1
|
Wang Y, Zeller M, Auffret V, Georgiopoulos G, Räber L, Roffi M, Templin C, Muller O, Liberale L, Ministrini S, Stamatelopoulos K, Stellos K, Camici GG, Montecucco F, Rickli H, Maza M, Radovanovic D, Cottin Y, Chague F, Niederseer D, Lüscher TF, Kraler S. Sex-specific prediction of cardiogenic shock after acute coronary syndromes: the SEX-SHOCK score. Eur Heart J 2024; 45:4564-4578. [PMID: 39217456 PMCID: PMC11560280 DOI: 10.1093/eurheartj/ehae593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/05/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND AIMS Cardiogenic shock (CS) remains the primary cause of in-hospital death after acute coronary syndromes (ACS), with its plateauing mortality rates approaching 50%. To test novel interventions, personalized risk prediction is essential. The ORBI (Observatoire Régional Breton sur l'Infarctus) score represents the first-of-its-kind risk score to predict in-hospital CS in ACS patients undergoing percutaneous coronary intervention (PCI). However, its sex-specific performance remains unknown, and refined risk prediction strategies are warranted. METHODS This multinational study included a total of 53 537 ACS patients without CS on admission undergoing PCI. Following sex-specific evaluation of ORBI, regression and machine-learning models were used for variable selection and risk prediction. By combining best-performing models with highest-ranked predictors, SEX-SHOCK was developed, and internally and externally validated. RESULTS The ORBI score showed lower discriminative performance for the prediction of CS in females than males in Swiss (area under the receiver operating characteristic curve [95% confidence interval]: 0.78 [0.76-0.81] vs. 0.81 [0.79-0.83]; P =.048) and French ACS patients (0.77 [0.74-0.81] vs. 0.84 [0.81-0.86]; P = .002). The newly developed SEX-SHOCK score, now incorporating ST-segment elevation, creatinine, C-reactive protein, and left ventricular ejection fraction, outperformed ORBI in both sexes (females: 0.81 [0.78-0.83]; males: 0.83 [0.82-0.85]; P < .001), which prevailed following internal and external validation in RICO (females: 0.82 [0.79-0.85]; males: 0.88 [0.86-0.89]; P < .001) and SPUM-ACS (females: 0.83 [0.77-0.90], P = .004; males: 0.83 [0.80-0.87], P = .001). CONCLUSIONS The ORBI score showed modest sex-specific performance. The novel SEX-SHOCK score provides superior performance in females and males across the entire spectrum of ACS, thus providing a basis for future interventional trials and contemporary ACS management.
Collapse
Affiliation(s)
- Yifan Wang
- Center for Molecular Cardiology, University of Zurich, Wagistreet 12, 8952 Schlieren, Switzerland
| | - Marianne Zeller
- Department of Cardiology, CHU Dijon Bourgogne, Dijon, France
- Physiolopathologie et Epidémiologie Cérébro-Cardiovasculaire (PEC2), EA 7460, Univ Bourgogne, Dijon, France
| | - Vincent Auffret
- Inserm LTSI U1099, Université de Rennes 1, CHU Rennes Service de Cardiologie, Rennes, France
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Patras, Greece
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Lorenz Räber
- Department of Cardiology, Swiss Heart Center, Inselspital Bern, Bern, Switzerland
| | - Marco Roffi
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Templin
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Luca Liberale
- Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa—Italian Cardiovascular Network, Genoa, Italy
| | - Stefano Ministrini
- Center for Molecular Cardiology, University of Zurich, Wagistreet 12, 8952 Schlieren, Switzerland
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Konstantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
- Helmholtz Institute for Translational AngioCardioScience (HI-TAC), MDC, Heidelberg University, Heidelberg, Germany
- Faculty of Medical Sciences, Biosciences Institute, Vascular Biology and Medicine Theme, Newcastle University, Newcastle upon Tyne, UK
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zurich, Wagistreet 12, 8952 Schlieren, Switzerland
| | - Fabrizio Montecucco
- Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa—Italian Cardiovascular Network, Genoa, Italy
| | - Hans Rickli
- Cardiology Department, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Maud Maza
- Department of Cardiology, CHU Dijon Bourgogne, Dijon, France
| | - Dragana Radovanovic
- AMIS Plus Data Centre, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Yves Cottin
- Department of Cardiology, CHU Dijon Bourgogne, Dijon, France
| | - Frédéric Chague
- Department of Cardiology, CHU Dijon Bourgogne, Dijon, France
| | - David Niederseer
- Hochgebirgsklinik, Medicine Campus Davos, Herman-Burchard-Strasse 1, Davos 7270, Switzerland
- Christine Kühne Center for Allergy Research and Education (CK-CARE), Medicine Campus Davos, Davos, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Wagistreet 12, 8952 Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Heart Division and Cardiovascular Academic Group, King’s College, London, UK
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Wagistreet 12, 8952 Schlieren, Switzerland
- Department of Cardiology and Internal Medicine, Cantonal Hospital Baden, Im Ergel 1, 5404 Baden, Switzerland
| |
Collapse
|
2
|
Zhang Q, Xu L, Xie Z, He W, Huang X. Machine learning-based prediction of mortality in acute myocardial infarction with cardiogenic shock. Front Cardiovasc Med 2024; 11:1402503. [PMID: 39469130 PMCID: PMC11513311 DOI: 10.3389/fcvm.2024.1402503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 09/20/2024] [Indexed: 10/30/2024] Open
Abstract
Background In the ICU, patients with acute myocardial infarction and cardiogenic shock (AMI-CS) often face high mortality rates, making timely and precise mortality risk prediction crucial for clinical decision-making. Despite existing models, machine learning algorithms hold the potential for improved predictive accuracy. Methods In this study, a predictive model was developed using the MIMIC-IV database, with external validation performed on the eICU-CRD database. We included ICU patients diagnosed with AMI-CS. Feature selection was conducted using the Boruta algorithm, followed by the construction and comparison of four machine learning models: Logistic Regression (LR), eXtreme Gradient Boosting (XGBoost), Adaptive Boosting (AdaBoost), and Gaussian Naive Bayes (GNB). Model performance was evaluated based on metrics such as AUC (Area Under the Curve), accuracy, sensitivity, specificity, and so on. The SHAP method was employed to visualize and interpret the importance of model features. Finally, we constructed an online prediction model and conducted external validation in the eICU-CRD database. Results In this study, a total of 570 and 391 patients with AMI-CS were included from the MIMIC-IV and eICU-CRD databases, respectively. Among all machine learning algorithms evaluated, LR exhibited the best performance with a validation set AUC of 0.841(XGBoost: 0.835, AdaBoost: 0.839, GNB: 0.826). The model incorporated five variables: prothrombin time, blood urea nitrogen, age, beta-blockers and Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers. SHAP plots are employed to visualize the importance of model features and to interpret the results. An online prediction tool was developed, externally validated with the eICU-CRD database, achieving an AUC of 0.755. Conclusion Employing the LR algorithm, we developed a predictive model for assessing the mortality risk among AMI-CS patients in the ICU setting. Through model predictions, this facilitates early detection of high-risk individuals, ensures judicious allocation of healthcare resources.
Collapse
Affiliation(s)
- Qitian Zhang
- Department of Cardiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Lizhen Xu
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Zhiyi Xie
- Department of Cardiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Weibin He
- Department of Cardiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Xiaohong Huang
- Department of Cardiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| |
Collapse
|
3
|
Siopi SA, Antonitsis P, Karapanagiotidis GT, Tagarakis G, Voucharas C, Anastasiadis K. Cardiac Failure and Cardiogenic Shock: Insights Into Pathophysiology, Classification, and Hemodynamic Assessment. Cureus 2024; 16:e72106. [PMID: 39575019 PMCID: PMC11581444 DOI: 10.7759/cureus.72106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2024] [Indexed: 11/24/2024] Open
Abstract
Heart failure is defined as increased intracardiac pressures, either alone or combined with reduced cardiac output. Clinically, it is presented with signs and symptoms of congestion and compensated perfusion. Cardiogenic shock, on the other hand, is the spectrum of hemodynamic disturbances that lead to hypoperfusion or need for circulatory support, due to cardiac disease. Both entities affect millions of people worldwide, have a dismal prognosis, and constitute a severe socioeconomic burden. Heart failure can be the aftermath of ischemic heart disease, hypertension, arrhythmias, or cardiomyopathies. It undergoes multiple classifications, facilitating its investigation and treatment. The pathogenetic mechanisms differ in various types of heart failure, regarding the affected ventricles, the duration of symptoms, and their primary/secondary onset. These mechanisms reflect the complex interactions between cardiopulmonary, vascular, and hepatorenal systems. Acute deterioration of cardiac function can lead to cardiogenic shock. Myocardial infarction accounts for 81% of such cases. Healthy lifestyle and timely management of coronary artery disease are paramount, as they can prevent this life-threatening situation and reduce mortality and the economic burden for healthcare systems. Irrespective of the etiology, cardiogenic shock is interpreted using the pressure-volume loop. This can be modified for each ventricle, the underlying pathophysiology, and the time since symptoms' onset. It therefore provides valuable information about the native circulation and the expected alterations under mechanical or pharmacological support, facilitating the decision-making progress. In 2019, given the phenotypical heterogeneity of cardiogenic shock, the Society for Cardiovascular Angiography and Interventions introduced a classification system. According to this, patients are stratified in five stages proportionally to the severity of their condition. Aside from this classification, various biochemical, imaging, and hemodynamic monitoring indices are used to assess coagulation pathway and cardiac, hepatorenal, and pulmonary function, enabling the heart team to tailor therapy. Additionally, the prognostication progress is facilitated by scores, such as the Observatoire Regional Breton sur l'Infarctus (ORBI) score, the intra-aortic balloon pump (IABP) SHOCK-II score, and the CardShock score, indicating suitable escalation or de-escalation strategies. Despite the current progress, there are several areas of advancement regarding the role of vasoactive drugs in cardiogenic shock, revascularization options, mechanical ventilation patterns, hypothermia treatment, and mechanical circulatory support protocols.
