1
|
Povlsen AL, Helgestad OKL, Josiassen J, Christensen S, Højgaard HF, Kjærgaard J, Hassager C, Schmidt H, Jensen LO, Holmvang L, Møller JE, Ravn HB. Invasive mechanical ventilation in cardiogenic shock complicating acute myocardial infarction: A contemporary Danish cohort analysis. Int J Cardiol 2024; 405:131910. [PMID: 38423479 DOI: 10.1016/j.ijcard.2024.131910] [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: 09/21/2023] [Revised: 02/04/2024] [Accepted: 02/26/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Invasive mechanical ventilation (IMV) is widely used in patients with cardiogenic shock following acute myocardial infarction (AMICS), but evidence to guide practice remains sparse. We sought to evaluate trends in the rate of IMV utilization, applied settings, and short term-outcome of a contemporary cohort of AMICS patients treated with IMV according to out-of-hospital cardiac arrest (OHCA) at admission. METHODS Consecutive AMICS patients receiving IMV in an intensive care unit (ICU) at two tertiary centres between 2010 and 2017. Data were analysed in relation to OHCA. RESULTS A total of 1274 mechanically ventilated AMICS patients were identified, 682 (54%) with OHCA. Frequency of IMV increased during the study period, primarily due to higher occurrence of OHCA admissions. Among 566 patients with complete ventilator data, positive-end-expiratory pressure, inspired oxygen fraction, and minute ventilation during the initial 24 h in ICU were monitored. No differences were observed between 30-day survivors and non-survivors with OHCA. In non-OHCA, these ventilator requirements were significantly higher among 30-day non-survivors (P for all<0.05), accompanied by a lower PaO2/FiO2 ratio (median 143 vs. 230, P < 0.001) and higher arterial lactate levels (median 3.5 vs. 1.5 mmol/L, P < 0.001) than survivors. Physiologically normal PaO2 and pCO2 levels were achieved in all patients irrespective of 30-day survival and OHCA status. CONCLUSION In the present contemporary cohort of AMICS patients, physiologically normal blood gas values were achieved both in OHCA and non-OHCA in the early phase of admission. However, increased demand of ventilatory support was associated with poorer survival only in non-OHCA patients.
Collapse
Affiliation(s)
- Amalie Ling Povlsen
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark; Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ole Kristian Lerche Helgestad
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Henrik Frederiksen Højgaard
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark; Department of Clinical Medicine, University of Southern Denmark, Denmark
| | - Jesper Kjærgaard
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark; Department of Clinical Medicine, University of Southern Denmark, Denmark
| | - Lisette Okkels Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Clinical Medicine, University of Southern Denmark, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Southern Denmark, Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark; Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Southern Denmark, Denmark
| |
Collapse
|
2
|
Rali AS, Tran L, Balakrishna A, Senussi M, Kapur NK, Metkus T, Tedford RJ, Lindenfeld J. Guide to Lung-Protective Ventilation in Cardiac Patients. J Card Fail 2024; 30:829-837. [PMID: 38513887 DOI: 10.1016/j.cardfail.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 03/23/2024]
Abstract
The incidence of acute respiratory insufficiency has continued to increase among patients admitted to modern-day cardiovascular intensive care units. Positive pressure ventilation (PPV) remains the mainstay of treatment for these patients. Alterations in intrathoracic pressure during PPV has distinct effects on both the right and left ventricles, affecting cardiovascular performance. Lung-protective ventilation (LPV) minimizes the risk of further lung injury through ventilator-induced lung injury and, hence, an understanding of LPV and its cardiopulmonary interactions is beneficial for cardiologists.
Collapse
Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN.
| | - Lena Tran
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Mourad Senussi
- Department of Medicine, Baylor St. Luke's Medical Center, Houston, TX
| | - Navin K Kapur
- Division of Cardiovascular Diseases, Tufts Medical Center, Boston, MA
| | - Thomas Metkus
- Departments of Medicine and Surgery, Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Joann Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
3
|
Thomas A, Banna S, Shahu A, Ali T, Schenck C, Patel B, Notarianni A, Phommalinh M, Kochar A, Heck C, van Diepen S, Miller PE. Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction. Am Heart J 2024; 272:116-125. [PMID: 38554762 DOI: 10.1016/j.ahj.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. METHODS We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. RESULTS We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% confidence interval: -7.6% to -1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). CONCLUSIONS Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.
Collapse
Affiliation(s)
- Alexander Thomas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Soumya Banna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Tariq Ali
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Bhoumesh Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT
| | - Andrew Notarianni
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT
| | | | - Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Cory Heck
- Heart and Vascular Center, Yale New Haven Hospital, New Haven, CT
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
4
|
Carrillo-Aleman L, Agamez-Luengas AA, Guia M, Renedo-Villarroya A, Alonso-Fernández N, Lopez-Gomez L, Bayoumy-Delis P, Sanchez-Nieto JM, Pascual-Figal D, Carrillo-Alcaraz A. Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock. Rev Port Cardiol 2024; 43:259-273. [PMID: 37949366 DOI: 10.1016/j.repc.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/11/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV). METHODS Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis. RESULTS Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage. CONCLUSIONS NIV seems to be relatively effective and safe in the treatment of early-stage CS.
Collapse
Affiliation(s)
| | | | - Miguel Guia
- Sleep and Non-invasive Ventilation Unit, Thorax Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; ISAMB, Instituto de Saúde Ambiental da Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
| | | | | | | | | | | | - Domingo Pascual-Figal
- Cardiology Department, Virgen de la Arrixaca Hospital, Ctra. Madrid-Cartagena, Murcia, Spain
| | | |
Collapse
|
5
|
Lopez MP, Applefeld W, Miller PE, Elliott A, Bennett C, Lee B, Barnett C, Solomon MA, Corradi F, Sionis A, Mireles-Cabodevila E, Tavazzi G, Alviar CL. Complex Heart-Lung Ventilator Emergencies in the CICU. Cardiol Clin 2024; 42:253-271. [PMID: 38631793 DOI: 10.1016/j.ccl.2024.02.010] [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] [Indexed: 04/19/2024]
Abstract
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
Collapse
Affiliation(s)
- Mireia Padilla Lopez
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Willard Applefeld
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - P. Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Elliott
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Courtney Bennett
- Heart and Vascular Institute, Leigh Valley Health Network, Allentown, PA, USA
| | - Burton Lee
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MA, USA
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MA, USA
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Sionis
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eduardo Mireles-Cabodevila
- Respiratory Institute, Cleveland Clinic, Ohio and the Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Guido Tavazzi
- Department of Critical Care Medicine, Intensive Care Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University School of Medicine, USA.
| |
Collapse
|
6
|
Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [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: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
Collapse
Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
| |
Collapse
|
7
|
Kiyatkin ME, Aasman B, Fazzari MJ, Rudolph MI, Vidal Melo MF, Eikermann M, Gong MN. Development of an automated, general-purpose prediction tool for postoperative respiratory failure using machine learning: A retrospective cohort study. J Clin Anesth 2023; 90:111194. [PMID: 37422982 PMCID: PMC10529165 DOI: 10.1016/j.jclinane.2023.111194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
STUDY OBJECTIVE Postoperative respiratory failure is a major surgical complication and key quality metric. Existing prediction tools underperform, are limited to specific populations, and necessitate manual calculation. This limits their implementation. We aimed to create an improved, machine learning powered prediction tool with ideal characteristics for automated calculation. DESIGN, SETTING, AND PATIENTS We retrospectively reviewed 101,455 anesthetic procedures from 1/2018 to 6/2021. The primary outcome was the Standardized Endpoints in Perioperative Medicine consensus definition for postoperative respiratory failure. Secondary outcomes were respiratory quality metrics from the National Surgery Quality Improvement Sample, Society of Thoracic Surgeons, and CMS. We abstracted from the electronic health record 26 procedural and physiologic variables previously identified as respiratory failure risk factors. We randomly split the cohort and used the Random Forest method to predict the composite outcome in the training cohort. We coined this the RESPIRE model and measured its accuracy in the validation cohort using area under the receiver operating curve (AUROC) analysis, among other measures, and compared this with ARISCAT and SPORC-1, two leading prediction tools. We compared performance in a validation cohort using score cut-offs determined in a separate test cohort. MAIN RESULTS The RESPIRE model exhibited superior accuracy with an AUROC of 0.93 (95% CI, 0.92-0.95) compared to 0.82 for both ARISCAT and SPORC-1 (P-for-difference < 0.0001 for both). At comparable 80-90% sensitivities, RESPIRE had higher positive predictive value (11%, 95% CI: 10-12%) and lower false positive rate (12%, 95% CI: 12-13%) compared to 4% and 37% for both ARISCAT and SPORC-1. The RESPIRE model also better predicted the established quality metrics for postoperative respiratory failure. CONCLUSIONS We developed a general-purpose, machine learning powered prediction tool with superior performance for research and quality-based definitions of postoperative respiratory failure.
