Cardiogenic Shock Complicating ST-segment Elevation Research Articles

Cardiac arrest and cardiogenic shock complicating ST-segment elevation myocardial infarction in China: A retrospective multicenter study

BackgroundData on the effect of cardiac arrest (CA), cardiogenic shock (CS), and their combination on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI) are limited. The present study sought to evaluate the clinical outcomes of STEMI complicated by CA and CS, and to identify the risk factors for CA or CS. MethodsThis study included 7468 consecutive patients with STEMI in China. The patients were divided into 4 groups (CA + CS, CA only, CS only, and No CA or CS). The endpoints were 30-day all-cause death and major adverse cardiovascular events. A Cox proportional hazards regression analysis was performed. ResultsCA, CS, and their combination were noted in 332 (4.4 %), 377 (5.0 %), and 117 (1.6 %) among all patients. During the 30-day follow-up, 817 (10.9 %) all-cause deaths and 964 (12.9 %) major adverse cardiovascular events occurred, and the incidence of all-cause mortality (3.6 %, 62.3 %, 74.1 %, 83.3 %) and major adverse cardiovascular events (5.4 %, 67.1 %, 75.0 %, and 87.2 %) significantly increased in the No CA or CS, CS only, CA only, and CA + CS groups, respectively. In the multivariate Cox regression models, compared with the No CA or CS group, the CA + CS, CA, and CS-only groups were associated with an increased risk of all-cause death and major adverse cardiovascular events. Patients with CA + CS had the highest risk of all-cause death (hazard ratio [HR], 25.259 [95 % confidence interval (CI) 19.221–33.195]) and major adverse cardiovascular events (HR 19.098, 95%CI 14.797–24.648). ConclusionsCA, CS, and their combination were observed in approximately 11 % of Chinese patients with STEMI, and were associated with increased risk for 30-day mortality and major adverse cardiovascular events in Chinese patients with STEMI.

Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction: An 18-Year Analysis of Temporal Trends, Epidemiology, Management, and Outcomes.

There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS). Adult (>18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P < 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P < 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P < 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P < 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P > 0.05). In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

Prognostic Utility of Culprit SYNTAX Score in Patients With Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction

A higher SYNTAX score (SS) is strongly associated with poor prognosis in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). However, the predictive value of culprit-lesion SYNTAX score (cul-SS) and SS has not been compared although the culprit-lesion-only primary percutaneous coronary intervention (PCI) strategy showed improved long-term survival recently. This study compared the predictive utility of cul-SS and SS for in-hospital mortality among the patients with CS-STEMI from during 2010-2019. Of the 215 patients, 79 (37%) died. SS ≥22, cul-SS ≥11, final thrombolysis in myocardial infarction (TIMI) flow ≤2, and no-reflow phenomenon were associated with in-hospital mortality. In patients with multi-vessel disease, the nonsurvivors with cul-SS ≥11 had a higher mortality rate than the survivors (75.0% vs. 44.9%, p = 0.001), whereas the SS ≥22 showed no significant difference. The cul-SS ≥11 revealed only an independent factor in the multivariate analysis (OR 2.6, p = 0.010). the AUC of cul-SS ≥11 for in-hospital mortality was modest (0.617 p < 0.05), which might be augmented up to 0.745 (p < 0.001) by the combination with TIMI flow ≤2, no-reflow phenomenon, and blood total CO2 content <15 mEq/L. The cul-SS might be more predictive than SS for in-hospital mortality in our patients with CS-STEMI.

Sex bias in admission to tertiary-care centres for acute myocardial infarction and cardiogenic shock.

