID: 31685215 DOI: 10.1016/j.amjcard.2019.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 10/25/2022]
Abstract
Management of ST-elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) has evolved in the last decade. There is paucity of data on readmissions in this study population. We aimed to assess the burden, major etiologies, and resource utilization for 30-day readmissions among patients with STEMI and CS. The Nationwide Readmission Database was queried from 2010 to 2014. All adult patients with an index admission for STEMI-CS were identified using International Classification of Diseases, ninth edition codes. Patient with mortality on index admission and transfers to other hospitals were excluded. A total of 18,659 admissions were identified with primary diagnosis of STEMI-CS for the study duration. Percutaneous coronary interventions was performed in 78.1% and mechanical circulatory devices were utilized in 53.9% with a mean length of stay of 10.6 (±0.2) days and mean cost of hospitalization of $47,744 (±327). Among these, 2,404 (12.9%) patients were readmitted within 30 days. Major etiologies for readmission include congestive heart failure (25.7%), acute myocardial infarction (9.4%), arrhythmias (4.5%), and sepsis (4.2%). The mean length of stay and cost of hospitalization for 30-day readmission were 5.9 (±0.3) days and $17,043 (±590), respectively. Older age, female gender, lower socioeconomic status, and discharge to home health care were significant predictors for readmission. In conclusion, there is a significant burden of 30-day readmission among patients with STEMI-CS. Percutaneous coronary interventions and mechanical circulatory devices were utilized in a majority of index admissions. Congestive heart failure was the single most common reason for 30-day readmission. Patients discharged to skilled nursing facility, patients with private insurance and higher socioeconomic status were less likely to be readmitted. Moreover, readmissions among STEMI-CS patients contribute to significant resource utilization.
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Shao H, Yang S, Stoecker C, Fonseca V, Hong D, Shi L. Addressing Regional Differences in Diabetes Progression: Global Calibration for Diabetes Simulation Model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1402-1409. [PMID: 31806197 PMCID: PMC9115837 DOI: 10.1016/j.jval.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/25/2019] [Accepted: 08/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To develop a practical solution for modeling diabetes progression and account for the variations in risks of diabetes complications in different regions of the world, which is critical for model-based evaluations on the value of diabetes intervention across populations from different regions globally. METHODS A literature search was conducted to identify eligible clinical trials to support calibration. The Building, Relating, Assessing, and Validating Outcomes (BRAVO) model was employed to simulate diabetes complications using the baseline characteristics of each clinical trial cohort. We utilized regression methods to estimate regional variations across the United States, Europe, Asia, and other regions (eg, Latin America, Africa) in 6 outcomes: myocardial infarction (MI), congestive heart failure (CHF), stroke, angina, revascularization, and mortality. RESULTS Regional variations were detected in 4 outcomes. Compared with other regions, individuals from the United States had higher risks of MI (hazard ratio [HR] 1.64; 95% confidence interval [CI]1.41-1.91) and revascularization (HR 3.6; 95% CI 2.94-4.41). Individuals from Europe had a lower risk of stroke (HR 0.61; 95% CI 0.46-0.81), and individuals from other regions outside of the United States, Europe, and Asia had a lower risk of CHF (HR 0.18; 95% CI 0.06-0.58). Finally, the simulated outcomes were regressed on observed outcomes using an ordinary least squares model, with an intercept (0.026), slope (1.005), and R-squared value (0.789) indicating good prediction accuracy. CONCLUSION Recalibrating the BRAVO model's diabetes risk engine to account for regional differences shows improved prediction accuracy when the model is applied to multi-region populations commonly recruited for clinical trials.
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Affiliation(s)
- Hui Shao
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Shuang Yang
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Charles Stoecker
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Vivian Fonseca
- School of Medicine, Tulane University, New Orleans, LA, USA
| | - Dongzhe Hong
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA.
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Venkatason P, Zubairi YZ, Wan Ahmad WA, Hafidz MI, Ismail MD, Hadi MF, Zuhdi ASM. In-hospital mortality of cardiogenic shock complicating ST-elevation myocardial infarction in Malaysia: a retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry. BMJ Open 2019; 9:e025734. [PMID: 31061031 PMCID: PMC6502239 DOI: 10.1136/bmjopen-2018-025734] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Cardiogenic shock (CS) complicating ST-elevation myocardial infarction (STEMI) carries an extremely high mortality. The clinical pattern of this life threatening complication has never been described in Malaysian setting. This study is to investigate the incidence, clinical characteristics and outcome of STEMI patients with CS in our population. DESIGN A retrospective analysis of STEMI patients from 18 hospitals across Malaysia contributing to the Malaysian National Cardiovascular Database-acute coronary syndrome) registry (NCVD-ACS) year 2006-2013. PARTICIPANTS 16 517 patients diagnosed of STEMI from 18 hospitals in Malaysia from the year 2006 to 2013. PRIMARY OUTCOME MEASURES In-hospital and 30 day post-discharge mortality. RESULTS CS complicates 10.6% of all STEMIs in this study. They had unfavourable premorbid conditions and poor outcomes. The in-hospital mortality rate was 34.1% which translates into a 7.14 times mortality risk increment compared with STEMI without CS. Intravenous thrombolysis remained as the main urgent reperfusion modality. Percutaneous coronary interventions (PCI) in CS conferred a 40% risk reduction over non-invasive therapy but were only done in 33.6% of cases. Age over 65, diabetes mellitus, hypertension, chronic lung and kidney disease conferred higher risk of mortality. CONCLUSION Mortality rates of CS complicating STEMI in Malaysia are high. In-hospital PCI confers a 40% mortality risk reduction but the rate of PCI among our patients with CS complicating STEMI is still low. Efforts are being made to increase access to invasive therapy for these patients.