Collapse
Affiliation(s)
- Michael E Kiyatkin
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Boudewijn Aasman
- Center for Health Data Innovations, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Melissa J Fazzari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maíra I Rudolph
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Marcos F Vidal Melo
- Department of Anesthesiology, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
8
|
Patlolla SH, Gilbert ON, Belford PM, Morris BN, Jentzer JC, Pisani BA, Applegate RJ, Zhao DX, Vallabhajosyula S. Escalation strategies, management, and outcomes of acute myocardial infarction-cardiogenic shock patients receiving percutaneous left ventricular support. Catheter Cardiovasc Interv 2023; 102:403-414. [PMID: 37473420 DOI: 10.1002/ccd.30786] [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: 01/24/2023] [Revised: 06/17/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND There are limited national-level data on the contemporary practices of mechanical circulatory support (MCS) use in acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS We utilized the Healthcare Cost and Utilization Project-National/Nationwide Inpatient Sample data (2005-2017) to identify adult admissions (>18 years) with AMI-CS. MCS devices were classified as intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD), or extracorporeal membrane oxygenation (ECMO). We evaluated trends in the initial device used (IABP alone, pLVAD alone or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. RESULTS Among 327,283 AMI-CS admissions, 131,435 (40.2%) had an MCS device placed with available information on timing of placement. IABP, pLVAD, and ≥2 MCS devices were used as initial device in 120,928 (92.0%), 8202 (6.2%), and 2305 (1.7%) admissions, respectively. Most admissions were maintained on the initial MCS device with 1%-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). Urban, medium, and large-sized hospitals and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted odds ratio: 1.56, 95% confidence interval: 1.38-1.75; p < 0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices, resulting in lower in-hospital mortality. CONCLUSIONS In this 13-year study, escalation of MCS in AMI-CS was associated with higher in-hospital mortality suggestive of higher acuity of illness. The increase in number of durable LVAD/heart transplantations alludes to the role of MCS as successful bridge strategies.
Collapse
Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Olivia N Gilbert
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Peter M Belford
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Benjamin N Morris
- Department of Anesthesia, Section of Critical Care Anesthesiology, Winston-Salem, North Carolina, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barbara A Pisani
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Anesthesia, Section of Critical Care Anesthesiology, Winston-Salem, North Carolina, USA
| | - Robert J Applegate
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - David X Zhao
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Saraschandra Vallabhajosyula
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
9
|
Shirakabe A, Matsushita M, Shibata Y, Shighihara S, Nishigoori S, Sawatani T, Kiuchi K, Asai K. Organ dysfunction, injury, and failure in cardiogenic shock. J Intensive Care 2023; 11:26. [PMID: 37386552 DOI: 10.1186/s40560-023-00676-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is caused by primary cardiac dysfunction and induced by various and heterogeneous diseases (e.g., acute impairment of cardiac performance, or acute or chronic impairment of cardiac performance). MAIN BODY Although a low cardiac index is a common finding in patients with CS, the ventricular preload, pulmonary capillary wedge pressure, central venous pressure, and systemic vascular resistance might vary between patients. Organ dysfunction has traditionally been attributed to the hypoperfusion of the organ due to either progressive impairment of the cardiac output or intravascular volume depletion secondary to CS. However, research attention has recently shifted from this cardiac output ("forward failure") to venous congestion ("backward failure") as the most important hemodynamic determinant. Both hypoperfusion and/or venous congestion by CS could lead to injury, impairment, and failure of target organs (i.e., heart, lungs, kidney, liver, intestines, brain); these effects are associated with an increased mortality rate. Treatment strategies for the prevention, reduction, and reversal of organ injury are warranted to improve morbidity in these patients. The present review summarizes recent data regarding organ dysfunction, injury, and failure. CONCLUSIONS Early identification and treatment of organ dysfunction, along with hemodynamic stabilization, are key components of the management of patients with CS.
Collapse
Affiliation(s)
- Akihiro Shirakabe
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan.
| | - Masato Matsushita
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Yusaku Shibata
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Shota Shighihara
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Suguru Nishigoori
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Tomofumi Sawatani
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Kazutaka Kiuchi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
10
|
Bhat AG, Verghese D, Harsha Patlolla S, Truesdell AG, Batchelor WB, Henry TD, Cubeddu RJ, Budoff M, Bui Q, Matthew Belford P, X Zhao D, Vallabhajosyula S. In-Hospital cardiac arrest complicating ST-elevation myocardial Infarction: Temporal trends and outcomes based on management strategy. Resuscitation 2023; 186:109747. [PMID: 36822461 DOI: 10.1016/j.resuscitation.2023.109747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND There are limited data on the relationship of ST-segment-elevation myocardial infarction (STEMI) management strategy and in-hospital cardiac arrest (IHCA). AIMS To investigate the trends and outcomes of IHCA in STEMI by management strategy. METHODS Adult with STEMI complicated by IHCA from the National Inpatient Sample (2000-2017) were stratified into early percutaneous coronary intervention (PCI) (day 0 of hospitalization), delayed PCI (PCI ≥ day 1), or medical management (no PCI). Coronary artery bypass surgery was excluded. Outcomes of interest included in-hospital mortality, adverse events, length of stay, and hospitalization costs. RESULTS Of 3,967,711 STEMI admissions, IHCA was noted in 102,424 (2.6%) with an increase in incidence during this study period. Medically managed STEMI had higher rates of IHCA (3.6% vs 2.0% vs 1.3%, p < 0.001) compared to early and delayed PCI, respectively. Revascularization was associated with lower rates of IHCA (early PCI: adjusted odds ratio [aOR] 0.44 [95% confidence interval (CI) 0.43-0.44], p < 0.001; delayed PCI aOR 0.33 [95% CI 0.32-0.33], p < 0.001) compared to medical management. Non-revascularized patients had higher rates of non-shockable rhythms (62% vs 35% and 42.6%), but lower rates of multiorgan damage (44% vs 52.7% and 55.6%), cardiogenic shock (28% vs 65% and 57.4%) compared to early and delayed PCI, respectively (all p < 0.001). In-hospital mortality was lower with early PCI (49%, aOR 0.18, 95% CI 0.17-0.18), and delayed PCI (50.9%, aOR 0.18, 95% CI 0.17-0.19) (p < 0.001) compared to medical management (82.5%). CONCLUSION Early PCI in STEMI impacts the natural history of IHCA including timing and type of IHCA.