Collapse
Affiliation(s)
- Stavroula A Siopi
- Cardiovascular Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | | | | | - Georgios Tagarakis
- Cardiothoracic Surgery, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Christos Voucharas
- Cardiothoracic Surgery, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | | |
Collapse
|
4
|
Yuriditsky E, Bakker J. What every intensivist should know about…Systolic arterial pressure targets in shock. J Crit Care 2024; 82:154790. [PMID: 38816174 DOI: 10.1016/j.jcrc.2024.154790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/10/2023] [Accepted: 12/17/2023] [Indexed: 06/01/2024]
Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
| | - Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, USA; Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA; Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
5
|
Bilchenko AO, Gritsenko OV, Kolisnyk VO, Rafalyuk OI, Pyzhevskii AV, Myzak YV, Besh DI, Salo VM, Chaichuk SO, Lehoida MO, Danylchuk IV, Polivenok IV. Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022. Front Cardiovasc Med 2024; 11:1377969. [PMID: 38606380 PMCID: PMC11007039 DOI: 10.3389/fcvm.2024.1377969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Background Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world. Materials and methods The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients. Results We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS. Conclusions Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.
Collapse
Affiliation(s)
- Anton O. Bilchenko
- Department of Prevention and Treatment of Emergency Conditions, L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | - Olga V. Gritsenko
- Department of Interventional Cardiology, V.T. Zaitcev Institute of General and Urgent Surgery of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | | | - Oleg I. Rafalyuk
- Department of Interventional Radiology, Lviv Regional Clinical Treatment and Diagnostic Cardiology Center, Lviv, Ukraine
| | - Andrii V. Pyzhevskii
- Department of Interventional Radiology, Lviv Regional Clinical Treatment and Diagnostic Cardiology Center, Lviv, Ukraine
| | - Yaroslav V. Myzak
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
| | - Dmytro I. Besh
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
- Department of Family Medicine, Danylo Halytsky National Medical University, Lviv, Ukraine
| | - Victor M. Salo
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
| | - Sergii O. Chaichuk
- Department of Interventional Cardiology, Oleksandrivska Clinical Hospital, Kyiv, Ukraine
| | - Mykhailo O. Lehoida
- Department of Cardiology, Vinnytsia Regional Clinical Treatment and Diagnostic Center of Cardiovascular Pathology, Vinnytsia, Ukraine
| | - Ihor V. Danylchuk
- Department of Cardiology, Vinnytsia Regional Clinical Treatment and Diagnostic Center of Cardiovascular Pathology, Vinnytsia, Ukraine
| | - Ihor V. Polivenok
- Department of Interventional Cardiology, V.T. Zaitcev Institute of General and Urgent Surgery of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
- Department of Therapy No 1, Kharkiv National Medical University, Kharkiv, Ukraine
| |
Collapse
|
6
|
Solangi BA, Shah JA, Kumar R, Batra MK, Ali G, Butt MH, Nisar A, Qamar N, Saghir T, Sial JA. Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock. World J Cardiol 2023; 15:439-447. [PMID: 37900262 PMCID: PMC10600783 DOI: 10.4330/wjc.v15.i9.439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/31/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates. Primary percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with CS. AIM To investigate the immediate mortality rates in patients with CS undergoing primary PCI and identify mortality predictors. METHODS We conducted a retrospective analysis of 305 patients with CS who underwent primary PCI at the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between January 2018 and December 2022. The primary outcome was immediate mortality, defined as mortality within index hospitalization. Univariate and multivariate logistic regression analyses were performed to identify predictors of immediate mortality. RESULTS In a sample of 305 patients with 72.8% male patients and a mean age of 58.1 ± 11.8 years, the immediate mortality rate was found to be 54.8% (167). Multivariable analysis identified Killip class IV at presentation [odds ratio (OR): 2.0; 95% confidence interval (CI): 1.2-3.4; P = 0.008], Multivessel disease (OR: 3.5; 95%CI: 1.8-6.9; P < 0.001), and high thrombus burden (OR: 2.6; 95%CI: 1.4-4.9; P = 0.003) as independent predictors of immediate mortality. CONCLUSION Immediate mortality rate in patients with CS undergoing primary PCI remains high despite advances in treatment strategies. Killip class IV at presentation, multivessel disease, and high thrombus burden (grade ≥ 4) were identified as independent predictors of immediate mortality. These findings underscore the need for aggressive management and close monitoring of patients with CS undergoing primary PCI, particularly in those with these high-risk characteristics.
Collapse
Affiliation(s)
- Bashir Ahmed Solangi
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan.
| | - Jehangir Ali Shah
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Rajesh Kumar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Mahesh Kumar Batra
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Gulzar Ali
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Muhammad Hassan Butt
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Ambreen Nisar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Nadeem Qamar
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Tahir Saghir
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| | - Jawaid Akbar Sial
- Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi 75510, Pakistan
| |
Collapse
|
7
|
Abstract
Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.
Collapse
Affiliation(s)
- Jason E. Bloom
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - William Chan
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - David M. Kaye
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - Dion Stub
- Department of CardiologyAlfred HealthMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| |
Collapse
|
8
|
Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| |
Collapse
|
9
|
Yamga E, Mantena S, Rosen D, Bucholz EM, Yeh RW, Celi LA, Ustun B, Butala NM. Optimized Risk Score to Predict Mortality in Patients With Cardiogenic Shock in the Cardiac Intensive Care Unit. J Am Heart Assoc 2023; 12:e029232. [PMID: 37345819 PMCID: PMC10356069 DOI: 10.1161/jaha.122.029232] [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: 12/22/2022] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
Background Mortality prediction in critically ill patients with cardiogenic shock can guide triage and selection of potentially high-risk treatment options. Methods and Results We developed and externally validated a checklist risk score to predict in-hospital mortality among adults admitted to the cardiac intensive care unit with Society for Cardiovascular Angiography & Interventions Shock Stage C or greater cardiogenic shock using 2 real-world data sets and Risk-Calibrated Super-sparse Linear Integer Modeling (RiskSLIM). We compared this model to those developed using conventional penalized logistic regression and published cardiogenic shock and intensive care unit mortality prediction models. There were 8815 patients in our training cohort (in-hospital mortality 13.4%) and 2237 patients in our validation cohort (in-hospital mortality 22.8%), and there were 39 candidate predictor variables. The final risk score (termed BOS,MA2) included maximum blood urea nitrogen ≥25 mg/dL, minimum oxygen saturation <88%, minimum systolic blood pressure <80 mm Hg, use of mechanical ventilation, age ≥60 years, and maximum anion gap ≥14 mmol/L, based on values recorded during the first 24 hours of intensive care unit stay. Predicted in-hospital mortality ranged from 0.5% for a score of 0 to 70.2% for a score of 6. The area under the receiver operating curve was 0.83 (0.82-0.84) in training and 0.76 (0.73-0.78) in validation, and the expected calibration error was 0.9% in training and 2.6% in validation. Conclusions Developed using a novel machine learning method and the largest cardiogenic shock cohorts among published models, BOS,MA2 is a simple, clinically interpretable risk score that has improved performance compared with existing cardiogenic-shock risk scores and better calibration than general intensive care unit risk scores.