There are limited data on sex-specific outcomes and management of cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). We investigated whether any sex bias exists in the admission to revascularization capable hospitals (RCH) or intensive cardiac care units (ICCU) and its impact on in-hospital mortality. We used the Spanish National Health System Minimum Basic Data from 2003 to 2015 to identify patients with CS-STEMI. The primary outcome was sex differences in in-hospital mortality. Among 340490 STEMI patients, 20262 (6%) had CS and 29.2% were female. CS incidence was higher in women than in men (7.9% vs 5.1%, P=.001). Women were older and had more hypertension and diabetes, and were less often admitted to RCH than men (from 58.7% in 2003 to 79.6% in 2015; and from 61.9% in 2003 to 85.3% in 2015; respectively, P=.01), and to ICCU centres (25.7% vs 29.2%, P=.001). Adjusted mortality was higher in women than men over time (from 79.5±4.3% to 65.8±6.5%; and from 67.8±6% to 58.1±6.5%; respectively, P<.001). ICCU availability was associated with higher use of Percutaneous coronary intervention (PCI) in women (46.8% to 67.2%; P<.001) but was even higher in men (54.8% to 77.4%; P<.001). In ICCU centres, adjusted mortality rates decreased in both sexes, but lower in women (from 74.9±5.4% to 66.3±6.6%) than in men (from 67.8±6.0% to 58.1±6.5%, P<.001). Female sex was an independent predictor of mortality (OR 1.18 95% CI 1.10-1.27, P<.001). Women with CS-STEMI were less referred to tertiary-care centres and had a higher adjusted in-hospital mortality than men.

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction: part 2

Cardiogenic shock is a leading cause of death in those experiencing ST-segment elevation myocardial infarction. The objective of therapeutic strategies is to preserve end-organ perfusion and reduce mortality. Prompt revascularisation by percutaneous coronary intervention or coronary artery bypass graft is considered the gold standard of care. Pharmacological and mechanical support is indicated in patients with persistent hypotension and evidence of end-organ hypoperfusion. However, there is a paucity of scientiĉ data regarding the best pharmacological agent or form of mechanical support. Prehospital care has a pivotal role in caring for these patients by monitoring them and providing physical and psychological support during transfer to acute care. Palliative care is complementary to curative therapies and should be perceived as integral to effective symptom management.

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction: 2

Cardiogenic shock is a leading cause of death in those experiencing ST-segment elevation myocardial infarction. The objective of therapeutic strategies is to preserve end-organ perfusion and reduce mortality. Prompt revascularisation by percutaneous coronary intervention or coronary artery bypass graft is considered the gold standard of care. Pharmacological and mechanical support is indicated in patients with persistent hypotension and evidence of end-organ hypoperfusion. However, there is a paucity of scientific data regarding the best pharmacological agent or form of mechanical support. Critical care nurses have a pivotal role in caring for these patients by monitoring them and providing physical care and psychological support. Palliative care is complementary to curative therapies and should be perceived as integral to effective symptom management.

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction: part 1

Cardiogenic shock associated with ST-segment elevation myocardial infarction (STEMI) is a potentially devastating complication. This type of shock consists of left ventricular dysfunction causing haemodynamic instability and end-organ hypoperfusion resulting in multi-organ dysfunction syndrome. Despite advances in the management of STEMI, especially in the realm of reperfusion strategies, mortality rates remain high. The pathophysiology is complex and multifactorial, resulting in a clinical presentation of hypotension and signs of hypoperfusion. Patient assessment comprises a targeted history and a thorough physical examination to detect signs of decompensation and end-organ hypoperfusion. Upon arrival in hospital, an echocardiograph is essential in the process of identifying a cause. Learning Outcomes After completing this module the paramedic will be able to: Define cardiogenic shock Understand the pathophysiology of a person in cardiogenic shock Recognise the clinical presentation and features of cardiogenic shock Understand patient assessment of a person who appears to be in cardiogenic shock

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction

Cardiogenic shock associated with ST segment elevation myocardial infarction (STEMI) is a potentially devastating complication. This type of shock consists of left ventricular dysfunction causing haemodynamic instability and end-organ hypoperfusion resulting in multi-organ dysfunction syndrome. Despite advances in management of STEMI, especially in the realm of reperfusion strategies, mortality rates remain high. The pathophysiology is complex and multifactorial, resulting in a clinical presentation of hypotension and signs of hypoperfusion. Patient assessment comprises a targeted history and a thorough physical examination, with echocardiography playing a pivotal role in identifying the cause.