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Affiliation(s)
- Padmaa Venkatason
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yong Z Zubairi
- Foundation Studies in Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Azman Wan Ahmad
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | | | | | - Mohd Firdaus Hadi
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
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Dalal PK, Mertens A, Shah D, Hanson I. Hemodynamic Support Using Percutaneous Transfemoral Impella 5.0 and Impella RP for Refractory Cardiogenic Shock. Case Rep Cardiol 2019; 2019:4591250. [PMID: 30809398 PMCID: PMC6364115 DOI: 10.1155/2019/4591250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/30/2018] [Indexed: 11/17/2022] Open
Abstract
Acute myocardial infarction (AMI) resulting in cardiogenic shock continues to be a substantial source of morbidity and mortality despite advances in recognition and treatment. Prior to the advent of percutaneous and more durable left ventricular support devices, prompt revascularization with the addition of vasopressors and inotropes were the standard of care in the management of this critical population. Recent published studies have shown that in addition to prompt revascularization, unloading of the left ventricle with the placement of the Impella percutaneous axillary flow pump can lead to improvement in mortality. Parameters such as the cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi), obtained through pulmonary artery catheterization, can help ascertain the productivity of right and left ventricular function. Utilization of these parameters can provide the information necessary to escalate support to the right ventricle with the insertion of an Impella RP or the left ventricle with the insertion of larger devices, which provide more forward flow. Herein, we present a case of AMI complicated by cardiogenic shock resulting in biventricular failure treated with the percutaneous insertion of an Impella RP and Impella 5.0 utilizing invasive markers of left and right ventricular function to guide the management and escalation of care.
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Affiliation(s)
- Pratik K. Dalal
- Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Amy Mertens
- Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Dinesh Shah
- Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Ivan Hanson
- Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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Bellumkonda L, Gul B, Masri SC. Evolving Concepts in Diagnosis and Management of Cardiogenic Shock. Am J Cardiol 2018; 122:1104-1110. [PMID: 30072134 DOI: 10.1016/j.amjcard.2018.05.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 01/03/2023]
Abstract
Despite efforts at early revascularization in acute coronary syndrome and advancing technologies in the field of temporary mechanical circulatory support (TMCS), the mortality from cardiogenic shock (CS) remains very high. Treatment of these patients involves understanding the trajectory of the condition and making complex decisions regarding the appropriate selection of medical and device therapies. The current definition of CS is not universally applicable and defines shock in absolute terms. CS should be thought of as a continuum rather than a binary diagnosis and is best defined as a clinical syndrome of tissue hypoperfusion resulting from cardiac dysfunction. Early intervention with appropriate timing and selection of apposite TMCS device may be the key to improving outcomes. TMCS device selection is a complex process requiring consideration of the severity of CS, patient-specific risks, technical limitations, overall goals of care, and assessment of futility of care. In this review, we discuss identification and pathophysiology of CS, and critically review acute management strategies, both medical and mechanical therapies and outline areas that need further investigation.
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Abstract
PURPOSE OF REVIEW We will briefly review the classification of shock and the hallmark features of each subtype. Available modalities for monitoring shock patients will be discussed, along with evidence supporting the use, common pitfalls, and practical considerations of each method. RECENT FINDINGS As older, invasive monitoring methods such as the pulmonary artery catheter have fallen out of favor, newer technologies for cardiac output estimation, echocardiography, and noninvasive tests such as passive leg raising have gained popularity. Newer forms of minimally invasive or noninvasive monitoring (such as pulse contour analysis and chest bioreactance) show promise but will need further investigation before they are considered validated for practical use. There remains no 'ideal' test or standard of care for cardiopulmonary monitoring of shock patients. SUMMARY Shock has potentially reversible causes of morbidity and mortality if appropriately diagnosed and managed. Older methods of invasive monitoring have significant limitations but are still critical for managing shock in certain patients and settings. Newer methods are easier to employ, but further validation is needed. Multiple modalities along with careful clinical assessment are often useful in distinguishing shock subtypes. Best practice standards for monitoring should be based on institutional expertise.
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[Infarct-related cardiogenic shock : Prognosis and treatment]. Med Klin Intensivmed Notfmed 2018; 113:267-276. [PMID: 29721682 DOI: 10.1007/s00063-018-0428-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Abstract
Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.