Collapse
Affiliation(s)
- Eric Yamga
- Department of Medicine Centre Hospitalier de l'Université de Montréal (CHUM) Montreal QC Canada
| | | | - Darin Rosen
- Johns Hopkins School of Medicine Baltimore MD USA
| | - Emily M Bucholz
- University of Colorado School of Medicine Aurora CO USA
- Heart Institute, Children's Hospital of Colorado Aurora CO USA
| | - Robert W Yeh
- Harvard Medical School Boston MA USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology Beth Israel Deaconess Medical Center Boston MA USA
| | - Leo A Celi
- Harvard Medical School Boston MA USA
- Laboratory for Computational Physiology, MIT Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge MA USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health Boston MA USA
| | - Berk Ustun
- Halıcıoğlu Data Science Institute University of California San Diego CA USA
| | - Neel M Butala
- University of Colorado School of Medicine Aurora CO USA
- Rocky Mountain Regional VA Medical Center Aurora CO USA
| |
Collapse
|
10
|
Delfiner MS, Romero CM, Dillane C, Feldman E, Hamad E. Correlation between severity of obesity and mortality in cardiogenic shock. Heart Lung 2023; 57:66-68. [PMID: 36084397 DOI: 10.1016/j.hrtlng.2022.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/13/2022] [Accepted: 08/28/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cardiogenic shock (CS) is associated with high mortality despite the development of risk stratification tools and new treatment strategies. Obesity, although a risk factor for cardiovascular disease, is not included in current risk stratification tools for CS. A relationship between mortality and obesity has only been shown in subsets populations of CS; there is not yet a clear relationship between severity of obesity and all-cause CS. OBJECTIVES In this study we evaluate the relationship between rising body mass index (BMI) and mortality in all-cause CS. METHODS All patients with BMI measurements and hospitalizations complicated by CS from 2014 to 2019 at a single quaternary care institution were identified. Patients were grouped by obesity classification. Multivariate logistic regression was performed to determine a relationship between higher obesity classifications with 30-day mortality in patients with CS. RESULTS Seventy-two patients were available for analysis. Mean BMI for those who survived compared to those who did not was 29.7 ± 8 kg/m2 vs 33.7 ± 7.6 kg/m2 (p = 0.04). The odds ratio for mortality with incremental increase in obesity classification was 1.6 (95% CI 1.1 - 2.6, p = 0.03) after adjusting for etiology of CS and other common associations with CS mortality. CONCLUSION This study suggests that the higher mortality risk with incremental increases in BMI should be taken into account when risk stratifying these patients.
Collapse
Affiliation(s)
- Matthew S Delfiner
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
| | - Carlos Manuel Romero
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Catherine Dillane
- Division of Cardiovascular Medicine, Atlanticare, Atlantic City, NJ, USA
| | | | - Eman Hamad
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| |
Collapse
|
11
|
Muzafarova T, Motovska Z. Laboratory Predictors of Prognosis in Cardiogenic Shock Complicating Acute Myocardial Infarction. Biomedicines 2022; 10:1328. [PMID: 35740350 PMCID: PMC9220203 DOI: 10.3390/biomedicines10061328] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiogenic shock is a state of reduced cardiac output leading to hypotension, pulmonary congestion, and hypoperfusion of tissues and vital organs. Despite the advances in intensive care over the last years, the morbidity and mortality of patients remain high. The available studies of patients with cardiogenic shock suggest a connection between clinical variables, the level of biomarkers, the results of imaging investigations, strategies of management and the outcome of this group of patients. The management of patients with cardiogenic shock initially complicating acute myocardial infarction is challenging, and the number of studies in this area is growing fast. The purpose of this review is to summarize the currently available evidence on cardiogenic shock initially complicating acute myocardial infarction with particular attention to predictors of prognosis, focusing on laboratory variables (established and new), and to discuss the practical implementation. Currently available scoring systems developed during the past few decades predict the clinical outcome of this group of patients using some of the established biomarkers among other variables. With the new laboratory biomarkers that have shown their predictive value in cardiogenic shock outcomes, a new design of scoring systems would be of interest. Identifying high-risk patients offers the opportunity for early decision-making.
Collapse
Affiliation(s)
| | - Zuzana Motovska
- Cardiocenter, Third Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady, 10034 Prague, Czech Republic;
| |
Collapse
|
12
|
Guo C, Teng H, Xu H, Wang X, Zhang J, Li J, Duan X, Wang J, Yuan J, Wu Y, Yang W, Shubin Q. Impact of shock index before IABP implantation on recent prognosis of patients with cardiogenic shock complicating acute myocardial infarction. Acta Cardiol 2022; 78:241-247. [PMID: 35501998 DOI: 10.1080/00015385.2022.2064955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To investigate the impact of shock index before Intra-Aortic Balloon Pump (IABP) implantation on recent prognosis of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) underwent primary percutaneous coronary intervention (PCI). METHODS A total of 103 patients with CS complicating AMI admitted in our hospital from June 2014 to May 2019 who underwent primary PCI with IABP support were enrolled in the study. We collected the data according to the medical records and collected their clinical manifestation and laboratory examination, as well as 28-day mortality, and also calculated the shock index (ratio of heart rate to systolic blood pressure) before IABP implantation. RESULTS Patients with higher SI at IABP insertion were associated with higher proportion of anterior infarction (81.5% vs. 61.2%, p = 0.022), previous history of PCI (24.1% vs. 8.16%, p = 0.030), culprit leision at left main (31.5% vs. 12.2%, p = 0.019), and final TIMI flow ≤ 2(55.5% vs. 26.5%, p = 0.003), invasive ventilation(40.7% vs. 20.4%, p = 0.026) as well as 28-day-mortality (81.5% vs. 61.2%, p = 0.022). SI at insertion may help predict recent outcome, with a cutoff value of 1.625, a sensitivity of 0.655 and a specificity of 0.708, and areas under the receiver-operating characteristic curve (AUCROC) was 0.713. On multiple analysis, SI, together with final TIMI flow, arterial pH and creatinine were independent predictive factors of recent prognosis among this population. CONCLUSION Among CS patients complicating AMI undergoing PCI with the support of IABP, higher SI before IABP implantation was associated with poorer prognosis, SI was an independent risk factor of 28-day mortality and may predict the 28-day outcome.
Collapse
Affiliation(s)
| | | | - Haobo Xu
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyu Wang
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhang
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Li
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Duan
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Wang
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiansong Yuan
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Wu
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weixian Yang
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiao Shubin
- Centre of Coronary Heart Disease, National Centre for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
13
|
Shankar A, Gurumurthy G, Sridharan L, Gupta D, Nicholson WJ, Jaber WA, Vallabhajosyula S. A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221075064. [PMID: 35153521 PMCID: PMC8829716 DOI: 10.1177/11795468221075064] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.
Collapse
Affiliation(s)
- Aditi Shankar
- Department of Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | - Lakshmi Sridharan
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Divya Gupta
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
14
|
Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study. Glob Heart 2021; 16:78. [PMID: 34900569 PMCID: PMC8641529 DOI: 10.5334/gh.988] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution. Methods: This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006–2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI). Results: Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI–CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI–CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI–CS group, whereas a history of heart failure was greater in non-AMI–CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI–CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI–CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI–CS and non-AMI–CS groups, respectively. Among AMI–CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI–CS group, only low LVEF and high lactate levels proved significant. Conclusions: This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.
Collapse
|
15
|
Kalra S, Ranard LS, Memon S, Rao P, Garan AR, Masoumi A, O'Neill W, Kapur NK, Karmpaliotis D, Fried JA, Burkhoff D. Risk Prediction in Cardiogenic Shock: Current State of Knowledge, Challenges and Opportunities. J Card Fail 2021; 27:1099-1110. [PMID: 34625129 DOI: 10.1016/j.cardfail.2021.08.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022]
Abstract
Cardiogenic shock (CS) is a condition associated with high mortality rates in which prognostication is uncertain for a variety of reasons, including its myriad causes, its rapidly evolving clinical course and the plethora of established and emerging therapies for the condition. A number of validated risk scores are available for CS prognostication; however, many of these are tedious to use, are designed for application in a variety of populations and fail to incorporate contemporary hemodynamic parameters and contemporary mechanical circulatory support interventions that can affect outcomes. It is important to separate patients with CS who may recover with conservative pharmacological therapies from those in who may require advanced therapies to survive; it is equally important to identify quickly those who will succumb despite any therapy. An ideal risk-prediction model would balance incorporation of key hemodynamic parameters while still allowing dynamic use in multiple scenarios, from aiding with early decision making to device weaning. Herein, we discuss currently available CS risk scores, perform a detailed analysis of the variables in each of these scores that are most predictive of CS outcomes and explore a framework for the development of novel risk scores that consider emerging therapies and paradigms for this challenging clinical entity.
