Complicating ST-segment Elevation Myocardial Infarction Research Articles

Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Clinical Outcomes of Ventricular Septal Rupture Complicating ST-Segment Elevation Myocardial Infarction: A Case Series from Siriraj Hospital and Literature Review

Objective: To access the clinical outcomes of ventricular septal rupture (VSR) complicating acute myocardial infarction (AMI) patients in the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand. Materials and Methods: The authors retrospectively reviewed the medical records of Siriraj Hospital between January 2005 and December 2021 in line with the International Classification of Disease, version 10 (ICD-10) code I23.2, which revealed 18 patients who matched the search. Among these, three patients were excluded from the present study as one patient could not access the admission data and the other two were not truly VSR. Results: In total, 15 VSR patients were included in the analysis, comprising eight males and seven females, with mean age of 67.53±7.95 years old. Of all the patients, 60% had anterior ST-segment elevation myocardial infarction. The mean left ventricular ejection fraction was 53.13±14.98%. Coronary angiography was performed in 14 patients (93.37%). In 50% of the patients, left anterior descending artery was the culprit lesion. Ten patients had multi-vessel diseases. Six patients underwent percutaneous coronary intervention (PCI), with the rate of successful reperfusion at 83.33%. For the six patients who underwent PCI, the procedure was performed before the VSR surgical repair. Ten patients underwent coronary artery bypass graft. For the 12 patients who underwent VSR surgical repair, the in-hospital survival rate was 100%. The overall in-hospital mortality rate was 20%. The non-survival patients did not receive the VSR surgical repair. After the median follow-up of three years, no additional mortality rate was reported. Conclusion: The mortality rate of VSR complicating AMI is high, especially, for patients who are not feasible for VSR repair. However, given the limitation in the number of patients involved in the present analysis, the authors could not identify the risk factors for developing in-hospital adverse outcomes. Keywords: Ventricular septal rupture; Acute myocardial infarction; Mechanical complications of myocardial infarction

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction

Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI). To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring<day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring≥day 2 after STEMI) in patients with STEMI. Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score. EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3days after STEMI. EVA was associated with a significantly higher risk of all-cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P=0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P=0.45). Multivariable predictors of LVA were: age≥65years; serum creatinine≥85μmol/L on admission; pulse pressure≤45mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade<3 after percutaneous coronary intervention; and left ventricular ejection fraction≤45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low-to-intermediate (22-34); intermediate-to-high (35-44); and high (≥45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P=0.23). EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient's baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable.

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.

Prognosis of adverse outcomes in patients with ST-elevation myocardial infarction and acute ischemic kidney injury

Abstract Background The category of patients with ST-segment elevation myocardial infarction (STEMI) remains in the focus of attention of cardiologists across the globe due to the high rates of hospital and long-term mortality. Acute ischemic kidney injury represents one of the most serious complications of STEMI, due to its highly negative impact on the disease prognosis. Therefore, it is critical for a clinician to identify STEMI and acute ischemic kidney injury patients who are at high risk of developing adverse outcomes. Purpose To identify key prognostic markers of adverse outcomes in patients with STEMI and acute ischemic kidney injury. Methods The study included 173 patients (ages 37–75), who were admitted to the intensive care unit with STEMI. Two groups of patients were identified based on their renal function: a group with STEMI and acute ischemic kidney injury (main group, n=111) and a group with STEMI and normal renal function (comparison group, n=62). Acute ischemic kidney injury diagnosis was confirmed on the basis of KDIGO (2012) recommendations - when patients with MI were hospitalized with creatinine level increased by up to ≥1.5 times as compared to baseline creatinine level before hospital admission. A critical condition for confirming the diagnosis was absence of chronic kidney disease and urinary tract disorders in patients' medical history. To identify risk factors of adverse outcomes, multivariate logistic regression analysis was used. Results Regression analysis was performed in order to build a predictive model for the development of adverse outcomes (death from cardiovascular causes, recurrent MI, unstable angina within 12 months). The analysis was based on the results of clinical, laboratory and instrumental evaluations of the focus patients. The derived prognostic model included the following features: age, level of the N-terminal fragment of brain natriuretic peptide (NT-pro-BNP), C-reactive protein level, creatinine level and local contractility index. A mathematical model for predicting the likelihood of adverse outcomes was developed on the basis of regression analysis data. ROC analysis including building of a ROC curve was conducted in order to test the quality of the model; the AUC was 0,996. The resulting model achieved 90,6% sensitivity, 100% specificity and 97,1% positive predictive value. Conclusion The following prognostic markers of adverse outcomes development in patients with STEMI and acute ischemic kidney injury were identified as most critical: age, NT-pro-BNP level, C-reactive protein level, creatinine level and local contractility index based on echocardiography results. The mathematical model for predicting the likelihood of adverse outcomes, developed as a result of the study, will become a powerful clinical tool for improving the survival rate in patients with STEMI and acute ischemic kidney injury. Funding Acknowledgement Type of funding sources: None.