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Management and predictors of outcome in unselected patients with cardiogenic shock complicating acute ST-segment elevation myocardial infarction: results from the Bremen STEMI Registry. Clin Res Cardiol 2017; 107:371-379. [DOI: 10.1007/s00392-017-1192-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/04/2017] [Indexed: 01/25/2023]
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Schmack B, Seppelt P, Weymann A, Alt C, Farag M, Arif R, Doesch AO, Raake PW, Kallenbach K, Mansur A, Popov AF, Karck M, Ruhparwar A. Extracorporeal life support with left ventricular decompression-improved survival in severe cardiogenic shock: results from a retrospective study. PeerJ 2017; 5:e3813. [PMID: 28975053 PMCID: PMC5624302 DOI: 10.7717/peerj.3813] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
Objective Extracorporeal life support (ECLS) is a life-saving procedure used in the treatment of severe cardiogenic shock. Within this retrospective single centre study, we examined our experience in this critically ill patient cohort to assess outcomes and clinical parameters by comparison of ECLS with or without selective left ventricular decompression. Methods Between 2004 and 2014 we evaluated 48 adult patients with INTERMACS level 1 heart failure (age 49.7 ± 19.5 years), who received either central ECLS with (n = 20, 41.7%) or ECLS without (n = 28, 58.3%, including 10 peripheral ECLS) integrated left ventricular vent in our retrospective single centre trial. Results Follow up was 100% with a mean of 0.83 ± 1.85 years. Bridge to ventricular assist device was feasible in 29.2% (n = 14), bridge to transplant in 10.4% (n = 5) and bridge to recovery in 8.3% (n = 4). Overall 30-day survival was 37.5%, 6-month survival 27.1% and 1-year survival 25.0%. ECLS support with left ventricular decompression showed favourable 30-day survival compared to ECLS without left ventricular decompression (p = 0.034). Thirty-day as well as long-term survival did not differ between the subgroups (central ECLS with vent, ECLS without vent and peripheral ECLS without vent). Multivariate logistic regression adjusted for age and gender revealed ECLS without vent as independent factor influencing 30-day survival. Conclusion ECLS is an established therapy for patients in severe cardiogenic shock. Independent of the ECLS approach, 30-day mortality is still high but with superior 30-day survival for patients with ECLS and left ventricular venting. Moreover, by unloading the ventricle, left ventricular decompression may provide an important time window for recovery or further treatment, such as bridge to bridge or bridge to transplant.
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Affiliation(s)
- Bastian Schmack
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Seppelt
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Medical Clinic III, Department of Cardiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Christina Alt
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mina Farag
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas O Doesch
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, INCCI National Heart Institute, Luxembourg, Luxembourg
| | - Ashham Mansur
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
| | - Aron-Frederik Popov
- Division of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Taniguchi Y, Sakakura K, Adachi Y, Akashi N, Watanabe Y, Noguchi M, Yamamoto K, Ugata Y, Wada H, Momomura SI, Fujita H. In-hospital outcomes of acute myocardial infarction with cardiogenic shock caused by right coronary artery occlusion vs. left coronary artery occlusion. Cardiovasc Interv Ther 2017; 33:338-344. [PMID: 28918455 DOI: 10.1007/s12928-017-0490-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 09/09/2017] [Indexed: 11/28/2022]
Abstract
In-hospital outcomes of acute myocardial infarction (AMI) with cardiogenic shock (CS) were still not satisfactory even in the primary percutaneous coronary intervention (PCI) era. The aim of this study was to compare in-hospital outcomes of AMI with CS caused by right coronary artery (RCA) occlusion vs. left coronary artery (LCA) occlusion. Consecutive 894 AMI patients from January 2010 to March 2015 were screened for inclusion. A total of 114 AMI patients with CS were included as the final study population, and were divided into the RCA group (n = 56) and LCA group (n = 58). The patient characteristics were compared between the two groups. Multivariate logistic regression analysis was performed to show whether the RCA group was associated with better outcomes even after controlling confounding factors. In-hospital mortality was significantly lower in the RCA group (8.9%) than in the LCA group (46.6%) (P < 0.001). The RCA group (vs. the LCA group) was inversely associated with in-hospital death (OR 0.08, 95% CI 0.02-0.21, P < 0.001) after controlling covariates. Aspartate transaminase value (per 50 U/L incremental: OR 1.22, 95% CI 1.03-1.45, P = 0.02), aging (per 10-year-old incremental: OR 2.14, 95% CI 1.26-3.63, P = 0.01) and using VA-ECMO (OR 22.13, 95% CI 5.22-93.90, P < 0.001) were also significantly associated with in-hospital death. In conclusion, among AMI patients with CS, IRA of RCA was significantly associated with the better in-hospital outcome.
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Affiliation(s)
- Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Yusuke Adachi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Naoyuki Akashi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Yusuke Watanabe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Masamitsu Noguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Yusuke Ugata
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Shin-Ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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Krishnan SK, Riley RF, Hira RS, Lombardi WL. Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention. Interv Cardiol Clin 2017; 6:407-416. [PMID: 28600093 DOI: 10.1016/j.iccl.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.
