Outcomes Of Cardiogenic Shock Research Articles

460 Does L-NAME treatment abolish the effect of baseline characteristics on the outcome of cardiogenic shock? Results from the LINCS study

460 Does L-NAME treatment abolish the effect of baseline characteristics on the outcome of cardiogenic shock? Results from the LINCS study

Baseline comorbidities and treatment strategy in elderly patients are associated with outcome of cardiogenic shock in a community-based population

Background Cardiogenic shock (CGS) historically results in high inhospital mortality, particularly in elderly patients. Factors that contribute to increased mortality and treatment strategies that improve short- and long-term outcomes in patients with CGS remain to be established. Methods The study consisted of 1263 consecutive patients with acute myocardial infarction admitted from Olmsted County, Minn, during the period 1988 to 2000; of these, 73 (6%) developed cardiogenic shock. Short- and long-term mortality was compared between the elderly and younger populations in both shock and nonshock groups. Results In patients with acute myocardial infarction, age of ≥65 years was associated with increased long-term mortality for nonshock patients (unadjusted relative risk [RR] 5.23, 95% CI 4.10–6.67, P < .001) and to a lesser degree in patients with cardiogenic shock (unadjusted RR 2.02, 95% CI 1.12–3.65, P = .02). Among cardiogenic shock patients, estimated survival at 1 and 5 years for elderly patients was 38% and 24%, respectively, and in younger patients, 57% and 52%, respectively. When adjusted for confounding variables, elderly noncardiogenic shock patients had significantly increased long-term mortality (adjusted RR 4.38, 95% CI 3.42–5.61, P < .001) compared to younger nonshock patients. In contrast, elderly patients with cardiogenic shock demonstrated a weaker trend toward worse outcomes (adjusted RR 1.80, 95% CI 1.00–3.27, P = .051) compared to younger patients with shock. Conclusions The relationship between age and long-term mortality is stronger among patients who do not develop cardiogenic shock. Advanced age was not found to be as strong a risk factor for survival in patients with cardiogenic shock; comorbidities and less aggressive treatment appear to be the major factors resulting in poor outcomes in the elderly patient with cardiogenic shock.

Percutaneous coronary revascularization improves the prognosis of patients with cardiogenic shock in acute coronary syndrome: a chronological study

Background: Cardiogenic shock complicating acute coronary syndrome (ACS) implies grim prognosis with conventional management. Previous studies of coronary intervention yielded controversial results and were rarely analyzed chronologically. This study was to determine the impact of percutaneous coronary revascularization on outcome by studying two time periods 5 years apart in which the revascularization was more frequent and techniques more refined in the later period. Methods and materials: All patients admitted to the intensive or coronary care unit for ACS in two 1.5-year study periods (Period I: Jan 1994–Jun 1995, Period II: Oct 1999–Apr 2000) were retrospectively screened. Patients who met strict criteria of cardiogenic shock within 24 h of ACS were enrolled. The demographics, management and in-hospital/3-month outcomes were analyzed. Results: Thirty-seven patients (33M/4F, aged 65±8 years) were enrolled in Period I and 32 patients (25M/7F, aged 68±13 years) in Period II. The incidence of cardiogenic shock was 11.8 and 9.3%, respectively. The demographics were similar except patients in Period II were older. Significantly more coronary angiography and interventions were done in the later period. The in-hospital (68 vs. 44%, P=0.047) and 3-month mortalities (70 vs. 44%, P=0.03) were significantly reduced in Period II. The in-hospital survivors in two study periods differed only in use of coronary angiography (94 vs. 50%, P=0.005) and interventions (83 vs. 33%, P=0.005) but not others. Conclusions: Percutaneous coronary revascularization does improve the clinical outcome of cardiogenic shock when analyzed chronologically. This treatment is warranted in every such patient in the interventional era.

Management and outcome of cardiogenic shock complicating acute myocardial infarction in hospitals with and without on-site catheterisation facilities

OBJECTIVETo determine whether the availability of on-site catheterisation and revascularisation facilities influenced hospital management and outcome of patients with acute myocardial infarction complicated by cardiogenic shock.METHODSPatients with acute myocardial infarction were enrolled prospectively in four nationwide surveys during 1992, 1994, 1996, and 1998. The characteristics, management, and outcome of patients with cardiogenic shock were compared between hospitals with on-site catheterisation facilities (group 1; 18 hospitals) and without such facilities (group 2; 8 hospitals).RESULTSOf 5351 patients with acute myocardial infarction, 254 (4.7%) developed cardiogenic shock. Group 1 patients (n = 186 of 3854; 4.6%) were younger (mean (SD) age, 69.6 (12) v 73.7 (10) years, p = 0.006) and had a lower proportion of women (36% v 52%, p = 0.03) than group 2 (n = 68 of 1243; 5.2%). There was no difference in other characteristics including the use of thrombolysis. Group 1 patients more often underwent coronary angiography (26%v 4%, p &lt; 0.001), angioplasty (21%v 4%, p = 0.002), and intra-aortic balloon counterpulsation (28% v 4%, p &lt; 0.001). Seven day mortality was lower among group 1 than among group 2 patients (61% v 77%, p = 0.02), even after age and sex adjustment (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.28 to 1.02). This outcome benefit persisted at 30 days (74%v 88%, p = 0.01; OR 0.45, 95% CI 0.18 to 0.98), and at 6 months (80% v 90%, p = 0.06; OR 0.57, 95% CI 0.22 to 1.33).CONCLUSIONSThe greater use of invasive and interventional procedures in hospitals with catheterisation facilities is associated with improved survival of patients with acute myocardial infarction complicated by cardiogenic shock. Immediate availability of invasive care facilities will improve the outcome of cardiogenic shock in the community setting.