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.

Incidence, timing, predictors, and impact of sustained ventricular arrythmias complicating ST-segment elevation myocardial infarction

To describe the incidence, predictors, and in-hospital impact of early SVA (eSVA, occurring < day 2 post-STEMI) and late SVA (lSVA, occurring ≥ day 2 post-STEMI) in STEMI patients. To derive and internally validate a risk score to identify patients at high-risk of lSVA. Data of 13523 patients enrolled in the ORBI registry were analysed. Logistic regression was performed to identify predictors of eSVA, lSVA, and in-hospital all-cause mortality. Predictors of lSVA were used to build a risk score. eSVA occurred in 678 patients (5%) whereas 120 patients (0.9%) experienced lSVA at a median timing of 3 days post-STEMI. eSVA associated with a significantly higher risk of all-cause mortality (adjusted OR: 1.90, 95%CI: 1.39–2.61, P < 0.001) whereas only a trend was observed with lSVA (adjusted OR: 1.69, 95%CI: 0.91–3.13, P = 0.09). Multivariable predictors of eSVA are listed in Table 1 . Multivariable predictors of lSVA are listed in the Figure. The score derived from these variables allowed the classification of patients into four risk categories: low (0–21), low-to-intermediate (22–34), intermediate-to-high (35–44), and high (≥ 45). Observed lSVA rates were 0.2%, 0.4%, 0.8%, and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P = 0.40). eSVA are 5-fold more common than lSVA in the setting of STEMI, mainly associated with other early complications, and portends a 2-fold higher risk of in-hospital mortality. Moreover, we developed a risk score-identifying patients at high risk of lSVA for whom early ICU discharge may not be suitable.

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction.

BackgroundThe neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI).MethodsA total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization.ResultsPatients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136–3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001).ConclusionNLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

Cardiogenic shock and cardiac arrest complicating ST-segment elevation myocardial infarction in the United States, 2000–2017

BackgroundThere are limited data on the outcomes of cardiogenic shock (CS) and cardiac arrest (CA) complicating ST-segment-elevation myocardial infarction (STEMI). MethodsAdult (>18 years) STEMI admissions were identified using the National Inpatient Sample (2000–2017) and classified as CS + CA, CS only, CA only and no CS/CA. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, use of do-not-resuscitate (DNR) status and palliative care referrals across the four cohorts. ResultsOf the 4,320,117 STEMI admissions, CS, CA and both were noted in 5.8%, 6.2% and 2.7%, respectively. In 2017, compared to 2000, there was an increase in CA (adjusted odds ratio [aOR] 1.83 [95% confidence interval {CI} 1.79–1.86]), CS (aOR 3.92 [95% CI 3.84–4.01]) and both (aOR 4.09 [95% CI 3.94–4.24]) (all p < 0.001). The CS+CA (77.2%) cohort had higher rates of multiorgan failure than CS only (59.7%) and CA only (26.3%), p < 0.001. The CA only cohort had lower rates (64%) of coronary angiography compared to the other groups (>70%), p < 0.001. In-hospital mortality was higher in CS+CA compared to CS alone (adjusted OR 1.87 [95% CI 1.83–1.91]), CA alone (adjusted OR 1.99 [95% CI 1.95–2.03]) or neither (aOR 18.37 [95% CI 18.02–18.71]). The CS+CA cohort had higher use of palliative care and DNR status. The presence of CS, either alone or in combination with CA, was associated with higher hospitalization costs. ConclusionsThe combination of CS and CA was associated with higher rates of non-cardiac organ failure and in-hospital mortality in STEMI compared to those with either CS or CA alone.

Clinical Manifestation, Timing Course, Precipitating Factors, and Protective Factors of Ventricular Free Wall Rupture Following ST-Segment Elevation Myocardial Infarction.