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Affiliation(s)
- Sandeep K Krishnan
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Robert F Riley
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - William L Lombardi
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
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Initial Experience of Transaortic Catheter Venting in Patients with Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. ASAIO J 2016; 62:117-22. [PMID: 26720735 DOI: 10.1097/mat.0000000000000327] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has become one of the often applied mechanical support for acute cardiogenic shock. During venoarterial (VA) ECMO support, left heart decompression should be considered when left ventricular (LV) distension develops with pulmonary edema and LV dysfunction. The aim of this study was to report the results of transaortic catheter venting (TACV), as an alternative venting method, performed during VA-ECMO in patients with acute cardiogenic shock. We retrospectively reviewed the records of seven patients who underwent both ECMO and TACV between February 2013 and February 2014. Extracorporeal membrane oxygenation was performed uneventfully, and TACV was introduced under transthoracic echocardiographic guidance in all cases. Hemodynamic parameters, LV ejection fraction, and LV end-diastolic dimension (LVEDD) were measured 24 hours after initiating TACV in survivors. There were no procedure-related complications. Four of the seven patients (58%) survived. Transaortic catheter venting led to an increase in mean blood pressure in all patients (p = 0.050). There was a significant difference between pre- and post-TACV-LVEDD (59 ± 14 vs. 50 ± 12 mm, p = 0.044), with a 10-23% reduction in LVEDD in survivors. Transaortic catheter venting might be an acceptable alternative to venting procedures and useful for LV recovery during VA-ECMO in patients with severe LV dysfunction.
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30
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Weymann A, Farag M, Sabashnikov A, Fatullayev J, Zeriouh M, Schmack B, Arif R, Müller F, Alt C, Raake P, Prakash Patil N, Popov AF, Rüdiger Simon A, Karck M, Ruhparwar A. Central Extracorporeal Life Support With Left Ventricular Decompression to Berlin Heart Excor: A Reliable “Bridge to Bridge” Strategy in Crash and Burn Patients. Artif Organs 2016; 41:519-528. [DOI: 10.1111/aor.12792] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/07/2016] [Accepted: 05/31/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Mina Farag
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery; Heart Center, University of Cologne; Cologne
| | - Javid Fatullayev
- Department of Cardiothoracic Surgery; Heart Center, University of Cologne; Cologne
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery; Heart Center, University of Cologne; Cologne
| | - Bastian Schmack
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Rawa Arif
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Florian Müller
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Christina Alt
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Philip Raake
- Department of Cardiology; University of Heidelberg; Heidelberg Germany
| | - Nikhil Prakash Patil
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex United Kingdom
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex United Kingdom
| | - Andre Rüdiger Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex United Kingdom
| | - Matthias Karck
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
| | - Arjang Ruhparwar
- Department of Cardiac Surgery; Heart and Marfan Center, University of Heidelberg; Heidelberg
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31
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Bouki KP, Pavlakis G, Papasteriadis E. Management of Cardiogenic Shock Due to Acute Coronary Syndromes. Angiology 2016; 56:123-30. [PMID: 15793600 DOI: 10.1177/000331970505600201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite advances in the treatment of patients with acute coronary syndromes, there has been no significant decrease in the incidence of cardiogenic shock, while its mortality remains frustratingly high. Shock is a progressive state of hypotension (systolic blood pressure <90 mm Hg) lasting at least 30 minutes, which leads to systemic hypoperfusion. It is more common in patients with ST-segment elevation myocardial infarction than in patients with other acute coronary syndromes. Revascularization is associated with better outcomes than intensive medical therapy, especially in patients <75 years of age with cardiogenic shock. Adjunctive therapies include inotropes, vasopressor therapy, intra-aortic balloon pump counterpulsation, and IIb/IIIa blockade to prevent no-reflow phenomenon during primary percutaneous transluminal coronary angioplasty. Other adjunctive therapies which are investigated are improved mechanical support devices, and as medical therapy for myocyte protection nicorandil, glucose/insulin/potassium infusions and direct inhibition of Na+/H+ exchanger.
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32
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Arbel Y, Mass R, Ziv-Baran T, Khoury S, Margolis G, Sadeh B, Flint N, Ben-Shoshan J, Finn T, Keren G, Shacham Y. Prognostic implications of fluid balance in ST elevation myocardial infarction complicated by cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:462-467. [DOI: 10.1177/2048872616652312] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yaron Arbel
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Mass
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shafik Khoury
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Margolis
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ben Sadeh
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Flint
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeremy Ben-Shoshan
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talya Finn
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gad Keren
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yacov Shacham
- Department of Cardiology, Tel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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33
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Joseph J, Patterson T, Arri S, McConkey H, Redwood SR. Primary Angioplasty For Patients in Cardiogenic Shock: Optimal Management. Interv Cardiol 2016; 11:39-43. [PMID: 29588703 DOI: 10.15420/icr.2016.11.1.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cardiogenic shock complicates approximately 5-10 % of all MI events and remains the most common cause of death among MI cases. Over the past few decades, the mortality rate associated with cardiogenic shock has decreased with the introduction of early revascularisation, although there are limited data for patients with triple-vessel disease and left main stem disease. In more recent years, there have been a number of advances in the mechanical circulatory support devices that can help improve the haemodynamics of patients in cardiogenic shock. Despite these advances, together with progress in the use of inotropes and vasopressors, cardiogenic shock remains associated with high morbidity and mortality rates. This review will outline the management of cardiogenic shock complicating acute MI with a smajor focus on revascularisation techniques and the use of mechanical circulatory support devices.