Collapse
Affiliation(s)
- Anusha G Bhat
- Division of Cardiovascular Medicine, Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Dhiran Verghese
- Division of Cardiovascular Medicine, Department of Medicine, Naples Heart Institute, Naples, FL, USA
| | | | - Alexander G Truesdell
- Virginia Heart, Falls Church, VA, USA; Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, USA
| | - Robert J Cubeddu
- Division of Cardiovascular Medicine, Department of Medicine, Naples Heart Institute, Naples, FL, USA
| | - Matthew Budoff
- Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Quang Bui
- Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| |
Collapse
|
11
|
Tralhão A. Parenteral antiplatelet therapy in acute myocardial infarction complicated by cardiogenic shock - A field still worthy of future randomized trials? Rev Port Cardiol 2023; 42:121-123. [PMID: 36115802 DOI: 10.1016/j.repc.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- António Tralhão
- Cardiac Intensive Care Unit, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, EPE, Carnaxide, Portugal.
| |
Collapse
|
12
|
Su X, Li J, Du L, Wei Y, Li H, Sang H. Acute myocardial infarction post-gastrointestinal bleeding: A clinical dilemma with poor prognosis. Saudi J Gastroenterol 2023; 29:47-52. [PMID: 36153929 PMCID: PMC10117005 DOI: 10.4103/sjg.sjg_301_22] [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: 02/03/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) complicating acute myocardial infarction (AMI) is a severe clinical condition with treatment contradiction and poor prognosis. This study aimed to evaluate the rate of in-hospital mortality in patients with GIB who subsequently suffered from AMI and to explore the potential risk factors for this condition. METHODS In this retrospective study, a total of 77 patients diagnosed with GIB, who subsequently suffered from AMI, were enrolled from January 2013 to March 2022. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality. RESULTS Among the 77 patients included in this study, 62 (80.52%) were males. The mean age of patients was 65.88 ± 12.15 years, and 48 patients (62.34%) were non-ST-segment elevation myocardial infarction (NSTEMI). There were 16 (20.78%) cases of in-hospital deaths. The subjects who died showed higher levels of white blood cell count (13.05 ± 5.76 vs. 9.31 ± 4.07 × 109/L, P = 0.003) and troponin I (TnI) (9.23 ± 9.17 vs. 4.12 ± 5.03 μg/L, P = 0.003). Besides, there were higher proportions of cardiogenic shock (81.25% vs. 26.23%, P < 0.001) and mechanical ventilator usage (75.0% vs. 11.48%, P < 0.001) among the patients who died. The multivariate logistic regression analysis showed that white blood cell count (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.02-1.39, P = 0.030), cardiogenic shock (OR 12.18, 95% CI 3.06-48.39, P = 0.017), and mechanical ventilator usage (OR 7.21, 95% CI 1.28-40.51, P = 0.025) were independently associated with in-hospital mortality. CONCLUSIONS The in-hospital mortality of patients with GIB who subsequently develop AMI is high. White blood cell count, cardiogenic shock, and mechanical ventilator usage are independent predictors of in-hospital mortality.
Collapse
Affiliation(s)
- Xin Su
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junlei Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Du
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuzhen Wei
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyu Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
13
|
Amado-Rodríguez L, Rodríguez-Garcia R, Bellani G, Pham T, Fan E, Madotto F, Laffey JG, Albaiceta GM. Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study. J Intensive Care 2022; 10:55. [PMID: 36567347 PMCID: PMC9791731 DOI: 10.1186/s40560-022-00648-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. METHODS Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. RESULTS From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. CONCLUSIONS Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073.
Collapse
Affiliation(s)
- Laura Amado-Rodríguez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Raquel Rodríguez-Garcia
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Eddy Fan
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Fabiana Madotto
- Department of Anesthesia, Critical Care and Emergency' Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
- School of Medicine, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain.
| |
Collapse
|
14
|
Hospitalization Duration for Acute Myocardial Infarction: A Temporal Analysis of 18-Year United States Data. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121846. [PMID: 36557048 PMCID: PMC9780977 DOI: 10.3390/medicina58121846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Background and objectives: Primary percutaneous coronary intervention (PCI)-related outcomes in acute myocardial infarction (AMI) have improved over time, but there are limited data on the length of stay (LOS) in relation to in-hospital mortality. Materials and Methods: A retrospective cohort of adult AMI admissions was identified from the National Inpatient Sample (2000−2017) and stratified into short (≤3 days) and long (>3 days) LOS. Outcomes of interest included temporal trends in LOS and associated in-hospital mortality, further sub-stratified based on demographics and comorbidities. Results: A total 11,622,528 admissions with AMI were identified, with a median LOS of 3 (interquartile range [IQR] 2−6) days with 49.9% short and 47.3% long LOS, respectively. In 2017, compared to 2000, temporal trends in LOS declined in all AMI, with marginal increases in LOS >3 days and decreases for ≤3 days (median 2 [IQR 1−3]) vs. long LOS (median 6 [IQR 5−9]). Patients with long LOS had lower rates of coronary angiography and PCI, but higher rates of non-cardiac organ support (respiratory and renal) and use of coronary artery bypass grafting. Unadjusted in-hospital mortality declined over time. Short LOS had comparable mortality to long LOS (51.3% vs. 48.6%) (p = 0.13); however, adjusted in-hospital mortality was higher in LOS >3 days when compared to LOS ≤ 3 days (adjusted OR 3.00, 95% CI 2.98−3.02, p < 0.001), with higher hospitalization (p < 0.001) when compared to long LOS. Conclusions: Median LOS in AMI, particularly in STEMI, has declined over the last two decades with a consistent trend in subgroup analysis. Longer LOS is associated with higher in-hospital mortality, higher hospitalization costs, and less frequent discharges to home compared to those with shorter LOS.
Collapse
|
15
|
Tralhão A. WITHDRAWN: Parenteral antiplatelet therapy in acute myocardial infarction complicated by cardiogenic shock - A field still needing future randomized trials? Rev Port Cardiol 2022:S0870-2551(22)00520-0. [PMID: 36526133 DOI: 10.1016/j.repc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, 10.1016/j.repc.2022.08.010. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
Collapse
Affiliation(s)
- António Tralhão
- Cardiac Intensive Care Unit, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, EPE, Carnaxide, Portugal.
| |
Collapse
|
16
|
Huang K, Zhang Y, Yang F, Luo X, Long W, Hou X. Effect of Enalapril Combined with Bisoprolol on Cardiac Function and Inflammatory Indexes in Patients with Acute Myocardial Infarction. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:6062450. [PMID: 36034944 PMCID: PMC9410778 DOI: 10.1155/2022/6062450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/20/2022]
Abstract
Objective The use of enalapril in combination with bisoprolol in patients with acute myocardial infarction (AMI) was studied for its effect on cardiac function and inflammatory parameters. Methods Sixty-two cases of AMI patients admitted to our clinic from November 2019 to November 2021 were selected for the study and grouped according to the random number table method, those enrolled were given conventional treatment such as oxygenation, absolute bed rest, and sedation, and administered low molecular heparin, aspirin, atorvastatin calcium tablets, clopidogrel, and nitrates. The control group (31 cases) was treated with enalapril maleate folic acid tablets, and the treatment group (31 cases) was treated with bisoprolol fumarate tablets on top of the control group, and the efficacy, adverse effects, cardiac function, inflammatory indexes, and oxidative stress indexes of the two arms were contrasted. Results The incidence of adverse reactions in the therapy cohort was 12.90% higher than that in the controlled arm, but the discrepancy was not medically relevant (P < 0.05). The SOD level was larger than the concentration in the corresponding drug therapy group, and the MDA level was lower than the concentration in the respective test cases (P < 0.05); the incidence of 12.90% adverse reactions in the treatment period was lower than that of 16.13% in the specific drug therapy group, but the variance was not scientifically evident (P > 0.05). Conclusion Enalapril application combined with bisoprolol in AMI patients is beneficial to boost the efficacy, promote the improvement of cardiac function, reduce the inflammatory response, and improve the oxidative stress with fewer adverse effects, which can ensure the therapeutic security.