Collapse
Affiliation(s)
- Sanjog Kalra
- The Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Lauren S Ranard
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
| | - Sehrish Memon
- Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
| | - Prashant Rao
- Beth Israel Deaconess Medical Center, Boston, Masschusetts
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Masschusetts
| | - Amirali Masoumi
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
| | | | - Navin K Kapur
- Tufts University Medical Center, Boston, Massachusetts
| | - Dimitri Karmpaliotis
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Justin A Fried
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
| | | |
Collapse
|
16
|
Gao F, Zhang Y. Inotrope Use and Intensive Care Unit Mortality in Patients With Cardiogenic Shock: An Analysis of a Large Electronic Intensive Care Unit Database. Front Cardiovasc Med 2021; 8:696138. [PMID: 34621796 PMCID: PMC8490645 DOI: 10.3389/fcvm.2021.696138] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/25/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose: To determine whether inotrope administration is associated with increased all-cause mortality in cardiogenic shock (CS) patients and to identify inotropes superior for improving mortality. Methods: This retrospective cohort study analyzed data retrieved from the Philips Electronic ICU (eICU) database, a clinical database of 200,859 patients from over 208 hospitals located throughout the United States. The database was searched for patients admitted with CS to the intensive care unit (ICU) between 2014 and 2015. We evaluated 34,381 CS patients. They were classified into the inotrope and non-inotrope groups based on whether inotropes were administered during hospitalization. The primary endpoint was all-cause hospital mortality. Findings: In total, 15,021 (43.69%) patients received inotropes during hospitalization. The in-hospital mortality rate was significantly higher in the inotrope group than in the non-inotrope group (2,999 [24.03%] vs. 1,547 [12.40%], adjusted hazard ratio: 2.24; 95% confidence interval [CI]: 2.09–2.39; p < 0.0001). After propensity score matching according to the cardiac index, 359 patients were included in each group. The risk of ICU (OR 5.65, 95% CI, 3.17–10.08, p < 0.001) and hospital (OR 2.63, 95% CI: 1.75–3.95, p < 0.001) mortality in the inotrope group was significantly higher. In the inotrope group, the administration of norepinephrine ≤0.1 μg/kg/min and dopamine ≤15 μg/kg/min did not increase the risk of hospital mortality, and milrinone administration was associated with a lower mortality risk (odds ratio: 0.559, 95% CI: 0.430–0.727, p < 0.001). Meanwhile, the administration of >0.1 μg/kg/min dobutamine, epinephrine, and norepinephrine and dopamine >15 μg/kg/min was associated with a higher risk of hospital mortality. Conclusions: Inotropes should be used cautiously because they may be associated with a higher risk of mortality in CS patients. Low-dose norepinephrine and milrinone may associated with lower risk of hospital mortality in these patients, and supportive therapies should be considered when high-dose inotropes are administered.
Collapse
Affiliation(s)
- Fei Gao
- Department of Emergency Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Yun Zhang
- Department of Emergency Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| |
Collapse
|
17
|
Basir MB, Lemor A, Gorgis S, Taylor AM, Tehrani B, Truesdell AG, Bharadwaj A, Kolski B, Patel K, Gelormini J, Todd J, Lasorda D, Smith C, Riley R, Marso S, Federici R, Kapur NK, O'Neill WW. Vasopressors independently associated with mortality in acute myocardial infarction and cardiogenic shock. Catheter Cardiovasc Interv 2021; 99:650-657. [PMID: 34343409 DOI: 10.1002/ccd.29895] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/04/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Increasing vasopressor dose is associated with increasing mortality in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS). It is unknown whether the use of vasopressors is independently harmful or if their use is secondary to decreasing intrinsic cardiac power output (CPO). Mechanical circulatory support (MCS) devices enhance CPO. We sought to evaluate the independent impact of increasing vasopressor dose on survival in the National Cardiogenic Shock Initiative (NCSI). METHODS The NCSI is a single arm prospective trial evaluating outcomes associated with the use of MCS using Impella in patients with AMICS. Early initiation of MCS placement before percutaneous coronary intervention (PCI) and rapid de-escalation of vasopressors guided by systematic use of invasive hemodynamic measures led to 70% in-hospital survival for the first 300 patients enrolled from July 2016 to December 2019 in 57 U.S. sites. RESULTS Hemodynamic measures were obtained immediately after MCS and PCI. Survival curves were constructed based on CPO and use of vasopressors. For patients with CPO ≤0.6 W, survival was 77.3%, 45.0%, and 35.3% when 0, 1, or ≥ 2 vasopressors were used (p = 0.02). Similarly, for patients with CPO >0.6 W survival was 81.7%, 72.6%, and 56.8%, respectively (p = 0.01). Logistic regression analysis demonstrated that increasing vasopressor requirements were independently associated with increasing mortality (p = 0.02). CONCLUSION Increasing vasopressor requirement is associated with increased mortality in AMICS independent of underlying CPO. Methods to decrease the need for vasopressors may enhance survival in AMICS.
Collapse
Affiliation(s)
- Mir B Basir
- Cardiology, Henry Ford Health System, Detroit, MI, USA
| | | | - Sarah Gorgis
- Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - Angela M Taylor
- Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Behnam Tehrani
- Cardiology, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | | | - Aditya Bharadwaj
- Cardiology, Loma Linda University Medical Center, Loma LInda, VA, USA
| | - Brian Kolski
- Cardiology, St. Joseph Hospital of Orange, Orange, CA, USA
| | - Kirit Patel
- Cardiology, St. Joseph Mercy Oakland, Pontiac, MI, USA
| | | | - Josh Todd
- Cardiology, Fort Sanders Medical Center, Knoxville, TN, USA
| | - David Lasorda
- Cardiology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Craig Smith
- Cardiology, UMass Memorial Medical Center, Worcester, MA, USA
| | - Robert Riley
- Cardiology, Christ Hospital, Cincinnati, OH, USA
| | - Steve Marso
- Cardiology, Overland Park Regional Medical Center & Research Medical Center, Overland Park, KS, USA
| | | | | | | | | |
Collapse
|
18
|
Cardiogenic Shock Complicating Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention Supported by Impella: Implications of Advanced Age and Refractory Shock on Outcomes. Crit Care Explor 2021; 3:e0447. [PMID: 34136823 PMCID: PMC8202667 DOI: 10.1097/cce.0000000000000447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: With percutaneous left ventricular mechanical circulatory support devices becoming increasingly available for patients with cardiogenic shock due to acute myocardial infarction and the lack of a clear mortality benefit to date, identifying optimal candidates for this technology is crucial. We studied the effectiveness of Impella Cardiac Pow (Abiomed, Danvers, MA) in various stages of cardiogenic shock and elderly cohorts. DESIGN: Retrospective review. SETTING: Data were collected for patients at a single community hospital between January 1, 2018, and December 31, 2019. SUBJECTS: Thirty-one consecutive adult patients with cardiogenic shock due to acute myocardial infarction who received Impella Cardiac Pow support. Shock stages were defined by the Society for Cardiovascular Angiography and Intervention (Stages A–E). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital death across Society for Cardiovascular Angiography and Intervention cardiogenic shock stages and in patients greater than or equal to 80 and less than 80 years old. Secondary outcomes were Valve Academic Research Consortium-2 vascular and bleeding complications, stroke, and renal failure requiring dialysis. The median age of the study population was 64 years, with seven patients (23%) being greater than or equal to 80 years old. No patients were in Society for Cardiovascular Angiography and Intervention Stage A, whereas there were seven in B, eight in C, six in D, and 10 (32%) in E. Overall in-hospital mortality occurred in 61% of patients. All 10 patients in Stage E died before hospital discharge. Mortality occurred in 54% of patients (13/24) age less than 80 years compared with 86% of those 80 years or older (6/7). A total of 38.7% of patients (12/31) and 32.3% of patients (10/31) experienced Valve Academic Research Consortium-2 bleeding and vascular events, which were evenly distributed across Society for Cardiovascular Angiography and Intervention cardiogenic shock Stages. CONCLUSIONS: In conclusion, patients with shock in extremis and those 80 years old and older may have a prohibitively high mortality despite Impella use. These findings merit further prospective investigation in a larger number of patients to evaluate the effectiveness of Impella (and other left ventricular mechanical circulatory devices) and the inherent resource utilization in advanced cardiogenic shock and the elderly.