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Affiliation(s)
- Jubin Joseph
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Tiffany Patterson
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Satpal Arri
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Hannah McConkey
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Simon R Redwood
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
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Byrd BF, Abraham TP, Buxton DB, Coletta AV, Cooper JHS, Douglas PS, Gillam LD, Goldstein SA, Graf TR, Horton KD, Isenberg AA, Klein AL, Kreeger J, Martin RP, Nedza SM, Navathe A, Pellikka PA, Picard MH, Pilotte JC, Ryan TJ, Rychik J, Sengupta PP, Thomas JD, Tucker L, Wallace W, Ward RP, Weissman NJ, Wiener DH, Woodruff S. A Summary of the American Society of Echocardiography Foundation Value-Based Healthcare: Summit 2014: The Role of Cardiovascular Ultrasound in the New Paradigm. J Am Soc Echocardiogr 2016; 28:755-69. [PMID: 26140937 DOI: 10.1016/j.echo.2015.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered. Third, moving forward, the ASE will continue to build a ‘‘living resource’’ on its website, http://www.asecho.org, for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound in the new value-based healthcare environment. The ASE looks forward to incorporating many of the Summit recommendations as it works with its members, legislators, payers, hospital administrators, and researchers to demonstrate and increase the value of cardiovascular ultrasound. All Summit attendees shared in the infectious enthusiasm generated by this proactive approach to ensuring cardiovascular ultrasound’s place as ‘‘The Value Choice’’ in cardiac imaging.
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Affiliation(s)
| | | | - Denis B Buxton
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - James H S Cooper
- Vanderbilt University Owen Graduate School of Management, Nashville, Tennessee
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | | | | | | | | | - Amol Navathe
- University of Pennsylvania and Navigant Consulting, Inc, Philadelphia, Pennsylvania
| | | | | | - John C Pilotte
- Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Thomas J Ryan
- The Ohio State University Heart Center, Columbus, Ohio
| | - Jack Rychik
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - James D Thomas
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois
| | - Leslie Tucker
- American Board of Internal Medicine and the ABIM Foundation, Philadelphia, Pennsylvania
| | | | | | - Neil J Weissman
- MedStar Health Research Institute, Washington, District of Columbia
| | | | - Sarah Woodruff
- Adult Congenital Heart Association, Philadelphia, Pennsylvania
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35
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Kolte D, Khera S, Dabhadkar KC, Agarwal S, Aronow WS, Timmermans R, Jain D, Cooper HA, Frishman WH, Menon V, Bhatt DL, Abbott JD, Fonarow GC, Panza JA. Trends in Coronary Angiography, Revascularization, and Outcomes of Cardiogenic Shock Complicating Non-ST-Elevation Myocardial Infarction. Am J Cardiol 2016; 117:1-9. [PMID: 26541908 DOI: 10.1016/j.amjcard.2015.10.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
Early revascularization is the mainstay of treatment for cardiogenic shock (CS) complicating acute myocardial infarction. However, data on the contemporary trends in management and outcomes of CS complicating non-ST-elevation myocardial infarction (NSTEMI) are limited. We used the 2006 to 2012 Nationwide Inpatient Sample databases to identify patients aged ≥ 18 years with NSTEMI with or without CS. Temporal trends and differences in coronary angiography, revascularization, and outcomes were analyzed. Of 2,191,772 patients with NSTEMI, 53,800 (2.5%) had a diagnosis of CS. From 2006 to 2012, coronary angiography rates increased from 53.6% to 60.4% in patients with NSTEMI with CS (ptrend <0.001). Among patients who underwent coronary angiography, revascularization rates were significantly higher in patients with CS versus without CS (72.5% vs 62.6%, p <0.001). Patients with NSTEMI with CS had significantly higher risk-adjusted in-hospital mortality (odds ratio 10.09, 95% confidence interval 9.88 to 10.32) as compared to those without CS. In patients with CS, an invasive strategy was associated with lower risk-adjusted in-hospital mortality (odds ratio 0.43, 95% confidence interval 0.42 to 0.45). Risk-adjusted in-hospital mortality, length of stay, and total hospital costs decreased over the study period in patients with and without CS (ptrend <0.001). In conclusion, we observed an increasing trend in coronary angiography and decreasing trend in in-hospital mortality, length of stay, and total hospital costs in patients with NSTEMI with and without CS. Despite these positive trends, overall coronary angiography and revascularization rates remain less than optimal and in-hospital mortality unacceptably high in patients with NSTEMI and CS.