Collapse
Affiliation(s)
- Kaiyue Huang
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| | - Yubin Zhang
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| | - Fulin Yang
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| | - Xue Luo
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| | - Weiying Long
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| | - Xingzhi Hou
- Internal Medicine-Cardiovascular Department, The People's Hospital of Yue Chi, No. 22, Jianshe Road East, Yuechi County, Sichuan Province, China
| |
Collapse
|
17
|
Su X, Wei Y, Pang S, Zhang Z, Zhang Y, Zheng P, Li H, Sang H, Dong J. Clinical Characteristics and Risk Factors of In-Hospital Mortality in Patients With Acute Myocardial Infarction With Subsequent Gastrointestinal Bleeding: A Single-Center Experience. Front Cardiovasc Med 2022; 9:942467. [PMID: 35911533 PMCID: PMC9326005 DOI: 10.3389/fcvm.2022.942467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/06/2022] [Indexed: 12/16/2022] Open
Abstract
Objective Gastrointestinal bleeding (GIB) post acute myocardial infarction (AMI) is a severe clinical condition with a poor prognosis. The purpose of the study was to evaluate the rate of in-hospital mortality in patients with GIB post-AMI and to identify the potential risk factors of this situation. Methods In this single-center retrospective study, a total of 154 patients diagnosed with AMI who subsequently suffered GIB were enrolled from October 2013 to December 2021. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality. Results Among the 154 subjects included in the final analysis, the mean age was 65.58 ± 11.20 years, and 104 (67.53%) were males. GIB occurred in 11 patients after thrombolytic therapy, 50 patients after percutaneous coronary intervention (PCI), and 93 patients during drug conservative treatment. A total of 41 patients died in the hospital. The in-hospital mortality rate of the thrombolysis group, PCI group, and drug conservative treatment group was 27.27% (3/11), 28.00% (14/50), and 25.81% (24/93), respectively. There was no difference in the in-hospital mortality among the three groups. The multivariate logistic regression analysis showed that the peak levels of TnI (OR 1.07, 95% CI 1.02–1.12, P = 0.011), condition of cardiogenic shock after admission (OR 14.52, 95% CI 3.36–62.62, P < 0.001), and the use of the mechanical ventilator (OR 8.14, 95% CI 2.03–32.59, P = 0.003) were significantly associated with in-hospital mortality. Conclusion Regardless of the treatment strategy for AMI, once GIB occurred, the prognosis was poor. High in-hospital mortality in patients with GIB post-AMI was independently associated with the peak levels of TnI, condition of cardiogenic shock, and the use of a mechanical ventilator.
Collapse
Affiliation(s)
- Xin Su
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuzhen Wei
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuo Pang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zeqing Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunxiao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peipei Zheng
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyu Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianzeng Dong
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
18
|
Rubinfeld GD, Berger JS, Smilowitz NR. Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes. Am J Med 2022; 135:e263-e278. [PMID: 35469734 PMCID: PMC9761405 DOI: 10.1016/j.amjmed.2022.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/11/2022] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding. METHODS Patients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment. RESULTS A total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01). CONCLUSION In the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.
Collapse
Affiliation(s)
- Gregory D Rubinfeld
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Department of Surgery, New York University School of Medicine, New York, NY
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, NY.
| |
Collapse
|
19
|
Relation of Ischemic Heart Disease to Outcomes in Patients With Acute Respiratory Distress Syndrome. Am J Cardiol 2022; 176:24-29. [PMID: 35606175 DOI: 10.1016/j.amjcard.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
Patients with ischemic heart disease (IHD) are often excluded from acute respiratory distress syndrome (ARDS) clinical trials. As a result, little is known about the impact of IHD in this population. We sought to assess the association between IHD and clinical outcomes in patients with ARDS. Participants from 4 ARDS randomized controlled trials with shared study criteria, definitions, and end points were included. Using multivariable logistic regression, we assessed for the association between IHD and a primary outcome of 60-day mortality. Secondary outcomes included 90-day mortality, 28-day ventilator-free days, and 28-day organ failure. Among 1,909 patients, 102 had a history of IHD (5.4%). Patients with IHD were more likely to be older and male (p <0.05). Noncardiac co-morbidities, severity of illness, and other markers of ARDS severity were not statistically different (all, p >0.05). Patients with IHD had a higher 60-day (39.2% vs 23.3%, p <0.001) and 90-day (40.2% vs 24.0%, p <0.001) mortality, and experienced more frequent renal (45.1% vs 32.0%, p = 0.006) and hepatic (35.3% vs 25.2%, p = 0.023) failure. After multivariable adjustment, 60-day (odds ratio [OR] 1.76; 95% confidence interval [CI]: 1.07 to 2.89, p = 0.025) and 90-day (OR 1.74; 95% CI: 1.06 to 2.85, p = 0.028) mortality remained higher. IHD was associated with 10% fewer ventilator-free days (incidence rate ratio 0.90; 95% CI: 0.85 to 0.96, p = 0.001). In conclusion, co-morbid IHD was associated with higher mortality and fewer ventilator-free days in patients with ARDS. Future studies are needed to identify predictors of mortality and improve treatment paradigms in this critically ill subgroup of patients.
Collapse
|
20
|
Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
Collapse
Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
| |
Collapse
|
21
|
Vallabhajosyula S, Kumar V, Sundaragiri PR, Cheungpasitporn W, Miller PE, Patlolla SH, Gersh BJ, Lerman A, Jaffe AS, Shah ND, Holmes DR, Bell MR, Barsness GW. Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals. Circ Heart Fail 2022; 15:e008991. [PMID: 35240866 PMCID: PMC9930186 DOI: 10.1161/circheartfailure.121.008991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. METHODS Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. RESULTS Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization. CONCLUSIONS Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Vinayak Kumar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, North Carolina
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota,Department of Health Services Research, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
22
|
Abstract
ABSTRACT Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.
Collapse
|
23
|
Kirilin VV, Dil SV, Kozulin KS, Panteleev OO, Ryabov VV. Arteriovenous shunt fraction as a marker for early diagnosis of acute respiratory distress syndrome against the background of cardiogenic pulmonary edema: a case report. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- V. V. Kirilin
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - S. V. Dil
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - K. S. Kozulin
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - O. O. Panteleev
- Cardiology Research Institute, Tomsk National Research Medical Center
| | - V. V. Ryabov
- Cardiology Research Institute, Tomsk National Research Medical Center
| |
Collapse
|
24
|
Concomitant Sepsis Diagnoses in Acute Myocardial Infarction-Cardiogenic Shock: 15-Year National Temporal Trends, Management, and Outcomes. Crit Care Explor 2022; 4:e0637. [PMID: 35141527 PMCID: PMC8820909 DOI: 10.1097/cce.0000000000000637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES: DESIGN: SETTING: PARTICIPANTS: INTERVENTIONS: MEASUREMENTS AND MAIN RESULTS: CONCLUSIONS:
Collapse
|
25
|
Vallabhajosyula S, Bhopalwala HM, Sundaragiri PR, Dewaswala N, Cheungpasitporn W, Doshi R, Prasad A, Sandhu GS, Jaffe AS, Bell MR, Holmes DR. Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study. Am Heart J 2022; 244:54-65. [PMID: 34774802 DOI: 10.1016/j.ahj.2021.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. CONCLUSIONS In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
| | | | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC
| | - Nakeya Dewaswala
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rajkumar Doshi
- Division of Cardiovascular Medicine, Department of Medicine, Saint Joseph University Medical Center, Paterson, NJ
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
26
|
Tehrani BN, Damluji AA, Batchelor WB. Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories. Curr Cardiol Rev 2022; 18:e251121198293. [PMID: 34823461 PMCID: PMC9413732 DOI: 10.2174/1573403x17666211125090929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 11/22/2022] Open
Abstract
Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.
Collapse
Affiliation(s)
- Behnam N Tehrani
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| | - Abdulla A Damluji
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Wayne B Batchelor
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| |
Collapse
|
27
|
Relationship between Driving Pressure and Mortality in Ventilated Patients with Heart Failure: A Cohort Study. Can Respir J 2021; 2021:5574963. [PMID: 34880958 PMCID: PMC8648448 DOI: 10.1155/2021/5574963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 10/09/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background Heart failure (HF) is a leading cause of mortality and morbidity worldwide, with an increasing incidence. Invasive ventilation is considered to be essential for patients with HF. Previous studies have shown that driving pressure is associated with mortality in acute respiratory distress syndrome (ARDS). However, the relationship between driving pressure and mortality has not yet been examined in ventilated patients with HF. We assessed the association of driving pressure and mortality in patients with HF. Methods We conducted a retrospective cohort study of invasive ventilated adult patients with HF from the Medical Information Mart for Intensive Care-III database. We used multivariable logistic regression models, a generalized additive model, and a two-piecewise linear regression model to show the effect of the average driving pressure within 24 h of intensive care unit admission on in-hospital mortality. Results Six hundred and thirty-two invasive ventilated patients with HF were enrolled. Driving pressure was independently associated with in-hospital mortality (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.06–1.18; P < 0.001) after adjusted potential confounders. A nonlinear relationship was found between driving pressure and in-hospital mortality, which had a threshold around 14.27 cmH2O. The effect sizes and CIs below and above the threshold were 0.89 (0.75 to 1.05) and 1.17 (1.07 to 1.30), respectively. Conclusions There was a nonlinear relationship between driving pressure and mortality in patients with HF who were ventilated for more than 48 h, and this relationship was associated with increased in-hospital mortality when the driving pressure was more than 14.27 cmH2O.