Ventricular free wall rupture (FWR) is a catastrophic complication of that occurs after acute myocardial infarction (AMI), and at present, its clinical characteristics are unclear. We analyzed a total of 6,712 consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI), and 78 patients with FWR after STEMI were enrolled in the study. Patients' demographic data, clinical manifestation, laboratory test results, and angiographic features were then collected and analyzed. FWR occurred in 78 cases (1.16%), and the inhospital mortality of FWR was up to 92.3%. Among the 78 FWR patients, 72 obtained accurate rupture time. FWR typically occurred within the first week after the infarct. Compared to late-phase FWR (more than 48 hours after STEMI) patients, early-phase FWR (during 48 hours after STEMI) patients showed significantly higher random glucose and higher percentage of anterior myocardial infarction. Besides, dual antiplatelet therapy (DAPT), β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) were used less frequently in early-phase FWR patients. Moreover, we first reported the precipitating factors of FWR. Defecating, transporting, acute emotional upset, diets, and invasive treatment turned out to be the main triggers for FWR. Furthermore, we found that patients who survived from FWR were younger, had higher β-blocker coverage in the inhospital treatment, and had a higher frequency of primary PCI. FWR remains an infrequent but devastating complication of STEMI. We have found several factors related to the occurrence and prognosis of FWR. This study provides evidence for a better understanding of FWR.

Uticaj srčane insuficijencije kao komplikacije akutnog infarkta miokarda na jednogodišnji mortalitet kod bolesnika lečenih primarnom perkutanom koronarnom intervencijom

Introduction: Cardiac insufficiency is the most common and most severe complication of patients with acute ST segment elevation myocardial infarction (STEMI). So far, there has been little data on the incidence and prognosis of cardiac insufficiency in patients with STEMI in primary percutaneous coronary intervention (PCI) era. Aim: The aim of this investigation is to determine the incidence and impact of cardiac insufficiency on one-year mortality in patients with STEMI treated with primary PCI method. Material and methods: Data on consecutive patients with STEMI was analyzed who were treated with primary PCI in the Coronary Care Unit of the Emergency Center in Belgrade, due to acute STEMI. The assessment of cardiac insufficiency was done according to the Killip classification. The primary outcome of the study was one-year mortality. Results: Out of 700 consecutive patients with STEMI treated with primary PCI, cardiac insufficiency occurred in 160 patients (22.9%). One-year mortality in patients with heart failure was significantly higher than in patients who did not develop this complication (34.4% versus 5.4%; p < 0.001). Using the multivariate Cox regression analysis, independent predictors of one-year mortality were isolated. Cardiac insufficiency was the strongest predictor of mortality. Patients with cardiac insufficiency were at the seven-fold higher risk of fatal outcome compared to patients without heart failure (HR 7.16; 95% CI 4.47-11.48; p < 0.001). Conclusion: Cardiac insufficiency is a frequent complication of acute ST segment elevation myocardial infarction in the primary PCI era. The occurrence of cardiac insufficiency as a complication of STEMI is associated with a seven-fold higher risk for one-year mortality.

P5646Risk factor paradox in STEMI-related sudden cardiac arrest

Abstract Background Cardiovascular risk factors (CVRF) are associated with an increased risk of atherosclerosis and ST-segment elevation myocardial infarction (STEMI). Sudden cardiac arrest (SCA) is currently the most feared complication of STEMI. The impact of CVRF on the rate of SCA is still unknown. Purpose To assess the association between CVRF and pre-hospital SCA during acute STEMI. Methods Data were taken between 2006 and 2014 from the e-MUST study that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Characteristics of patients who presented SCA were compared to those of patients who did not, and multivariable logistic regression was developed including all variables that differed between the two groups, in order to identify characteristics associated with an increased risk of SCA. Results Over the study period, 13,253 STEMI patients were included (median age 60.1 [51.4 - 73.0], 78.1% males). Among them, 7,513 patients (58.1%) had ≥2 CVRF, 3,979 (30.8%) had 1 CVRF, and 1,432 (11.1%) did not present any CVRF. Pre-hospital SCA witnessed by emergency medical services occurred in 749 (5.6%) patients. SCA victims were younger compared to the non-SCA group (58.0 vs. 60.3 years (P&lt;0.001), with a higher proportion of patients without known CVRF (17.2 vs. 10.7%, P&lt;0.001). There was no statistical difference in sex ratio (77.5% vs. 78.2%, P=0.69) and presence of past history of coronary artery disease (18.7% vs. 19.5%, P=0.56). Patients with ≥2 CVRF had the lowest rate of SCA (4.6%), while the highest SCA rate occurred among patients without CVRF (8.9%). On multivariate analysis, the presence of ≥2 CVRF was associated with a twice-lower risk of SCA (OR 0.52, 95% CI 0.41–0.65, P&lt;0.001, when the group without risk factors was taken as a reference group). Conclusion The prevalence of CVRF is high among patients presenting STEMI. However, once STEMI has occurred, presence of CVRF is associated with a lower rate of SCA per STEMI, creating a risk factor paradox in STEMI-related SCA.