Culprit Vessel-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Cardiogenic Shock Complicating ST-Segment-Elevation Myocardial Infarction: A Collaborative Meta-Analysis.

The optimal revascularization strategy in patients with multivessel disease presenting with cardiogenic shock complicating ST-segment-elevation myocardial infarction remains unknown. Databases were searched from 1999 to October 2016. Studies comparing immediate/single-stage multivessel percutaneous coronary intervention (MV-PCI) versus culprit vessel-only PCI (CO-PCI) in patients with multivessel disease, ST-segment-elevation myocardial infarction, and cardiogenic shock were included. Primary end point was short-term (in-hospital or 30 days) mortality. Secondary end points included long-term mortality, cardiovascular death, reinfarction, and repeat revascularization. Safety end points were in-hospital stroke, renal failure, and major bleeding. The meta-analysis included 11 nonrandomized studies and 5850 patients (1157 MV-PCI and 4693 CO-PCI). There was no significant difference in short-term mortality with MV-PCI versus CO-PCI (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81-1.43; P=0.61). Similarly, there were no significant differences in long-term mortality (OR, 0.84; 95% CI, 0.54-1.30; P=0.43), cardiovascular death (OR, 0.72; 95% CI, 0.42-1.23; P=0.23), reinfarction (OR, 1.65; 95% CI, 0.84-3.26; P=0.15), or repeat revascularization (OR, 1.13; 95% CI, 0.76-1.69; P=0.54) between the 2 groups. There was a nonsignificant trend toward higher in-hospital stroke (OR, 1.64; 95% CI, 0.98-2.72; P=0.06) and renal failure (OR, 1.30; 95% CI, 0.98-1.72; P=0.06), with no difference in major bleeding (OR, 1.47; 95% CI, 0.39-5.63; P=0.57) with MV-PCI when compared with CO-PCI. This meta-analysis of nonrandomized studies suggests that in patients with cardiogenic shock complicating ST-segment-elevation myocardial infarction, there may be no significant benefit with single-stage MV-PCI compared with CO-PCI. Given the limitations of observational data, randomized trials are needed to determine the role of MV-PCI in this setting.

635 - Prognosis of acute right ventricular failure as the primary cause of cardiogenic shock complicating ST-segment elevation myocardial infarction

635 - Prognosis of acute right ventricular failure as the primary cause of cardiogenic shock complicating ST-segment elevation myocardial infarction

Effect of Coronary Thrombectomy in Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction

Optimal coronary reflow is the critical key issue to ameliorate clinical outcomes in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (Shock-STEMI). We investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural coronary thrombectomy may provide clinical advantages to attempt optimal coronary reflow in patients with Shock-STEMI. Of 7,650 patients with acute myocardial infarction registered in the Tokyo CCU Network Scientific Council from January 2009 to December 2011, a total of 180 consecutive patients (144 men, 68 ± 13years) with Shock-STEMI who showed pre-PCI procedural Thrombolysis in Myocardial Infarction flow grade 0 (absent initial coronary flow) were recruited. Achievements of post-PCI procedural Thrombolysis in Myocardial Infarction flow grade 3 (optimal coronary reflow) and also in-hospital mortality were evaluated in those in accordance with and without coronary thrombectomy. Coronary thrombectomy was performed in 128 patients with Shock-STEMI (71% of all). Overall in-hospital mortality was 41% and that in anterior Shock-STEMI with a necessity of mechanical circulatory support increased by 59% (i.e., profound shock). Coronary thrombectomy did not affect any improvements in the achievement of optimal coronary reflow (65% vs 58%, p= 0.368) and in-hospital mortality (42% vs 37%, p= 0.484) in these patients. Even when focused on 76 patients with profound shock, neither an achievement of optimal coronary reflow (56% vs 47%, p= 0.518) nor in-hospital mortality (58% vs 65%, p= 0.601) were different between with and without coronary thrombectomy. Multivariate logistic analysis did not demonstrate any association of coronary thrombectomy (p= 0.798), left main Shock-STEMI (p= 0.258), and use of mechanical circulatory support (p= 0.119) except a concentration of hemoglobin (for each 1g/dl increase, odds ratio 1.247, 95% confidence interval 1.035 to 1.531, p= 0.019) with optimal coronary reflow. In conclusion, pre-PCI procedural coronary thrombectomy may have serious limitations on attempting optimal coronary reflow that indicates a necessity of promising strategies for this critical illness.