Collapse
|
28
|
Obradovic D, Freund A, Feistritzer HJ, Sulimov D, Loncar G, Abdel-Wahab M, Zeymer U, Desch S, Thiele H. Temporary mechanical circulatory support in cardiogenic shock. Prog Cardiovasc Dis 2021; 69:35-46. [PMID: 34801576 DOI: 10.1016/j.pcad.2021.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
Cardiogenic shock (CS) represents one of the foremost concerns in the field of acute cardiovascular medicine. Despite major advances in treatment, mortality of CS remains high. International societies recommend the development of expert CS centers with standardized protocols for CS diagnosis and treatment. In these terms, devices for temporary mechanical circulatory support (MCS) can be used to support the compromised circulation and could improve clinical outcome in selected patient populations presenting with CS. In the past years, we have witnessed an immense increase in the utilization of MCS devices to improve the clinical problem of low cardiac output. Although some treatment guidelines include the use of temporary MCS up to now no large randomized controlled trial confirmed a reduction in mortality in CS patients after MCS and additional research evidence is necessary to fully comprehend the clinical value of MCS in CS. In this article, we provide an overview of the most important diagnostic and therapeutic modalities in CS with the main focus on contemporary MCS devices, current state of art and scientific evidence for its clinical application and outline directions of future research efforts.
Collapse
Affiliation(s)
- Danilo Obradovic
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Hans-Josef Feistritzer
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Dmitry Sulimov
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Goran Loncar
- Institute for Cardiovascular Diseases 'Dedinje', University of Belgrade, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Mohamed Abdel-Wahab
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany.
| |
Collapse
|
29
|
Patlolla SH, Sundaragiri PR, Cheungpasitporn W, Doshi R, Vallabhajosyula S. Impact of concomitant respiratory infections in the management and outcomes acute myocardial infarction-cardiogenic shock. Indian Heart J 2021; 73:565-571. [PMID: 34627570 PMCID: PMC8514410 DOI: 10.1016/j.ihj.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/26/2021] [Accepted: 07/13/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence and impact of respiratory infections in cardiogenic shock complicating acute myocardial infarction (AMI-CS). METHODS Using the National Inpatient Sample (2000-2017), this study identified adult (≥18 years) admitted with AMI-CS complicated by respiratory infections. Outcomes of interest included in-hospital mortality of AMI-CS admissions with and without respiratory infections, hospitalization costs, hospital length of stay, and discharge disposition. Temporal trends of prevalence, in-hospital mortality and cardiac procedures were evaluated. RESULTS Among 557,974 AMI-CS admissions, concomitant respiratory infections were identified in 84,684 (15.2%). Temporal trends revealed a relatively stable trend in prevalence of respiratory infections over the 18-year period. Admissions with respiratory infections were on average older, less likely to be female, with greater comorbidity, had significantly higher rates of NSTEMI presentation, and acute non-cardiac organ failure compared to those without respiratory infections (all p < 0.001). These admissions received lower rates of coronary angiography (66.8% vs 69.4%, p < 0.001) and percutaneous coronary interventions (44.8% vs 49.5%, p < 0.001), with higher rates of mechanical circulatory support, pulmonary artery catheterization, and invasive mechanical ventilation compared to AMI-CS admissions without respiratory infections (all p < 0.001). The in-hospital mortality was lower among AMI-CS admissions with respiratory infections (31.6% vs 38.4%, adjusted OR 0.58 [95% CI 0.57-0.59], p < 0.001). Admissions with respiratory infections had longer lengths of hospital stay (127-20 vs 63-11 days, p < 0.001), higher hospitalization costs and less frequent discharges to home (27.1% vs 44.7%, p < 0.001). CONCLUSIONS Respiratory infections in AMI-CS admissions were associated with higher resource utilization but lower in-hospital mortality.
Collapse
Affiliation(s)
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajkumar Doshi
- Department of Medicine, University of Nevada School of Medicine, Reno, NV, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
30
|
Patlolla SH, Gurumurthy G, Sundaragiri PR, Cheungpasitporn W, Vallabhajosyula S. Body Mass Index and In-Hospital Management and Outcomes of Acute Myocardial Infarction. ACTA ACUST UNITED AC 2021; 57:medicina57090926. [PMID: 34577849 PMCID: PMC8464976 DOI: 10.3390/medicina57090926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Contemporary data on the prevalence, management and outcomes of acute myocardial infarction (AMI) in relation to body mass index (BMI) are limited. Materials and Methods: Using the National Inpatient Sample from 2008 through 2017, we identified adult AMI hospitalizations and categorized them into underweight (BMI < 19.9 kg/m2), normal BMI and overweight/obese (BMI > 24.9 kg/m2) groups. We evaluated in-hospital mortality, utilization of cardiac procedures and resource utilization among these groups. Results: Among 6,089,979 admissions for AMI, 38,070 (0.6%) were underweight, 5,094,721 (83.7%) had normal BMI, and 957,188 (15.7%) were overweight or obese. Over the study period, an increase in the prevalence of AMI was observed in underweight and overweight/obese admissions. Underweight AMI admissions were, on average, older, with higher comorbidity, whereas overweight/obese admissions were younger and had lower comorbidity. In comparison to the normal BMI and overweight/obese categories, significantly lower use of coronary angiography (62.3% vs. 74.6% vs. 37.9%) and PCI (40.8% vs. 47.7% vs. 19.6%) was observed in underweight admissions (all p < 0.001). The underweight category was associated with significantly higher in-hospital mortality (10.0% vs. 5.5%; OR 1.23 (95% CI 1.18–1.27), p < 0.001), whereas being overweight/obese was associated with significantly lower in-hospital mortality compared to normal BMI admissions (3.1% vs. 5.5%; OR 0.73 (95% CI 0.72–0.74), p < 0.001). Underweight AMI admissions had longer lengths of in-hospital stay with frequent discharges to skilled nursing facilities, while overweight/obese admissions had higher hospitalization costs. Conclusions: In-hospital management and outcomes of AMI vary by BMI. Underweight status was associated with worse outcomes, whereas the obesity paradox was apparent, with better outcomes for overweight/obese admissions.
Collapse
Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Gayathri Gurumurthy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Pranathi R. Sundaragiri
- Primary Care Internal Medicine, Wake Forest Baptist Health Westwood, High Point, NC 27262, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, High Point, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
| |
Collapse
|
31
|
Vallabhajosyula S, Desai VK, Sundaragiri PR, Cheungpasitporn W, Doshi R, Singh V, Jaffe AS, Lerman A, Barsness GW. Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1075. [PMID: 34422987 PMCID: PMC8339860 DOI: 10.21037/atm-20-5193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/22/2021] [Indexed: 12/25/2022]
Abstract
Background The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era. Methods From the National Inpatient Sample, adult NSTEMI admissions were identified [2000–2017]. Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition. Results Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53–60 years), more likely to be female (48% vs. 25–44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9–3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11–1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92–0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75–0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94–1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65–74%; early 15% vs. 22–27%) and PCI (27% vs. 35–44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges. Conclusions Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA.,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viral K Desai
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Rajkumar Doshi
- Department of Medicine, University of Nevada Reno School of Medicine, Reno, Nevada, USA
| | - Vikas Singh
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Mechanical ventilation is frequently needed in patients with cardiogenic shock. The aim of this review is to summarize and discuss the current evidence and the pathophysiological mechanism that a clinician should consider while setting the ventilator. RECENT FINDINGS Little attention has been placed specifically to ventilatory strategies in patients with cardiogenic shock undertaking mechanical ventilation. Lung failure in patients with cardiogenic shock is associated with worsening outcome as well as a delay in mechanical ventilation institution. The hemodynamic profile and cardiogenic shock cause, considering the preload dependency of the failing heart, must be defined to adjust ventilatory setting. SUMMARY Evidence is growing regarding the role of lung failure as adverse prognostic factor and beneficial effect of positive pressure ventilation as part of first-line treatment in patients with cardiogenic failure.