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36
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Vural M, Şahin İ, Avcı İ, Kızkapan F, Yıldız S. Treatment of left main shock syndrome with percutaneous coronary intervention in the absence of an advanced left ventricular assist device or ECMO. Anatol J Cardiol 2015; 15:505-7. [PMID: 26006141 PMCID: PMC5779146 DOI: 10.5152/akd.2015.6195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Mutlu Vural
- Clinic of Cardiology, Bağcılar Education and Research Hospital; İstanbul-Turkey.
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37
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Age adjusted nationwide trends in the incidence of all cause and ST elevation myocardial infarction associated cardiogenic shock based on gender and race in the United States. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:2-5. [DOI: 10.1016/j.carrev.2014.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/11/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022]
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38
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Chang L, Yeh R. Evaluation and Management of ST-elevation Myocardial Infarction and Shock. Eur Cardiol 2014; 9:88-91. [PMID: 30310492 DOI: 10.15420/ecr.2014.9.2.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock is the deadliest complication of acute ST-elevation myocardial infarction. Prompt recognition and intervention are critical for patient survival. The diagnosis of cardiogenic shock is primarily a clinical one based on signs and symptoms of low cardiac output and heart failure, and can be confirmed with placement of a pulmonary arterial catheter. Vasopressor and inotropic therapies are typically required, and in severe cases, an intra-aortic balloon pump can provide additional haemodynamic support. Although mortality for cardiogenic shock associated with ST-elevation myocardial infarction remains high, early reperfusion strategies primarily via percutaneous coronary intervention or coronary artery bypass graft surgery have led to improved outcomes.
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Affiliation(s)
| | - Robert Yeh
- Cardiology Division, Massachusetts General Hospital, Boston, US
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39
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Central extracorporeal life support with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. J Cardiothorac Surg 2014; 9:60. [PMID: 24678718 PMCID: PMC3974212 DOI: 10.1186/1749-8090-9-60] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this prospective study was to evaluate the effects and functional outcome of central extracorporeal life support (ECLS) with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. METHODS Between August 2010 and August 2013, 12 consecutive patients (2 female) with a mean age of 31.6 ± 15.1 years received central ECLS with left ventricular decompression for the treatment of refractory cardiogenic shock and lung failure. Underlying disease was acute cardiac decompensation due to dilated cardiomyopathy (n = 3, 25%), coronary artery disease with acute myocardial infarction (AMI) (n = 3, 25%), and acute myocarditis (n = 6, 50%). We routinely implemented ECLS by cannulating the ascending aorta, right atrium and inserting a left ventricular decompression cannula vent via the right superior pulmonary vein. RESULTS All patients were successfully bridged to either recovery (n = 3, 25%), long-term biventricular support (n = 6, 50%) or cardiac transplantation (n = 3, 25%). Seven patients (58.3%) were discharged after a mean hospital stay of 42 ± 11.9 days. The overall survival from ECLS implantation to the end of the study was 58.3%. The cumulative ICU stay was 23.1 ± 9.6 days. The length of support was 8.0 ± 4.3 days (range 3-17 days). CONCLUSIONS We strongly recommend left ventricular decompression in refractory cardiogenic shock and lung failure to avoid pulmonary edema, left heart distension and facilitate myocardial recovery.
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40
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Dharma S, Dakota I, Firdaus I, Wardeh AJ, Jukema JW. The Use of Intra-aortic Balloon Pump in a Real-World Setting: A Comparison between Survivors and Nonsurvivors from Acute Coronary Syndrome Treated with IABP. The Jakarta Acute Coronary Syndrome Registry. Int J Angiol 2014; 22:213-22. [PMID: 24436615 DOI: 10.1055/s-0033-1348884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Real-world data on acute coronary syndrome (ACS) patients who received intra-aortic balloon pump (IABP) support are limited. The objective of this study was to evaluate the characteristics of ACS patients who received IABP support from a real-world ACS registry. Patients with ACS (N = 121) who received IABP support were enrolled. Characteristics of survivors and nonsurvivors were compared at 30 days. Mortality rate of patients with ACS who received IABP was 47%. The survivors (N = 64) had less often cardiogenic shock (p < 0.001), more often IABP usage as back-up for a revascularization procedure (p = 0.002), less often resuscitation (p = 0.043), and less mechanical ventilator support (p < 0.001) than nonsurvivors. The nonsurvivors had a significantly higher leukocyte count (p = 0.033), a higher serum creatinine level (p < 0.001), a higher blood sugar on admission (p = 0.001), higher creatine kinase MB levels (p = 0.002), and a higher serum uric acid level (p < 0.001), but significantly lower left and right ventricular function (p = 0.014 and p = 0.003, respectively) than survivors. At 30 days, non-ST elevation (STE)-ACS patients had lower mortality rate than ST segment elevation myocardial infarction patients (log-rank test, p < 0.001), and non-STE-ACS patients who had not suffered from cardiogenic shock showed the lowest mortality rate (log-rank test, p < 0.001). By multivariate analysis, a heart rate ≥ 100 beats per minute before IABP insertion was the strongest predictor of 30-day mortality (hazard ratio = 5.69; 95% confidence interval, 1.49 to 21.78; p = 0.011). In ACS patients presenting with either cardiogenic shock, resuscitated, or patients who needed mechanical ventilation suffered from high mortality, despite the use of IABP. IABP appears to be safe and tended to be favorable in noncardiogenic shock ACS patients, particularly non-STE-ACS. A heart rate of ≥ 100 beats per minute prior to IABP insertion was the strongest predictor of 30-day mortality.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Isman Firdaus