Percutaneous Coronary Intervention for Nonculprit Vessels in Cardiogenic Shock Complicating ST-Segment Elevation Acute Myocardial Infarction*

We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. A prospective, multicenter, observational study. Cardiac ICU of a university hospital. Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. None. Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46-383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61-1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62-1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51-6.89; p = 0.344). Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.

Impact of thrombus aspiration during primary percutaneous coronary intervention in cardiogenic shock complicating ST-segment elevation myocardial infarction

To assess the impact on in-hospital and long-term survival of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). From September 2001 to May 2010 we collected data from 155 patients affected with STEMI complicated by CS undergoing PPCI (12.4% of all PPCI) including 70 patients (45.2%) in TA group and 85 patients (54.8%) in conventional PCI group. Patients in TA group were more likely to have right ventricular infarction (24.3% vs 5.9%, p=0.002), higher mean left ventricular ejection fraction (40% ± 9% vs 35% ± 7%, p<0.0001) and lower left main coronary artery occlusion (2.8% vs 21.2%, p=0.002). TA was associated with a lower rate of in-hospital and long-term mortality (31.4% vs 48.2%, p=0.05 and 42.8% vs 64.7%, p=0.01 respectively) at a mean follow-up time of 6.1 ± 2.1 years. At multivariate analysis the only independent predictor of in-hospital and long-term survival was the procedural success (HR 0.18 95% CI 0.025-0.31, p=0.03 and HR 0.46 95% CI 0.09-0.74, p=0.034 respectively). In this retrospective study TA, performed during PPCI for STEMI complicated by CS, was not an independent predictor of in-hospital and long-term survival.

Clinical evidence of exaggerated inflammation in patients with a cardiogenic shock complicating ST-segment elevation myocardial infarction

We characterized the degree of systemic and coronary inflammation and the impact of those on clinical state in patients with a cardiogenic shock complicating first anterior ST-segment elevation myocardial infarction (STEMI). Methods: We recruited 14 consecutive patients with cardiogenic shock (10 men, 69 ± 12 years) and 18 well-matched baseline characteristics without shock (17 men, 64 ± 9 years) undergoing percutaneous coronary intervention (PCI) for an early phase of a first anterior STEMI in whom plasma level of cardiac enzyme was less elevated. We measured systemic and coronary levels of C-reactive protein, interleukin-6, and angiotensin II, and evaluated the relation of those to myocardial tissue-level reperfusion using both angiographic myocardial blush grade from 0 to 3, with the highest grade indicating normal myocardial perfusion, and a resolution of the sum of ST-segment elevation in 12-lead electrocardiogram. Results: In-hospital mortality was 57% in patients with cardiogenic shock and 6% without shock (p = 0.005). Coronary levels of C-reactive protein (9.2 ± 6.9 vs. 1.7 ± 2.1 mg/L, p = 0.001), interleukin-6 (379 ± 137 vs. 24 ± 20 pg/mL, p = 0.003), and angiotensin II (19 ± 10 vs. 10 ± 6 pg/mL, p = 0.010) were extremely higher in patients with shock than without shock. Interleukin-6 and angiotensin II, but not C-reactive protein, revealed higher in coronary levels than in systemic levels. The presence of both myocardial blush grade el reperfusion (p = 0.012). Conclusions: The exaggerated systemic and coronary inflammation, presumably associated with myocardial mal-reperfusion, was presented in patients with a cardiogenic shock complicating first anterior STEMI.