Collapse
|
33
|
Pham T, Pesenti A, Bellani G, Rubenfeld G, Fan E, Bugedo G, Lorente JA, Fernandes ADV, Van Haren F, Bruhn A, Rios F, Esteban A, Gattinoni L, Larsson A, McAuley DF, Ranieri M, Thompson BT, Wrigge H, Brochard LJ, Laffey JG. Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study. Eur Respir J 2021; 57:13993003.03317-2020. [PMID: 33334944 DOI: 10.1183/13993003.03317-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS). METHODS An international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared. FINDINGS 12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (CHF; 8.2%). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1% versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality, but similar adjusted mortality compared to those with ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only two quadrants involved. INTERPRETATION More than one-third of patients receiving mechanical ventilation have hypoxaemia and new infiltrates with a hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached.
Collapse
Affiliation(s)
- Tài Pham
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Dept of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto and Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Eddy Fan
- Dept of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Angel Lorente
- Critical Care Dept, Hospital Universitario de Getafe, Madrid, Spain.,CIBER Enfermedades Respiratorias, Madrid, Spain.,Universidad Europea, Madrid, Spain
| | | | - Frank Van Haren
- Intensive Care Unit, Canberra Hospital, Garran, Australia.,Australian National University Medical School, Canberra Hospital, Garran, Australia.,University of Canberra, Faculty of Health, Canberra, Australia
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Rios
- Intensive Care Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Andres Esteban
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Luciano Gattinoni
- University of Göttingen, Dept of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Anders Larsson
- Dept of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Marco Ranieri
- Alma Mater Studiorum-Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Bologna, Italy
| | - B Taylor Thompson
- Massachusetts General Hospital, Harvard School of Medicine, Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Boston, MA, USA
| | - Hermann Wrigge
- Dept of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.,Dept of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Co-senior authors
| | - John G Laffey
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Heath Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Dept of Anesthesia, St Michael's Hospital and University of Toronto, Toronto, ON, Canada.,School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Co-senior authors
| | | |
Collapse
|
34
|
Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Piña IL, Kapur NK, Dangas GD. Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e815-e829. [DOI: 10.1161/cir.0000000000000959] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.
Collapse
|
35
|
Vallabhajosyula S, Jentzer JC, Prasad A, Sangaralingham LR, Kashani K, Shah ND, Dunlay SM. Epidemiology of cardiogenic shock and cardiac arrest complicating non-ST-segment elevation myocardial infarction: 18-year US study. ESC Heart Fail 2021; 8:2259-2269. [PMID: 33837667 PMCID: PMC8120375 DOI: 10.1002/ehf2.13321] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/20/2022] Open
Abstract
Aims This study aims to evaluate the impact of the combination of cardiogenic shock (CS) and cardiac arrest (CA) complicating non‐ST‐segment elevation myocardial infarction (NSTEMI). Methods and results Adult (>18 years) NSTEMI admissions using the National Inpatient Sample database (2000 to 2017) were stratified by the presence of CA and/or CS. Outcomes of interest included in‐hospital mortality, early coronary angiography, hospitalization costs, and length of stay. Of the 7 302 447 hospitalizations due to NSTEMI, 147 795 (2.0%) had CS only, 155 522 (2.1%) had CA only, and 41 360 (0.6%) had both CS and CA. Compared with 2000, the adjusted odds ratios (ORs) and 95% confidence interval (CIs) for CS, CA, and both CS and CA in 2017 were 3.75 (3.58–3.92), 1.46 (1.42–1.50), and 4.52 (4.16–4.87), respectively (all P < 0.001). The CS + CA (61.2%) cohort had higher multiorgan failure than CS (42.3%) and CA only (32.0%) cohorts, P < 0.001. The CA only cohort had lower rates of overall (52% vs. 59–60%) and early (17% vs. 18–27%) angiography compared with the other groups (all P < 0.001). CS + CA admissions had higher in‐hospital mortality compared with those with CS alone (aOR 4.12 [95% CI 4.00–4.24]), CA alone (aOR 1.69 [95% CI 1.65–1.74]), or without CS/CA (aOR 22.66 [95% CI 22.06–23.27]). The presence of CS, either alone or with CA, was associated with higher hospitalization costs and longer hospital length of stay. Conclusions The combination of CS and CA is associated with higher rates of acute non‐cardiac organ failure and in‐hospital mortality in NSTEMI admissions as compared with those with either CS or CA alone.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Health Services Research, Mayo Clinic, Rochester, MN, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Health Services Research, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
36
|
Metkus T, Miller PE, Alviar CL, Jentzer JC, van Diepen S, Katz JN, Morrow DA, Schulman S, Eid S. Incidence, predictors and prognosis of respiratory support in non-ST segment elevation myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:200–206. [PMID: 32324057 DOI: 10.1177/2048872620919947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/26/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized. METHODS We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002-2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models. RESULTS A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, p<0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support (p<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74-1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88-3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time. CONCLUSION Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.
Collapse
Affiliation(s)
- Thomas Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, USA
| | | | - Sean van Diepen
- Department of Critical Care and Division of Cardiology and Department of Medicine, University of Alberta Canada
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, NC USA
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Schulman
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Shaker Eid
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| |
Collapse
|
37
|
Vallabhajosyula S, Payne SR, Jentzer JC, Sangaralingham LR, Kashani K, Shah ND, Prasad A, Dunlay SM. Use of Post-Acute Care Services and Readmissions After Acute Myocardial Infarction Complicated by Cardiac Arrest and Cardiogenic Shock. Mayo Clin Proc Innov Qual Outcomes 2021; 5:320-329. [PMID: 33997631 PMCID: PMC8105498 DOI: 10.1016/j.mayocpiqo.2020.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE To evaluate post-acute care utilization and readmissions after cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI). METHODS With use of an administrative claims database, AMI patients from January 1, 2010, to May 31, 2018, were stratified into CA+CS, CA only, CS only, and AMI alone. Outcomes included 90-day post-acute care (inpatient rehabilitation or skilled nursing facility) utilization and 1-year emergency department visits and readmissions. RESULTS Of 163,071 AMI patients, CA+CS, CA only, and CS only were noted in 3965 (2.4%), 8221 (5.0%), and 6559 (4.0%), respectively. In-hospital mortality was noted in 10,686 (6.6%) patients: CA+CS, 1935 (48.8%); CA only, 2948 (35.9%); CS only, 1578 (24.1%); and AMI alone, 4225 (2.9%) (P<.001). Among survivors, post-acute care services were used in 67,799 (44.5%), with higher use in the CS+CA cohort (1310 [64.6%]; hazard ratio [HR], 1.19; 95% CI, 1.06 to 1.33; P=.003) and CA cohort (2738 [51.9%]; HR, 1.27; 95% CI, 1.20 to 1.35; P<.001) but not in the CS cohort (3048 [61.2%]; HR, 1.03; 95% CI, 0.97 to 1.11; P=.35) compared with the AMI cohort (60,703 [43.3%]). Compared with the AMI cohort (48,990 [35.0%]), patients with CS only (2,085 [41.9%]; HR, 1.16; 95% CI, 1.10 to 1.22; P<.001) but not those with CA+CS (724 [35.7%]; HR, 1.07; 95% CI, 0.98 to 1.17; P=.14) had higher rates of readmissions (P=.03). Readmissions were lower in those with CA (1,590 [30.2%]; HR, 0.94; 95% CI, 0.89 to 0.99). Repeated AMI, coronary artery disease, and heart failure were the most common readmission reasons. There were no differences for emergency department visits. CONCLUSION CA is associated with increased post-acute care use, whereas CS is associated with increased readmission risk in AMI survivors.