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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41
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Schmidt J, Maier A, Christ M. [Echocardiography in emergency admissions. Recognition of cardiac low-output failure]. Med Klin Intensivmed Notfmed 2013; 107:571-81; quiz 582-3. [PMID: 23052991 DOI: 10.1007/s00063-012-0167-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Detection of acute cardiac dysfunction and differential diagnosis of low cardiac output syndrome is challenging for emergency physicians. For the critical ill patient it is essential to rapidly identify the underlying disease to initiate the correct therapy and optimize patient outcome. Echocardiography is the diagnostic tool of choice for the evaluation of low cardiac output states. In the setting of the emergency department the use of focused echocardiography instead of detailed echocardiographic studies of cardiologists is appropriate and should be provided for emergency care. The differentiation in preserved versus reduced left ventricular ejection fraction as a first assessment is helpful, particularly for physicians not well trained in echocardiography. The structured and focused approach to evaluate or exclude differential diagnoses of cardiac dysfunction is the key for optimal management of acute and critically ill patients with low cardiac output.
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Affiliation(s)
- J Schmidt
- Klinik für Notfall- und Internistische Intensivmedizin, Klinikum Nürnberg, Prof.-Ernst-Nathan-Straße 1, Nürnberg, Germany.
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42
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Elmayergi N, Nguyen T, Hiebert B, Philipp RK, Jassal DS, Tam JW, Hussain F. A "no-option" left main PCI registry: outcomes and predictors of in hospital mortality-utility of the logistic EuroSCORE. Catheter Cardiovasc Interv 2013. [PMID: 23197480 DOI: 10.1002/ccd.24769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although high-risk left main PCI populations have been previously described, there is little data describing outcomes and the role of the logistic EuroSCORE in surgical turndown cohorts or patients in extremis due to acute infarction or cardiogenic shock from left main ischemia. METHODS Consecutive patients with unprotected LM PCI who were surgical turndowns or in extremis were included in this retrospective cohort from 2004 to 2009 at two tertiary centers. Predictors of in-hospital mortality were identified utilizing routine and stepwise logistic regression. RESULTS There were a total of 56 patients with mean age of 69 (±13). There were 23 (41%) patients with cardiogenic shock. The mean logistic EuroSCORE was 23.5% ± 21%. In-hospital death occurred in 12 (21%) patients, largely restricted to the shock subgroup (11/12). Univariate predictors of mortality included peak CK levels (P = 0.01), transfusion (P = 0.01), cardiogenic shock (P < 0.002), male gender (P = 0.027), and logistic EuroSCORE (P = 0.01). Stepwise logistic regression yielded logistic EuroSCORE (P = 0.04, OR: 1.25 (95% CI: 1.01-1.56) for every 5% increase) and peak CK level (P = 0.001, OR: 1.23 (95% CI: 1.09-1.40) for every 500 unit increase) as independent predictors of in-hospital mortality. The AUC ROC for logistic EuroSCORE was 0.73; and for logistic EuroSCORE plus peak CK level was 0.89. CONCLUSION PCI appears to be a reasonable option in the high risk "no option" LM population, with the logistic EuroSCORE and peak CK levels being independent predictors of in-hospital mortality. Specifically, the logistic EuroSCORE and peak CK level combined discriminate in-hospital mortality with a high degree of certainty.
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Affiliation(s)
- Nader Elmayergi
- Department of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
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43
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Wadke R, Sanborn TA. Cardiogenic Shock: Background, Shock Trial/Registry, Evolving Data, Changing Survival, Best Medical Therapy. Interv Cardiol Clin 2013; 2:397-406. [PMID: 28582101 DOI: 10.1016/j.iccl.2013.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cardiogenic shock remains associated with unacceptably high mortality, but recent improvements with early revascularization, continued support with pharmacologic agents, and use of an intra-aortic balloon pump have led to improvements in the rate of mortality. Timely intervention with cardiac surgery in patients with mechanical complications, 3-vessel disease, and left main disease is beneficial. Continued research and ever-improving understanding of this once deadly condition have helped further in improving prognosis. Cutting-edge technologies, such as myocyte cell implantation and the use of a cooling system, will help in pushing the boundaries farther.