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

Relationship of the ORBIT and HAS-BLED scores with Killip class 3-4 in patients with ST-segment elevation myocardial infarction.

Heart failure (HF) complicating ST-segment elevation myocardial infarction (STEMI) is recognized as an ominous complication. The HAS-BLED and Outcomes Registry for Better Informed Treatment (ORBIT) scores are used to assess the bleeding risk in patients with anticoagulated atrial fibrillation. This study aimed to investigate the relationship of the ORBIT and HAS-BLED scores with Killip class 3-4 in patients with STEMI.639 patients with STEMI were enrolled in this study. The ORBIT and HAS-BLED scores were recorded after admission, and all patients were divided into 2 groups: the Killip class 1-2 and Killip class 3-4 groups. Different clinical parameters were compared. The predictive values of the ORBIT and HAS-BLED scores for Killip classes 3 to 4 were assessed using receiver-operating characteristic (ROC) analyses. Univariate and multivariate logistic analyses were used to evaluate the relationships between variables and Killip class 3-4.The ORBIT and HAS-BLED scores were higher in the Killip class 3-4 group than in the Killip class 1-2 group (P < .05). The areas under the ROC curve of the ORBIT and HAS-BLED scores for predicting the higher Killip classification were 0.818 (95% CI: 0.786–0.847, P < .0001) and 0.674 (95% CI: 0.636–0.710, P < .0001), respectively. In multivariate logistic analysis, the high ORBIT score was positively associated with Killip classes 3 to 4 after adjustment (odds ratio: 2.306, 95% CI: 1.084–4.911, P = .012).A graded relationship was found in the elevated ORBIT and HAS-BLED scores and Killip classes 3 to 4 in patients with STEMI. The ORBIT score is independently associated with the Killip 3-4 in patients with STEMI.

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.

Abstract 16859: Prevalence of Mechanical Complications and Associated Mortality in Patients With ST-Segment Elevation Myocardial Infarction (STEMI) Treated With Thrombolysis (TT) Compared to Primary-PCI (P-PCI): A Nationwide Study Using National Inpatient Sample (NIS)

Introduction: Papillary muscle rupture (PMR), ventricular septal rupture (VSR) and cardiac free wall rupture (FWR), are dreaded complications of STEMI and are associated with increased morbidity and mortality. In multiple previous small to intermediate sized studies, TT as compared to P-PCI was associated with an increase in these mechanical complications. However, large scale observational studies are lacking. Methods: Adult admissions with a primary diagnosis of STEMI between 1999 and 2014 were extracted from the NIS using the ICD-9 code 410.x, except 410.7x (NSTEMI). ICD-9-CM procedure codes 36.01 to 36.07, 36.09, 00.66 and 99.10 were used to stratify the extracted data into patients who underwent P-PCI (Time-to procedure function was used to filter PCI performed within first 24 hours of presentation) and those treated with TT. The incidence of PMR (ICD-9 Code 429.6) and VSR (ICD-9 Code 429.71), VSR (ICD-9 Code 429.71) and FWR (ICD-9 Code 429.79) within 30 days of hospitalization were compared between these two groups. We performed multivariate analysis using Cox Proportional Hazard Regression to control for confounders and determine the hazard of all three complications in patients who had undergone P-PCI vs TT, and the relative mortality of these complications by reperfusion strategy. Results: Of the weighted 2,534,019 admissions for STEMIs, 1,335,711 (52.71%) underwent P-PCI whereas 125,009 (4.93%) were treated with TT. Among these, 748 (0.02%) developed PMR, 3122 (0.12%) developed VSR, and 4850 (0.19%) developed FWR. The adjusted hazard for a complication according to reperfusion modality, and the mortality by treatment are depicted below in Table 1. Conclusions: As compared with P-PCI, patient who were treated with TT had a higher risk of mechanical complications, including PMR, VSR and FWR, and a higher mortality associated with each of these complications.

TCT-805 Temporal Trends and Outcomes of Percutaneous Ventricular Septal Rupture Closure in ST-elevation Myocardial Infarction in the United States

Data regarding the utilization and outcomes of percutaneous closure of ventricular septal rupture (VSR) complicating ST-segment elevation myocardial infarction (STEMI) in the United States are lacking. We queried the National Inpatient Sample 2006-2014 to identify STEMI hospitalizations in adult