Abstract P188: Impact of Metabolic Crisis on Fatal Outcome in Patients with Cardiogenic Shock Complicating ST-segment Elevation Myocardial Infarction

We investigated the relation of initial metabolic acidemia to in-hospital mortality in patients treated with emergency coronary angioplasty for shock complicating first anterior ST-segment elevation myocardial infarction (STEMI). Methods A total of 23 consecutive patients (17 men, 73±12 years) with Killip class IV class due to anterior STEMI were studied. Using median levels of arterial base excess (BE, −5.8 mmol/L), the patients were divided into high and low BE groups, and both groups were compared regarding microvascular revascularization and clinical outcomes. To evaluate myocardial tissue-level reperfusion, severe microvascular injury was defined by the presence of both angiographic myocardial blush grade 0/1 and less than 30 % resolution of ST-elevation after angioplasty. Results In-hospital mortality was 92 % in the high BE group (−12.0±4.9 mmol/L) as compared with 9 % in the low BE group (−0.9±2.4mmol/L, p=0.0001 vs. high BE group). Baseline clinical and angiographic characteristics were not different between the two groups. Arterial gas analysis showed lower pH and higher levels of lactate in the high BE group than in the low BE group (7.22±0.16 vs. 7.42±0.06, p=0.006, 8.52±4.43 vs. 2.42±1.33, p=0.016). Despite successfully culprit angioplasty in all cases, the incidence of severe microvascular injury was significantly high in the high BE group as compared with the low BE group (83 vs. 36 %, p=0.018). Initial levels of BE showed a significant negative relation to ST-segment resolution (r=0.61, p=0.002). A multivariate regression analysis demonstrated a potent association of initial levels of BE with severe microvascular injury (r 2 =0.341, p=0.015). Conclusions We identified the pivotal association of initial metabolic crisis with severe microvascular reperfusion injury leading to high in-hospital mortality in patients with cardiogenic shock complicating STEMI.

Cardiogenic shock developing in the coronary care unit in patients with ST-elevation myocardial infarction

A relevant proportion of patients with ST-segment elevation myocardial infarction may develop cardiogenic shock after presentation, and the identification of these patients would be very important in order to improve their outcome. The aim of the current study was to identify, among patients in the BLITZ-1, the clinical predictors, and describe the outcome of patients who developed cardiogenic shock during hospitalization. The study was a nationwide survey of patients admitted to a coronary care units for an acute myocardial infarction with or without ST-segment elevation myocardial infarction in October 2001. The 30-day follow-up was conducted by hospital visits and concerned major cardiac events occurred from hospital discharge. A total of 1345 patients presenting with ST-segment elevation myocardial infarction or left bundle branch block/pacemaker were included in this analysis. A total of 97 patients (7.2%) had cardiogenic shock, 26 patients at presentation, whereas 71 patients (73.2%) developed shock during hospital stay. Mortality was 71.8% among patients who developed cardiogenic shock during hospitalization as compared with 65.4% among those who were already in shock upon admission (P = 0.54). By multivariable analysis, we identified Killip class more than 1, lower systolic blood pressure at presentation, older age, unsuccessful reperfusion and diabetes as independent predictors of developing shock during hospitalization. The present study shows that the largest proportion of cardiogenic shock complicating ST-segment elevation myocardial infarction is observed after initial hospitalization, particularly in patients with Killip class more than 1, low systolic blood pressure at presentation and advanced age. The identification of these patients may help in preventing this complication by more aggressive pharmacological therapies, mechanical haemodynamic support, as well as coronary revascularization.