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Affiliation(s)
- Rahul Wadke
- Hospitalist Division, Department of Internal Medicine, Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Timothy A Sanborn
- Head Cardiology Division, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building, Third Floor, Evanston, IL 60201, USA
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Tehrani S, Malik A, Hausenloy DJ. Cardiogenic Shock and the ICU Patient. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiogenic shock is one of the most important complications of acute myocardial infarction (MI) and acute left ventricular failure (LVF). It threatens the life of 5–10% of patients with ST-segment elevation myocardial infarction (STEMI) particularly in the presence of inappropriately low peripheral vascular resistance. Cardiogenic shock results in poor tissue perfusion, end-organ damage and carries a high mortality risk. The goal of therapy is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial blood pressure, which is achieved with the use of inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption and extended myocardial ischaemia. Current therapeutic approaches include early coronary artery revascularisation (which has significantly improved the survival rate), fluid resuscitation, inotropic support and mechanical circulatory support using intra-aortic balloon pumps or ventricular assist devices. In this article, we review the pathophysiology, diagnosis and management of cardiogenic shock.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Abdul Malik
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Derek J Hausenloy
- Reader in Cardiovascular Medicine
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
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Figueiredo A, Germano N, Guedes P, Marcelino P. The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics. Curr Cardiol Rev 2013; 7:136-45. [PMID: 22758612 PMCID: PMC3263478 DOI: 10.2174/157340311798220458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/19/2011] [Accepted: 04/21/2011] [Indexed: 01/19/2023] Open
Abstract
Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.
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Sjauw KD, Engström AE, Vis MM, Boom W, Baan J, de Winter RJ, Tijssen JGP, Piek JJ, Henriques JPS. Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock. Neth Heart J 2013; 20:402-9. [PMID: 22847042 DOI: 10.1007/s12471-012-0312-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality. METHODS From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n = 59) and 'IABP post PCI' (n = 140). Outcomes were assessed by propensity stratification and multivariate logistic regression. RESULTS All-cause 30-day mortality for the IABP versus the no IABP group was 47 % vs. 28 %, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64 % vs. 40 %, resulting in an OR of 1.56 (95 % CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality. CONCLUSION In our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the 'no IABP' group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.
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Affiliation(s)
- K D Sjauw
- Department of Cardiology, Academic Medical Center-University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands,
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Li Q, Goodman SG, Yan RT, Gore JM, Polasek P, Lai K, Baer C, Goldberg RJ, Pinter A, Ahmad K, Kornder JM, Yan AT. Pre-Hospital Cardiac Arrest in Acute Coronary Syndromes: Insights from the Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events. Cardiology 2013; 126:27-34. [DOI: 10.1159/000353365] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/22/2013] [Indexed: 11/19/2022]
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[Intra-aortic balloon pump in infarction-related cardiogenic shock. Time to say goodbye]. Med Klin Intensivmed Notfmed 2012; 107:567-70. [PMID: 23052992 DOI: 10.1007/s00063-012-0168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
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Aissaoui N, Puymirat E, Tabone X, Charbonnier B, Schiele F, Lefèvre T, Durand E, Blanchard D, Simon T, Cambou JP, Danchin N. Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries. Eur Heart J 2012; 33:2535-43. [PMID: 22927559 DOI: 10.1093/eurheartj/ehs264] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS. METHOD AND RESULTS Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival. CONCLUSIONS Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.
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Affiliation(s)
- Nadia Aissaoui
- Division of Coronary Artery Disease and Intensive Cardiac Care, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France.
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Awad HH, Anderson FA, Gore JM, Goodman SG, Goldberg RJ. Cardiogenic shock complicating acute coronary syndromes: insights from the Global Registry of Acute Coronary Events. Am Heart J 2012; 163:963-71. [PMID: 22709748 DOI: 10.1016/j.ahj.2012.03.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 03/12/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite advances in the management of patients with an acute coronary syndrome (ACS), cardiogenic shock (CS) remains the leading cause of death in these patients. The objective of this observational study was to describe the characteristics, management, and hospital outcomes of patients with an ACS complicated by CS. Our secondary study objective was to describe trends in the incidence and hospital case-fatality rates (CFRs) of CS and predictors of increased hospital mortality in these high-risk patients. METHODS The population consisted of patients enrolled in the GRACE study between 1999 and 2007 who were hospitalized with an ACS. RESULTS During the years under study, 2,992 patients (4.6%) developed CS. Patients with CS were more likely to be older, have a history of diabetes or atrial fibrillation, and present with a higher pulse rate or cardiac arrest. Cardiac catheterization was performed on 1,706 (57%) and in-hospital revascularization on 1,408 patients (47%) with CS. Patients with CS were less likely to receive evidence-based cardiac medications compared with patients who did not develop CS. The in-hospital CFR of patients with CS was 59.4%, compared with 2.3% in those who did not develop CS. Factors associated with an increased risk of dying in patients with CS included advanced age, diabetes mellitus, angina, and stroke. Adjusted incidence rates and hospital CFRs of CS showed modest declines over time. CONCLUSION Continued efforts are needed to reduce the incidence and CFRs of CS complicating ACS.
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