Collapse
|
19
|
Cosentino N, Resta ML, Somaschini A, Campodonico J, D’Aleo G, Di Stefano G, Lucci C, Moltrasio M, Bonomi A, Cornara S, Demarchi A, De Ferrari G, Bartorelli AL, Marenzi G. ST-Segment Elevation Acute Myocardial Infarction Complicated by Cardiogenic Shock: Early Predictors of Very Long-Term Mortality. J Clin Med 2021; 10:2237. [PMID: 34064067 PMCID: PMC8196779 DOI: 10.3390/jcm10112237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/07/2021] [Accepted: 05/20/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is the leading cause of in-hospital mortality in ST-segment elevation myocardial infarction (STEMI). Only limited data are available on the long-term outcome of STEMI patients with CS undergoing contemporary treatment. We aimed to investigate long-term mortality and its predictors in STEMI patients with CS and to develop a risk score for long-term mortality prediction. METHODS AND RESULTS We retrospectively included 465 patients with STEMI complicated by CS and treated with primary angioplasty and intra-aortic balloon pump between 2005 and 2018. Long-term mortality, including both in-hospital mortality and all-cause mortality following discharge from the index hospitalization, was the primary endpoint. The long-term mortality (median follow-up 4 (2.0-5.2) years) was 60%, including in-hospital mortality (34%). At multivariate analysis, independent predictors of long-term mortality were age (HR 1.41, each 10-year increase), admission left ventricular ejection fraction (HR 1.51, each 10%-unit decrease) and creatinine (HR 1.28, each mg/dl increase), and acute kidney injury (HR 1.81). When these predictors were pooled together, the area under the curve (AUC) for long-term mortality was 0.80 (95% CI 0.75-0.84). Using the four variables, we developed a risk score with a mean (cross-validation analysis) AUC of 0.79. When the score was applied to in-hospital mortality, its AUC was 0.79, and 0.76 when the score was applied to all-cause mortality following discharge. CONCLUSIONS In STEMI patients with CS, the risk of death is still substantial in the years following the index event. A simple clinical score at the time of the index event accurately predicts long-term mortality risk.
Collapse
Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Marta L. Resta
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Alberto Somaschini
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Jeness Campodonico
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Giampaolo D’Aleo
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Giovanni Di Stefano
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Claudia Lucci
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Marco Moltrasio
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Alice Bonomi
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| | - Stefano Cornara
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Andrea Demarchi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology—Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.S.); (S.C.); (A.D.)
- Unit of Cardiology, Department of Molecular Medicine, Università degli studi di Pavia, 271000 Pavia, Italy
| | - Gaetano De Ferrari
- Dipartimento di Scienze Mediche, Cardiologia Città della Salute e della Scienza, Università di Torino, 10126 Torino, Italy;
| | - Antonio L. Bartorelli
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (M.L.R.); (J.C.); (G.D.); (G.D.S.); (C.L.); (M.M.); (A.B.); (A.L.B.); (G.M.)
| |
Collapse
|
20
|
Yagi T, Nagao K, Tachibana E, Yonemoto N, Sakamoto K, Ueki Y, Imamura H, Miyamoto T, Takahashi H, Hanada H, Chiba N, Tani S, Matsumoto N, Okumura Y. Treatment With Vasopressor Agents for Cardiovascular Shock Patients With Poor Renal Function; Results From the Japanese Circulation Society Cardiovascular Shock Registry. Front Med (Lausanne) 2021; 8:648824. [PMID: 34012971 PMCID: PMC8126606 DOI: 10.3389/fmed.2021.648824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
According to the guidelines for cardiogenic shock, norepinephrine is associated with fewer arrhythmias than dopamine and may be the better first-line vasopressor agent. This study aimed to evaluate the utility of norepinephrine vs. dopamine as first-line vasopressor agent for cardiovascular shock depending on the presence and severity of renal dysfunction at hospitalization. This was a secondary analysis of the prospective, multicenter Japanese Circulation Society Cardiovascular Shock Registry (JCS Shock Registry) conducted between 2012 and 2014, which included patients with shock complicating emergency cardiovascular disease at hospital arrival. The analysis included 240 adult patients treated with norepinephrine alone (n = 98) or dopamine alone (n = 142) as the first-line vasopressor agent. Primary endpoint was mortality at 30 days after hospital arrival. The two groups had similar baseline characteristics, including estimated glomerular filtration rate (eGFR), and similar 30-day mortality rates. The analysis of the relationship between 30-day mortality rate after hospital arrival and vasopressor agent used in patients categorized according to the eGFR-based chronic kidney disease classification revealed that norepinephrine as the first-line vasopressor agent might be associated with better prognosis of cardiovascular shock in patients with mildly compromised renal function at admission (0.0 vs. 22.6%; P = 0.010) and that dopamine as the first-line vasopressor agent might be beneficial for cardiovascular shock in patients with severely compromised renal function [odds ratio; 0.22 (95% confidence interval 0.05-0.88; P = 0.032)]. Choice of first-line vasopressor agent should be based on renal function at hospital arrival for patients in cardiovascular shock. Clinical Trial Registration: http://www.umin.ac.jp/ctr/, Unique identifier: 000008441.
Collapse
Affiliation(s)
- Tsukasa Yagi
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Ken Nagao
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Eizo Tachibana
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Naohiro Yonemoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Biostatistics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuo Sakamoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yasushi Ueki
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Imamura
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takamichi Miyamoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Musashino Red Cross Hospital, Musashino, Japan
| | - Hiroshi Takahashi
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Hiroyuki Hanada
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobutaka Chiba
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Nihon University Hospital, Tokyo, Japan
| | - Shigemasa Tani
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| |
Collapse
|
21
|
Jiang C, Wu S, Wang M, Zhao X, Li H. J-curve relationship between admission SBP and 2-year cardiovascular mortality in older patients admitted for acute coronary syndrome. J Hypertens 2021; 39:926-934. [PMID: 33201050 PMCID: PMC8048722 DOI: 10.1097/hjh.0000000000002737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/17/2020] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the relationship between admission SBP and subsequent cardiovascular and all-cause mortality in older patients hospitalized for acute coronary syndrome (ACS). METHODS This is a retrospective observational study. Data from the CBD Bank (Cardiovascular Center Beijing Friendship Hospital Database Bank) were used to analyze the cardiovascular and all-cause mortality during hospitalization and over the follow-up period in relation to admission SBP among patients aged at least 65 years admitted for ACS from December 2012 through July 2019. Results were presented according to SBP quartiles: Q1, less than 120 mmHg; Q2, from 120 to 129 mmHg; Q3, from 130 to 143 mmHg; and Q4, at or above 144 mmHg. RESULTS A total of 6785 patients were included in this cohort study. Mean (SD) patient age was 74.0 (6.5) years, and 47.6% were women. Mean (SD) follow-up time was 2.54 (1.82) years. A nonlinear relation was observed between SBP at admission and cardiovascular and all-cause mortality during hospitalization and over the follow-up period using restricted cubic splines. After adjustment for potential confounders, patients in Q1 had higher risk for 2-year cardiovascular death by Cox proportional hazard model compared with patients in Q2 [hazard ratio, 1.58; 95% confidence interval (CI), 1.12-2.21, P = 0.009], whereas patients in Q3 or Q4 exhibited a trend towards increased risk for 2-year cardiovascular death (hazard ratio, 1.33, 95% CI, 0.95-1.86, P = 0.094, for Q3 vs. Q2; and hazard ratio, 1.28, 95% CI, 0.91-1.82, P = 0.160, for Q4 vs. Q2). Meanwhile, when compared with patients in Q1, patients in Q2 had lower risk for 2-year cardiovascular death (hazard ratio, 0.64; 95% CI, 0.45-0.89, P = 0.009) whereas patients in Q3 or Q4 had similar risk for cardiovascular death (hazard ratio, 0.85, 95% CI, 0.63-1.14, P = 0.272, for Q3 vs. Q1; and hazard ratio, 0.82, 95% CI, 0.59-1.13, P = 0.221, for Q4 vs. Q1). However, low-admission SBP was not an independent predictor of 2-year all-cause mortality in this population. CONCLUSION Among patients aged at least 65 years admitted for ACS, there is a J-curve relationship between supine admission SBP and risk for 2-year cardiovascular death, with a nadir at 120-129 mmHg.