Collapse
Key Words
- AMI, acute myocardial infarction
- CA, cardiac arrest
- CS, cardiogenic shock
- ED, emergency department
- HR, hazard ratio
- ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- MCS, mechanical circulatory support
- PCI, percutaneous coronary intervention
- SNF, skilled nursing facility
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Stephanie R. Payne
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Lindsey R. Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilay D. Shah
- Department of Health Services Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Cambridge, MA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Department of Health Services Research, Mayo Clinic, Rochester, MN
| |
Collapse
|
38
|
Influence of Human Immunodeficiency Virus Infection on the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock. J Acquir Immune Defic Syndr 2021; 85:331-339. [PMID: 32740372 DOI: 10.1097/qai.0000000000002442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with HIV infection and AIDS. SETTING Twenty percent sample of all US hospitals. METHODS A retrospective cohort of AMI-CS during 2000-2017 from the National Inpatient Sample was evaluated for concomitant HIV and AIDS. Outcomes of interest included in-hospital mortality and use of cardiac procedures. A subgroup analysis was performed for those with and without AIDS within the HIV cohort. RESULTS A total 557,974 AMI-CS admissions were included, with HIV and AIDS in 1321 (0.2%) and 985 (0.2%), respectively. The HIV cohort was younger (54.1 vs. 69.0 years), more often men, of non-White race, uninsured, from a lower socioeconomic status, and with higher comorbidity (all P < 0.001). The HIV cohort had comparable multiorgan failure (37.8% vs. 39.0%) and cardiac arrest (28.7% vs. 27.4%) (P > 0.05). The cohorts with and without HIV had comparable rates of coronary angiography (70.2% vs. 69.0%; P = 0.37) but less frequent early coronary angiography (hospital day zero) (39.1% vs. 42.5%; P < 0.001). The cohort with HIV had higher unadjusted but comparable adjusted in-hospital mortality compared with those without [26.9% vs. 37.4%; adjusted odds ratio 1.04 (95% confidence interval: 0.90 to 1.21); P = 0.61]. In the HIV cohort, AIDS was associated with higher in-hospital mortality [28.8% vs. 21.1%; adjusted odds ratio 4.12 (95% confidence interval: 1.89 to 9.00); P < 0.001]. CONCLUSIONS The cohort with HIV had comparable rates of cardiac procedures and in-hospital mortality; however, those with AIDS had higher in-hospital mortality.
Collapse
|
39
|
Jentzer JC, Alviar CL, Miller PE, Metkus T, Bennett CE, Morrow DA, Barsness GW, Kashani KB, Gajic O. Trends in Therapy and Outcomes Associated With Respiratory Failure in Patients Admitted to the Cardiac Intensive Care Unit. J Intensive Care Med 2021; 37:543-554. [PMID: 33759608 DOI: 10.1177/08850666211003489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To describe the epidemiology, outcomes, and temporal trends of respiratory failure in the cardiac intensive care unit (CICU). MATERIALS AND METHODS Retrospective cohort analysis of 2,986 unique Mayo Clinic CICU patients from 2007 to 2018 with respiratory failure. Temporal trends were analyzed, along with hospital and 1-year mortality. Multivariable logistic regression was used to determine adjusted hospital mortality trends. RESULTS The prevalence of respiratory failure in the CICU increased from 15% to 38% during the study period (P < 0.001 for trend). Among patients with respiratory failure, the utilization of invasive ventilation decreased and noninvasive ventilation modalities increased over time. Hospital mortality and 1-year mortality were 24% and 54%, respectively, with variation according to the type of respiratory support (highest among patients receiving invasive ventilation alone: 35% and 46%, respectively). Hospital mortality was highest among patients with concomitant cardiac arrest and/or shock (52% for patients with both). Hospital mortality decreased in the overall population from 35% to 25% (P < 0.001 for trend), but was unchanged among patients receiving positive-pressure ventilation. CONCLUSIONS The prevalence of respiratory failure in CICU more than doubled during the last decade. The use of noninvasive respiratory support increased, while overall mortality declined over time. Cardiac arrest and shock accounted for the majority of deaths. Further research is needed to optimize the outcomes of high-risk CICU patients with respiratory failure.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale National Clinician Scholars Program, New Haven, CT, USA
| | - Thomas Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA.,Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA
| |
Collapse
|
40
|
Proudfoot AG, Jain A. Striking the balance in admissions with non-ST-segment elevation myocardial infarction requiring advanced respiratory support. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:116-118. [PMID: 33724347 DOI: 10.1093/ehjacc/zuab004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Alastair G Proudfoot
- Barts Heart Centre, St Bartholomew's Hospital, Department of Perioperative Medicine, West Smithfield, London, UK.,William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Charité - Universitätsmedizin, Berlin, Germany.,Deutsches Herzzentrum Berlin, Berlin,Germany
| | - Ajay Jain
- Barts Heart Centre, St Bartholomew's Hospital, Department of Perioperative Medicine, West Smithfield, London, UK
| |
Collapse
|
41
|
Vallabhajosyula S, Verghese D, Bell MR, Murphree DH, Cheungpasitporn W, Miller PE, Dunlay SM, Prasad A, Sandhu GS, Gulati R, Singh M, Lerman A, Gersh BJ, Holmes DR, Barsness GW. Fibrinolysis vs. primary percutaneous coronary intervention for ST-segment elevation myocardial infarction cardiogenic shock. ESC Heart Fail 2021; 8:2025-2035. [PMID: 33704924 PMCID: PMC8120407 DOI: 10.1002/ehf2.13281] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 12/29/2022] Open
Abstract
AIMS There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). METHODS Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status. RESULTS During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs. CONCLUSIONS The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA,Division of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterMNUSA,Center for Clinical and Translational ScienceMayo Clinic Graduate School of Biomedical SciencesRochesterMNUSA,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of MedicineEmory University School of Medicine1364 Clifton Road NEAtlantaGA30322USA,Department of MedicineAmita Health Saint Joseph HospitalChicagoILUSA
| | - Dhiran Verghese
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of MedicineEmory University School of Medicine1364 Clifton Road NEAtlantaGA30322USA,Department of MedicineAmita Health Saint Joseph HospitalChicagoILUSA
| | - Malcolm R. Bell
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi School of MedicineJacksonMSUSA
| | - Paul Elliott Miller
- Division of Cardiovascular Medicine, Department of MedicineYale University School of MedicineNew HavenCTUSA
| | - Shannon M. Dunlay
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA,Department of Health Sciences ResearchMayo ClinicRochesterMNUSA
| | - Abhiram Prasad
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Rajiv Gulati
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Mandeep Singh
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Amir Lerman
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - David R. Holmes
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | |
Collapse
|
42
|
Vallabhajosyula S, Prasad A, Sandhu G, Bell M, Gulati R, Eleid M, Best P, Gersh BJ, Singh M, Lerman A, Holmes DR, Rihal CS, Barsness G. Ten-year trends, predictors and outcomes of mechanical circulatory support in percutaneous coronary intervention for acute myocardial infarction with cardiogenic shock. EUROINTERVENTION 2021; 16:e1254-e1261. [PMID: 31746759 PMCID: PMC9725008 DOI: 10.4244/eij-d-19-00226] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS. METHODS AND RESULTS Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p<0.001) and greater resource utilisation. IABP-assisted PCI had lower in-hospital mortality and lesser resource utilisation compared to pLVAD/ECMO. CONCLUSIONS MCS-assisted PCI identified a sicker AMI-CS cohort. There was a decrease in IABP and an increase in pLVAD/ECMO.
Collapse
Affiliation(s)
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Gurpreet Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Malcolm Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mackram Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Patricia Best
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
43
|
Schrader M, Sathananthan M, Jeganathan N. Patients With Idiopathic Pulmonary Fibrosis Admitted to the ICU With Acute Respiratory Failure-A Reevaluation of the Risk Factors and Outcomes. J Intensive Care Med 2021; 37:342-351. [PMID: 33511890 DOI: 10.1177/0885066621989244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Idiopathic pulmonary fibrosis (IPF) patients admitted to the ICU with acute respiratory failure (ARF) are known to have a poor prognosis. However, the majority of the studies published to date are older and had small sample sizes. Given the advances in ICU care since the publication of these studies, we sought to reevaluate the outcomes and risk factors associated with mortality in these patients. METHODS Retrospective study using a large multi-center ICU database. We identified 411 unique patients with IPF admitted with ARF between 2014-2015. RESULTS Of all IPF patients admitted to the ICU with ARF, 81.3% required mechanical ventilation (MV): 48.9% invasive and 32.4% non-invasive alone. The hospital mortality rate was 34.5% for all patients; 48.8% in patients requiring invasive MV, 21.8% in those requiring non-invasive MV and 19.5% with no MV. In multiple regression analyses, age, APACHE score, invasive MV, and hyponatremia at admission were associated with increased mortality whereas post-op status was associated with lower mortality. In patients requiring invasive MV, baseline PaO2/FiO2 ratio was also predictive of mortality. Non-pulmonary organ failures were present in less than 20% of the patients. CONCLUSIONS Although the overall mortality rate for IPF patients admitted to the ICU with ARF has improved, the mortality rates for patients requiring invasive MV remains high at approximately 50%. Older age, high APACHE score, and low baseline PaO2/FiO2 ratio are factors predictive of increased mortality in this population.