Collapse
Affiliation(s)
| | - Shanshan Wu
- National Clinical Research Center for Digestive Diseases
| | - Man Wang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xueqiao Zhao
- Clinical Atherosclerosis Research Laboratory, Division of Cardiology, University of Washington, Seattle, USA
| | - Hongwei Li
- Department of Internal Medicine and Geriatrics
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, China
| |
Collapse
|
22
|
A Critical Review of Hemodynamically Guided Therapy for Cardiogenic Shock: Old Habits Die Hard. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:29. [PMID: 33776402 PMCID: PMC7985592 DOI: 10.1007/s11936-021-00903-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/15/2022]
Abstract
Purpose of review Here, we review the importance of using hemodynamic data to guide therapy and risk stratification in cardiogenic shock as well as the various definitions of this syndrome that have been used in prior studies. Furthermore, we provide perspective regarding the controversy surrounding pulmonary artery (PA) catheter use as well as current society guidelines and scientific statements. Lastly, we review the technical aspects for accurate interpretation of data of cardiogenic shock. Recent findings More recent studies specifically evaluating cardiogenic shock patients have shown higher mortality when PA catheters were not used. Furthermore, initiatives are underway to develop more standardized definitions of cardiogenic shock, including the SCAI Shock Classification Scheme. Only by having a standardized fashion of conveying severity of shock will we be able to more systematically study this patient population and improve outcomes moving forward. Summary PA catheters are critical to the prognostication and management of a subset of patients with cardiopulmonary disease, particularly in those with pulmonary hypertension, cardiogenic shock, or requiring mechanical circulatory support or undergoing evaluation for advanced heart failure therapies.
Collapse
|
23
|
Jentzer JC, Schrage B, Holmes DR, Dabboura S, Anavekar NS, Kirchhof P, Barsness GW, Blankenberg S, Bell MR, Westermann D. Influence of age and shock severity on short-term survival in patients with cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:604-612. [PMID: 33580778 DOI: 10.1093/ehjacc/zuaa035] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/28/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
AIMS Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS. METHODS AND RESULTS Patients with a diagnosis of CS from Mayo Clinic (2007-15) and University Clinic Hamburg (2009-17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years. CONCLUSION Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.
Collapse
Affiliation(s)
- 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
| | - Benedikt Schrage
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), University Heart Centre Hamburg, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Salim Dabboura
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), University Heart Centre Hamburg, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Paulus Kirchhof
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), University Heart Centre Hamburg, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Stefan Blankenberg
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), University Heart Centre Hamburg, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), University Heart Centre Hamburg, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| |
Collapse
|
24
|
Padkins M, Breen T, Anavekar N, van Diepen S, Henry TD, Baran DA, Barsness GW, Kashani K, Holmes DR, Jentzer JC. Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure. ESC Heart Fail 2020; 7:3971-3982. [PMID: 32909377 PMCID: PMC7754759 DOI: 10.1002/ehf2.12995] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF. METHODS AND RESULTS We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007-2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2-1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage. CONCLUSIONS Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.
Collapse
Affiliation(s)
- Mitchell Padkins
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Thomas Breen
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Nandan Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, Cincinnati, OH, USA
| | - David A Baran
- Advanced Heart Failure Center and Eastern Virginia Medical School, Sentara Heart Hospital, Norfolk, VA, 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
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
25
|
The predictive value of age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock. Coron Artery Dis 2020; 30:569-574. [PMID: 31490203 DOI: 10.1097/mca.0000000000000776] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The aim of the present study was to assess the predictive value of the age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock secondary to ST-elevation myocardial infarction. MATERIAL AND METHODS This single-center, retrospective study was based on a comprehensive analysis of the hospital records of 318 consecutive cardiogenic shock patients. The age, creatinine, ejection fraction score was calculated for each patient using the equation of age/ejection fraction +1 if creatinine level is >2 mg/dl. The study population was stratified into tertiles: T1, T2, and T3, based on the age, creatinine, ejection fraction score. The primary endpoint of the study was the incidence of in-hospital mortality. RESULTS The incidence of in-hospital mortality was significantly greater in patients with a high age, creatinine, ejection fraction score (T3 group) compared with the intermediate (T2 group) or the low score group (T1 group) [86.8% (n = 92 patients) vs. 57.5% (n = 61 patients) vs. 34.9% (n = 37 patients), respectively; P < 0.05 for each]. In multivariable models, after adjusting for all covariables, the risk of in-hospital mortality was 3.21 (95% confidence interval: 2.29-4.58) for patients allocated to the T3 group. The optimal cutoff for the age, creatinine, ejection fraction score for in-hospital mortality was 2.24, with a sensitivity of 74% and a specificity of 77%. CONCLUSION To the best of our knowledge, this is the first study that has demonstrated a prognostic value of the age, creatinine, ejection fraction score in patients with ST-elevation myocardial infarction-related cardiogenic shock.
Collapse
|
26
|
Magder S. Diastolic pressure should be used to guide management of patients in shock: PRO. J Crit Care 2020; 51:241-243. [PMID: 31126439 DOI: 10.1016/j.jcrc.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/30/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023]
Abstract
Based primarily on the rational that adequate diastolic pressure is needed to maintain sufficient coronary blood for myocardial needs, diastolic pressure has been proposed as a treatment target for patients in shock. To date, clinical evidence supporting this is limited to observational data. Key points are that what is important for tissues is flow not pressure; the coronary circulation has very large flow reserves and can maintain flow with a low pressure; raising arterial pressure by only increasing vascular resistance does not alter tissue perfusion and could even increase myocardial oxygen demand. Targeting diastolic pressure can lead to over use of vasopressors, which studies have associated with worse outcome. Pressor management in shock should include assessment of indicators of tissue perfusion and changes in flow if possible.
Collapse
Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada..
| |
Collapse
|
27
|
Temporal Trends and Clinical Outcomes Associated with Vasopressor and Inotrope Use in The Cardiac Intensive Care Unit. Shock 2020; 53:452-459. [DOI: 10.1097/shk.0000000000001390] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
28
|
Abstract
PURPOSE OF REVIEW Data and interventional trials regarding vasopressor and inotrope use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In this article, we review the current use of vasopressor and inotrope agents during cardiogenic shock. RECENT FINDINGS Two recent Cochrane analyses concluded that there was not sufficient evidence to prove that any one vasopressor or inotrope was superior to another in terms of mortality. A recent RCT and a meta-analysis on individual data suggested that norepinephrine may be preferred over epinephrine in patients with cardiogenic shock . For inotrope agents, when norepinephrine fails to restore perfusion, dobutamine represents the first-line agent. Levosimendan is a calcium sensitizer agent, which improves acute hemodynamics, albeit with uncertain effects on mortality. SUMMARY When blood pressure needs to be restored, norepinephrine is a reasonable first-line agent. Dobutamine is the first-line inotrope agent wheraes levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers. Current information regarding comparative effective outcomes is nonetheless sparse and their use should be limited as a temporary bridge to recovery, mechanical circulatory support or heart transplantation.
Collapse
|
29
|
Predicting Survival in Patients Treated With Extracorporeal Membrane Oxygenation After Myocardial Infarction. Crit Care Med 2019; 46:e359-e363. [PMID: 29373359 DOI: 10.1097/ccm.0000000000002995] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute myocardial infarction is the most common cause of cardiogenic shock. Although the number of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with venoarterial extracorporeal membrane oxygenation increased during the last decade, detailed data on survival are lacking. We sought to analyze covariates that were independently associated with survival in this patient population and to externally validate the newly developed prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by venoarterial Extracorporeal membrane oxygenation (ENCOURAGE) score. DESIGN Retrospective clinical study. SETTING A single academic teaching hospital. PATIENTS Adult patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation from June 2008 to September 2016. INTERVENTIONS Fourteen individual variables were assessed for their association with the primary endpoint. These variables were prespecified by the study team as being the most likely to affect survival. A receiver operating characteristic analysis was also performed to test the ability of the ENCOURAGE score to predict survival in this patient cohort. MEASUREMENTS AND MAIN RESULTS The primary endpoint of the study was in-hospital survival. A total of 61 patients were included in the analysis. Thirty-seven (60.7%) could be weaned from venoarterial extracorporeal membrane oxygenation and 36 (59.0%) survived. Survival was significantly higher in patients less than 65 years old (odds ratio, 14.6 [CI, 2.5-84.0]; p = 0.003), whose body mass index was less than 32 kg/m (odds ratio, 5.5 [CI, 1.2-25.4]; p = 0.029) and international normalized ratio was less than 2 (odds ratio, 7.3 [CI, 1.3-40.1]; p = 0.022). In patients where the first lactate drawn was less than 3 mmol/L, the survival was not significantly higher (odds ratio, 4.4 [CI, 0.6-32.6]; p = 0.147). The C-statistic for predicting survival using a modified version of the ENCOURAGE score, which replaced prothrombin activity less than 50% with an international normalized ratio greater than 2, was 0.74 (95% CI, 0.61-0.87). CONCLUSIONS In this single-center study, several important covariates were associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation and the ENCOURAGE score was found to be externally valid for predicting survival to hospital discharge.