Collapse
Affiliation(s)
- Matthew Schrader
- Department of Internal Medicine, University of California, Riverside, California CA, USA
| | - Matheni Sathananthan
- Department of Medicine, Loma Linda University Health, Loma Linda, California CA, USA
| | - Niranjan Jeganathan
- Department of Medicine, Loma Linda University Health, Loma Linda, California CA, USA
| |
Collapse
|
44
|
Vallabhajosyula S, Kumar V, Sundaragiri PR, Cheungpasitporn W, Bell MR, Singh M, Jaffe AS, Barsness GW. Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States. PLoS One 2020; 15:e0243810. [PMID: 33338071 PMCID: PMC7748387 DOI: 10.1371/journal.pone.0243810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/26/2020] [Indexed: 12/27/2022] Open
Abstract
Background There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). Objective To assess the influence of insurance status on STEMI outcomes. Methods Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. Results Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. Conclusions Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, United States of America
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
| | - Vinayak Kumar
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Pranathi R. Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, United States of America
| | - Malcolm R. Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Allan S. Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| |
Collapse
|
45
|
Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease. J Clin Med 2020; 9:jcm9113702. [PMID: 33218121 PMCID: PMC7698908 DOI: 10.3390/jcm9113702] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005–2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD–38.5%, 2.6%; CKD-III–79.1%, 6.5%; CKD-IV–84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21–1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69–0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77–0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.
Collapse
|
46
|
Comparison of Complications and In-Hospital Mortality in Takotsubo (Apical Ballooning/Stress) Cardiomyopathy Versus Acute Myocardial Infarction. Am J Cardiol 2020; 132:29-35. [PMID: 32762963 DOI: 10.1016/j.amjcard.2020.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022]
Abstract
There are limited data on the incidence of complications and in-hospital outcomes, in patients with Takotsubo cardiomyopathy (TC), as compared with acute myocardial infarction (AMI). From 2007 to 2014, a retrospective cohort of TC was compared with AMI using the National Inpatient Sample database. Complications were classified as acute heart failure, ventricular arrhythmic, cardiac arrest, high-grade atrioventricular block, mechanical, vascular/access, pericardial, stroke, and acute kidney injury. Temporal trends, clinical characteristics, and in-hospital outcomes were compared. During the 8-year period, 3,329,876 admissions for AMI or TC were identified. TC diagnosis was present in 88,849 (2.7%). Compared with AMI admissions, those with TC were older, female, and of white race. Use of pulmonary artery catheter and mechanical ventilation was higher, but hemodialysis lower in TC. The overall frequency of complications was higher in TC (38.2% vs 32.6%). Complication rates increased in both groups over time, but the delta was greater for TC (23% [2007] vs 43% [2014]) compared with AMI (27% vs 36%). The TC cohort had a higher rate of heart failure (29% vs 16.6%) and strokes (0.5% vs 0.2%), but lower rates of other complications (all p <0.001). In-hospital mortality was lower for TC (2.6% vs 3.1%; p <0.001). TC was an independent predictor of lower in-hospital mortality in admissions with complications. In conclusion, compared with AMI, TC is associated with greater likelihood of heart failure, but lower rates of other complications and mortality. There has been a temporal increase in the rates of in-hospital complications and mortality due to TC.
Collapse
|
47
|
Vallabhajosyula S, Ya'Qoub L, Singh M, Bell MR, Gulati R, Cheungpasitporn W, Sundaragiri PR, Miller VM, Jaffe AS, Gersh BJ, Holmes DR, Barsness GW. Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young. Circ Heart Fail 2020; 13:e007154. [PMID: 32988218 DOI: 10.1161/circheartfailure.120.007154] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults. METHODS A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay. RESULTS A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P<0.001). Compared with men, women with AMI-CS were more frequently of Black race, from a lower socioeconomic status, with higher comorbidity, and admitted to rural and small hospitals (all P<0.001). Women had lower rates of ST-segment elevation presentation (73.0% versus 78.7%), acute noncardiac organ failure, cardiac arrest (34.3% versus 35.7%), and received less-frequent coronary angiography (78.3% versus 81.4%), early coronary angiography (49.2% versus 54.1%), percutaneous coronary intervention (59.2% versus 64.0%), and mechanical circulatory support (50.3% versus 59.2%; all P<0.001). Female sex was an independent predictor of in-hospital mortality (23.0% versus 21.7%; adjusted odds ratio, 1.11 [95% CI, 1.07-1.16]; P<0.001). Women had lower hospitalization costs ($156 372±$198 452 versus $167 669±$208 577; P<0.001) but comparable lengths of stay compared with men. CONCLUSIONS In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN.,Division of Pulmonary and Critical Care Medicine, Department of Medicine (S.V.), Mayo Mayo Clinic, Rochester, MN.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN (S.V.).,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA (S.V.)
| | - Lina Ya'Qoub
- Division of Cardiovascular Medicine, Department of Medicine, Louisiana State University School of Medicine, Shreveport (L.Y.)
| | - Mandeep Singh
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - Rajiv Gulati
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson (W.C.)
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine (P.R.S.), Mayo Mayo Clinic, Rochester, MN
| | - Virginia M Miller
- Department of Physiology and Biomedical Engineering (V.M.M.), Mayo Mayo Clinic, Rochester, MN.,Department of Surgery (V.M.M.), Mayo Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| | - Gregory W Barsness
- Department of Cardiovascular Medicine (S.V., M.S., M.R.B., R.G., A.S.J., B.J.G., D.R.H., G.W.B.), Mayo Mayo Clinic, Rochester, MN
| |
Collapse
|
48
|
Abstract
Supplemental Digital Content is available in the text. The medical complexity and critical care needs of patients admitted to cardiac ICUs are increasing, and prospective studies examining the underlying cardiac and noncardiac diagnoses, the management strategies, and the prognosis of cardiac ICU patients with respiratory failure are needed.
Collapse
|
49
|
Vallabhajosyula S, Vallabhajosyula S, Dunlay SM, Hayes SN, Best PJM, Brenes-Salazar JA, Lerman A, Gersh BJ, Jaffe AS, Bell MR, Holmes DR, Barsness GW. Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults. Mayo Clin Proc 2020; 95:1916-1927. [PMID: 32861335 PMCID: PMC7582223 DOI: 10.1016/j.mayocp.2020.01.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/11/2020] [Accepted: 01/31/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). MATERIALS AND METHODS A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay. RESULTS In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality. CONCLUSION Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN.
| | | | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Jorge A Brenes-Salazar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Geriatric Medicine and Gerontology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Clinical Core Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
50
|
Management and outcomes of uncomplicated ST-segment elevation myocardial infarction patients transferred after fibrinolytic therapy. Int J Cardiol 2020; 321:54-60. [PMID: 32810551 DOI: 10.1016/j.ijcard.2020.08.012] [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: 02/11/2020] [Revised: 07/14/2020] [Accepted: 08/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy ('drip-and-ship') for ST-segment elevation myocardial infarction (STEMI) in the United States. METHODS During 2009-2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. RESULTS A total of 27,454 STEMI admissions receiving a 'drip-and-ship strategy', 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11-0.27]; p < .001) but not CA without revascularization (OR 0.72 [95% CI 0.42-1.21]; p = .21) was associated with lower in-hospital mortality. The fibrinolysis alone cohort had higher use of do-not-resuscitate status (12.8%) and fewer discharges to home (56.6%) compared to cohorts undergoing CA without (1.7%; 86.9%) and with (0.3% and 91.2%) revascularization, respectively. Presence of complications, do-not-resuscitate status, and higher comorbidity were predictive of lower CA and revascularization use. CONCLUSION Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes.
Collapse
|