Collapse
|
30
|
Wang B, Aihemaiti G, Cheng B, Li X. Red Blood Cell Distribution Width Is Associated with All-Cause Mortality in Critically Ill Patients with Cardiogenic Shock. Med Sci Monit 2019; 25:7005-7015. [PMID: 31530796 PMCID: PMC6765343 DOI: 10.12659/msm.917436] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/03/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND There is no previously published epidemiological study exploring the association between red blood cell distribution width (RDW) and mortality in patients with cardiogenic shock (CS). The aim of this study was to examine the association between RDW and the risk of all-cause mortality in these patients. MATERIAL AND METHODS We analyzed clinical data from the MIMIC-III V1.4 database. We collected data on each patient's demographic parameters, vital signs, laboratory parameters, vital signs, comorbidities, and scoring systems on ICU admission. Cox proportional hazards models were used to assess the association between RDW levels and the 30-day, 90-day, and 365-day mortality in patients with CS. RESULTS There were 1131 patients meeting inclusion criteria in our study. In multivariate analysis, following adjustment for age, sex, and ethnicity, higher RDW in tertiles and quintiles were all associated with increased risk of 30-day, 90-day, and 365-day all-cause mortality. Furthermore, after adjusting for more relevant confounders, RDW remained a significant predictor of risk of 30-day, 90-day, and 365-day mortality (tertile 3 versus tertile 1: HR, 95% CI: 1.66, 1.19-2.31; 1.73, 1.28-2.33; 1.80, 1.38-2.34). Similarly significant robust associations were found in RDW levels stratified by quintiles. CONCLUSIONS Higher RDW is associated with increased risk of all-cause mortality in critically ill patients with CS.
Collapse
Affiliation(s)
- Benji Wang
- Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, P.R. China
| | - Gulandanmu Aihemaiti
- Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, P.R. China
| | - Bihuan Cheng
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Xiaomei Li
- Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, P.R. China
| |
Collapse
|
31
|
Moraes PIM, Alves CR, Souza MT, Kawakami SE, Goncalves I, Barbosa AHP, Moreno AC, Caixeta AM, Carvalho AC. Cardiogenic shock after ST elevation myocardial infarction and IABP-SHOCK II risk score validation in a cohort treated with pharmacoinvasive strategy. Open Heart 2019; 6:e001069. [PMID: 31413846 PMCID: PMC6667936 DOI: 10.1136/openhrt-2019-001069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 11/04/2022] Open
Abstract
Objective To validate the Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) score in patients with cardiogenic shock after ST elevation myocardial infarction (STEMI) treated with pharmacoinvasive strategy (PhIS) and to analyse the influence of ischaemia time on different risk strata. Methods We analysed 2143 patients with STEMI who underwent reperfusion with tenecteplase in primary health services between May 2010 and April 2017 and were transferred to a tertiary hospital for cardiac catheterisation and continuity of care. Those who evolved to cardiogenic shock were scored as low (0-2), moderate (3-4) or high (5-9) risk of death in 30 days and pairwise-log-rank test was used to compare strata. Time intervals between symptoms onset and lytic (pain-to-needle) and fibrinolytic-catheterisation were also compared. Results Cardiogenic shock occurred in 212 (9.9%) individuals. The 30-day mortality using the IABP-SHOCK II score was 26.6% for low-risk (n=94), 53.2% for moderate-risk (n=62) and 76% for high-risk (n=25) analysed patients (p<0.001). Validation of the score showed good discrimination for death, area under the curve of 0.73 (CI: 0.66 to 0.81; p<0.001). The median intervals of pain-to-needle and fibrinolytic-catheterisation showed no association with the group stratification (220 vs 251 vs 200 min; p=0.22 and 390 vs 435 vs 315 min; p=0.18, respectively). Conclusions In patients with cardiogenic shock after STEMI treated with PhIS, risk stratification using IABP-SHOCK II score was adequate. There was no influence of pain-to-needle and fibrinolytic-catheterisation times on the ability to the score model stratification.
Collapse
Affiliation(s)
- Pedro Ivo M Moraes
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Claudia Rodrigues Alves
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Tulio Souza
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Suzi Emiko Kawakami
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Iran Goncalves
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Antonio Celio Moreno
- Department of Cardiology, Hospital do Servidor Público Municipal, Sao Paulo, Brazil
| | - Adriano Mendes Caixeta
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil.,Department of Cardiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Antonio Carlos Carvalho
- Discipline of Cardiology - Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
32
|
Konstantinou K, Tsioufis C, Koumelli A, Mantzouranis M, Kasiakogias A, Doumas M, Tousoulis D. Hypertension and patients with acute coronary syndrome: Putting blood pressure levels into perspective. J Clin Hypertens (Greenwich) 2019; 21:1135-1143. [PMID: 31301119 PMCID: PMC8030564 DOI: 10.1111/jch.13622] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/30/2019] [Accepted: 05/21/2019] [Indexed: 12/16/2022]
Abstract
Arterial hypertension is a well-established cardiovascular risk factor, and blood pressure (BP) control has largely improved the prognosis of hypertensive patients. A number of studies have assessed the role of BP levels in the prognosis of patients with acute coronary syndromes. Pathophysiologic links of hypertension to acute myocardial infarction (MI) include endothelial dysfunction, autonomic nervous system dysregulation, impaired vasoreactivity, and a genetic substrate. A history of hypertension is highly prevalent among patients presenting with MI, and some, but not all, studies have associated it with a worse prognosis. Some data support that low levels of admission and in-hospital BP may indicate an increased risk for subsequent events. Risk scores used in patients with MI have, therefore, included BP levels and a history of hypertension in their variables. Of note, good long-term BP control, ideally initiated prior to discharge, should be pursued in order to improve secondary prevention.
Collapse
Affiliation(s)
- Konstantinos Konstantinou
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Areti Koumelli
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Manos Mantzouranis
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Alexandros Kasiakogias
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Michalis Doumas
- Second Propedeutic Department of Internal Medicine, Medical SchoolAristotle University of Thessaloniki, Hippocration HospitalThessalonikiGreece
| | - Dimitris Tousoulis
- First Cardiology Clinic, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| |
Collapse
|
33
|
Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J 2019; 40:2671-2683. [DOI: 10.1093/eurheartj/ehz363] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/17/2019] [Accepted: 05/11/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortality remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment.
Collapse
Affiliation(s)
- Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | - E Magnus Ohman
- Duke Heart Center, Duke University Medical Center, Box 3126 DUMC, Durham, NC 27710, USA
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Medizinische Klinik B, Bremserstraße 79, D-67063 Ludwigshafen, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| |
Collapse
|
34
|
Chioncel O, Collins SP, Ambrosy AP, Pang PS, Radu RI, Ahmed A, Antohi EL, Masip J, Butler J, Iliescu VA. Therapeutic Advances in the Management of Cardiogenic Shock. Am J Ther 2019; 26:e234-e247. [PMID: 30839372 PMCID: PMC6404765 DOI: 10.1097/mjt.0000000000000920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS. AREAS OF UNCERTAINTY Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies. DATA SOURCES The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study. THERAPEUTIC ADVANCES Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes. CONCLUSIONS Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.
Collapse
Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine and Indianapolis EMS, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Razvan I Radu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Ali Ahmed
- Veteran Affairs Medical Center and George Washington University, Washington DC, USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Josep Masip
- Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain; Department of Intensive Care, Consorci Sanitari Integral, Barcelona, Spain
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MI, USA
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| |
Collapse
|
35
|
Delmas C, Orloff E, Bouisset F, Moine T, Citoni B, Biendel C, Porterie J, Carrié D, Galinier M, Elbaz M, Lairez O. Predictive factors for long-term mortality in miscellaneous cardiogenic shock: Protective role of beta-blockers at admission. Arch Cardiovasc Dis 2019; 112:738-747. [PMID: 31155464 DOI: 10.1016/j.acvd.2019.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/08/2019] [Accepted: 04/15/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite advances in intensive care medicine, management of cardiogenic shock (CS) remains difficult and imperfect, with high mortality rates, regardless of aetiology. Predictive data regarding long-term mortality rates in patients presenting CS are sparse. AIM To describe prognostic factors for long-term mortality in CS of different aetiologies. METHODS Two hundred and seventy-five patients with CS admitted to our tertiary centre between January 2013 and December 2014 were reviewed retrospectively. Mortality was recorded in December 2016. A Cox proportional-hazards model was used to determine predictors of long-term mortality. RESULTS Most patients were male (72.7%), with an average age of 64±16 years and a history of cardiomyopathy (63.5%), mainly ischaemic (42.3%). Leading causes of CS were myocardial infarction (35.3%), decompensated heart failure (34.2%) and cardiac arrest (20.7%). Long-term mortality was 62.5%. After multivariable analysis, previous use of beta-blockers (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.89; P=0.02) and coronary angiography exploration at admission (HR 0.57, 95% CI 0.38-0.86; P=0.02) were associated with a lower risk of long-term mortality. Conversely, age (HR 1.02 per year, 95% CI 1.01-1.04; P<0.001), catecholamine support (HR 1.45 for each additional agent, 95% CI 1.20-1.75; P<0.001) and renal replacement therapy (HR 1.66, 95% CI 1.09-2.55; P=0.02) were associated with an increased risk of long-term mortality. CONCLUSIONS Long-term mortality rates in CS remain high, reaching 60% at 1-year follow-up. Previous use of beta-blockers and coronary angiography exploration at admission were associated with better long-term survival, while age, renal replacement therapy and the use of catecholamines appeared to worsen the prognosis, and should lead to intensification of CS management.
Collapse
Affiliation(s)
- Clément Delmas
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Intensive cardiac care unit, Rangueil university hospital, 31059 Toulouse, France.
| | - Elisabeth Orloff
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France
| | - Frédéric Bouisset
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France
| | - Thomas Moine
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France
| | | | - Caroline Biendel
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Intensive cardiac care unit, Rangueil university hospital, 31059 Toulouse, France
| | - Jean Porterie
- Department of cardiovascular surgery, Rangueil university hospital, 31059 Toulouse, France
| | - Didier Carrié
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Purpan medical school, university Paul Sabatier, 31300 Toulouse, France
| | - Michel Galinier
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Rangueil medical school, university Paul Sabatier, 31059 Toulouse, France
| | - Meyer Elbaz
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Rangueil medical school, university Paul Sabatier, 31059 Toulouse, France
| | - Olivier Lairez
- Department of cardiology, Rangueil university hospital, 31059 Toulouse, France; Rangueil medical school, university Paul Sabatier, 31059 Toulouse, France; Cardiac imaging centre, Toulouse university hospital, 31059 Toulouse, France; Department of nuclear medicine, Rangueil university hospital, 31059 Toulouse, France
| |
Collapse
|
36
|
Abstract
Cardiogenic shock (CS) represents an advanced state of morbidity along the pathophysiologic pathway of end-organ hypoperfusion caused by reduced cardiac output and blood pressure. Acute coronary syndromes remain the most common cause of CS. The spectrum of hypoperfusion states caused by low cardiac output ranges from pre-CS to refractory CS and can be characterized by an array of hemodynamic parameters. This review provides the foundation for a hemodynamic understanding of CS including the use of hemodynamic monitoring for diagnosis and treatment, the cardiac and vascular determinants of CS, and a hemodynamic approach to risk stratification and management of CS.
Collapse
Affiliation(s)
- Ariel Furer
- Internal Medicine T, Tel-Aviv Sourasky Medical Center, 6 Wiezmann street, Tel Aviv 64239, Israel.
| | - Jeffrey Wessler
- Division of Cardiology, Columbia University, 161 Fort Washington Avenue, New York, NY 10032-3784, USA
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University, 161 Fort Washington Avenue, New York, NY 10032-3784, USA; Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| |
Collapse
|
37
|
Mechanical support for high-risk coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 2018; 34:287-296. [PMID: 33060951 PMCID: PMC7525900 DOI: 10.1007/s12055-018-0740-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 11/04/2022] Open
Abstract
Mechanical circulatory support devices are being used to an increasing extent. The use of these devices as an adjunct to cardiac surgery to support ventricular function has contributed to improved outcomes for the highest risk patients. In the context of patients undergoing coronary artery bypass grafting, there are several potential indications for mechanical circulatory support: preoperatively in the setting of acute cardiogenic shock, or in patients with intractable angina with or without haemodynamic compromise; at induction of anaesthesia prophylactically in patients with critical coronary anatomy and/or severely impaired left ventricular function; intraoperatively in the setting of failure to wean from cardiopulmonary bypass; or postoperatively in patients who develop an intractable low cardiac output state. The use of the intra-aortic balloon pump, veno-arterial extracorporeal membrane oxygenation, TandemHeart, Impella and central ventricular assist devices will be considered in the setting of high-risk patients undergoing coronary artery bypass grafting.
Collapse
|
38
|
Abstract
Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.
Collapse
Affiliation(s)
- Deepak Acharya
- From the Section of Advanced Heart Failure, Mechanical Circulatory Support, and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
39
|
Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Frederique G, Quenot JP, Kimmoun A, Cariou A, Lassus J, Harjola VP, Meziani F, Louis G, Rossignol P, Duarte K, Girerd N, Mebazaa A, Vignon P, Mattei M, Thivilier C, Perez P, Auchet T, Fritz C, Boisrame-Helme J, Mercier E, Garot D, Perny J, Gette S, Hammad E, Vigne C, Dargent A, Andreu P, Guiot P. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2018; 72:173-182. [DOI: 10.1016/j.jacc.2018.04.051] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/28/2022]
|
40
|
Strom JB, Zhao Y, Shen C, Chung M, Pinto DS, Popma JJ, Yeh RW. National trends, predictors of use, and in-hospital outcomes in mechanical circulatory support for cardiogenic shock. EUROINTERVENTION 2018; 13:e2152-e2159. [DOI: 10.4244/eij-d-17-00947] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
41
|
van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 1135] [Impact Index Per Article: 141.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
Collapse
|
42
|
Krishnan SK, Riley RF, Hira RS, Lombardi WL. Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention. Interv Cardiol Clin 2017; 6:407-416. [PMID: 28600093 DOI: 10.1016/j.iccl.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.
Collapse
Affiliation(s)
- Sandeep K Krishnan
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Robert F Riley
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - William L Lombardi
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| |
Collapse
|
43
|
Pöss J, Köster J, Fuernau G, Eitel I, de Waha S, Ouarrak T, Lassus J, Harjola VP, Zeymer U, Thiele H, Desch S. Risk Stratification for Patients in Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2017; 69:1913-1920. [DOI: 10.1016/j.jacc.2017.02.027] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/19/2017] [Accepted: 02/06/2017] [Indexed: 01/08/2023]
|
44
|
|
45
|
Predictors of in-hospital mortality among cardiogenic shock patients. Prognostic and therapeutic implications. Int J Cardiol 2016; 224:114-118. [DOI: 10.1016/j.ijcard.2016.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/08/2016] [Accepted: 09/12/2016] [Indexed: 12/28/2022]
|
46
|
Masoumi A, Rosenblum HR, Garan AR. Cardiogenic Shock in Older Adults. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0522-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
47
|
Persico N, Bourenne J, Roch A. Veno-arterial extracorporeal membrane oxygenation for acute myocardial infarction-associated cardiogenic shock: can we predict survival before decision of implantation? J Thorac Dis 2016; 8:2331-2333. [PMID: 27746968 DOI: 10.21037/jtd.2016.08.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicolas Persico
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France;; Emergency Department, APHM, CHU Nord, Marseille, France
| | | | - Antoine Roch
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France;; Emergency Department, APHM, CHU Nord, Marseille, France
| |
Collapse
|
48
|
|
49
|
Acute myocardial infarction and cardiogenic shock: pharmacologic and mechanical hemodynamic support pathways. Coron Artery Dis 2016; 26:535-44. [PMID: 25968304 DOI: 10.1097/mca.0000000000000259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Cardiogenic shock (CS) is still the predominant cause of in-hospital death in patients with acute myocardial infarction, although mortality has been reduced in recent years. Early percutaneous coronary intervention and coronary artery bypass grafting are causal therapies implemented in CS, supported by catecholamines, fluids, intra-aortic balloon pumping, and also active percutaneous assist devices. There is only limited evidence from randomized studies of any of these treatments in CS, except for early revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This review will present treatment pathways of CS complicating acute myocardial infarction, with a major focus on revascularization, intensive care unit treatment, and mechanical support devices.
Collapse
|
50
|
Fellner B, Rohla M, Jarai R, Smetana P, Freynhofer MK, Egger F, Zorn G, Weiss TW, Huber K, Geppert A. Activated protein C levels and outcome in patients with cardiogenic shock complicating acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:348-358. [DOI: 10.1177/2048872616637036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Barbara Fellner
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Miklos Rohla
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Rudolf Jarai
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Peter Smetana
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Matthias K Freynhofer
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Florian Egger
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Gerlinde Zorn
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas W Weiss
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - Alexander Geppert
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| |
Collapse
|