Aspirin and Percutaneous Coronary Angioplasty Are Associated with a Decline in Mortality from Cardiogenic Shock

Background and Methods: Despite the significant progress in the care and outcome of patients with acute myocardial infarction (AMI), the impact of evolving therapies on the incidence and outcome of patients with cardiogenic shock complicating AMI has been questioned. We analyzed trends in the incidence, care and outcome of cardiogenic shock from four national surveys conducted during 1992–1998. Results: Of the 5,351 AMI patients admitted to all coronary care units in Israel, 254 (4.7%) developed cardiogenic shock. The incidence of cardiogenic shock decreased over time (5.8, 5.1, 4.3 and 4.4% for the years 1992, 1994, 1996 and 1998, respectively, p = 0.08). Concomitantly, there was an increase in utilization of coronary angiography, urgent angioplasty and intra-aortic balloon counterpulsation. In addition, there was an increase in hospital use of aspirin, nitrates, ACE inhibitors and β-blockers. Patients with shock were more likely to die within 7 days compared with AMI patients not having shock (65 vs. 4%; p < 0.001). During the study period, the mortality of patients with shock decreased: at 7 days (72% in 1992 to 60% in 1998; p = 0.09), at 30 days (87 to 70%, respectively; p = 0.01) and at 6 months (89 to 77%, respectively; p = 0.02). Both aspirin and angioplasty were independently associated with improved outcome after adjustment for baseline characteristics and study period. Conclusions: Although the mortality rate of cardiogenic shock complicating AMI remains high, the increased utilization of aspirin and angioplasty is associated with improved outcome.

Trends in cardiogenic shock: report from the SHOCK Study. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

We analysed time trends in patient characteristics, management, and outcomes of cardiogenic shock complicating acute myocardial infarction in the international, prospective SHOCK Trial Registry and pre-study Registry. Despite therapeutic advances in its management, the incidence and high mortality of this complication has remained unchanged for decades. However, in recent years mortality was reported to decrease in one community concomitant with increasing use of revascularization. Thirty-six centres registered 1380 patients with suspected cardiogenic shock complicating acute myocardial infarction from January 1992 to August 1997. Patient and myocardial infarction characteristics, haemodynamics, medications, procedure use, and vital status at discharge were recorded. In all, 79% of patients had shock due to predominant pump failure (non-mechanical aetiology). The aetiology, patient profile, and clinical characteristics of cardiogenic shock did not differ over time, except for increases in the incidence of prior bypass surgery (P=0.054) and transfers to tertiary centres (P=0.008). In all, 44% underwent revascularization (n=485), with angioplasty performed more often than bypass surgery (69% vs 31%). The revascularization rate increased over time (P=0.006) with a significant decrease in the time to revascularization (P=0.033). The use of Swan-Ganz catheterization decreased over time (P=0.018), as did the mean length of hospitalization (P=0.034). Overall in-hospital mortality was high (63%) but decreased over time in all patients (P=0.004) and those with pump failure (P=0.018). Mortality was lower for patients who underwent revascularization compared to those who were not revascularized (41% vs 79%, P<0.001). Cardiogenic shock complicating acute myocardial infarction is associated with a high mortality rate, but mortality decreased significantly from 1992 to 1997. This partly reflects the greater use of revascularization, which was associated with better outcomes. The reported international trend towards shorter admissions for myocardial infarction was also observed in this cohort.

Platelet glycoprotein IIb/IIIa blockade and outcome of cardiogenic shock complicating acute coronary syndromes without persistent ST-segment elevation

OBJECTIVESThe study examined whether antiplatelet treatment with eptifibatide affected the frequency and outcome of shock among patients in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial who had acute coronary syndromes but not persistent ST-segment elevation.BACKGROUNDPreliminary reports suggest a salutary effect of antiplatelet agents when shock complicates acute myocardial infarction.METHODSWe analyzed the impact of antiplatelet treatment with eptifibatide on the frequency and outcome of cardiogenic shock developing after enrollment. PURSUIT was a double-blind, randomized trial that examined the efficacy of eptifibatide (180 μg/kg bolus + continuous infusion of 2.0 μg/kg/min for ≤96 h) versus placebo among patients who had acute coronary syndromes but not persistent ST-segment elevation.RESULTSShock developed in 2.5% of the 9,449 patients at a median (25th, 75th interquartiles) of 94.0 (38, 206) h. Death by 30 days occurred in 65.8% of shock patients. Patients who had acute myocardial infarction upon enrollment had a greater incidence of shock (2.9% vs. 2.1%, p = 0.01), developed shock earlier (40.2% <48 h vs. 20.9%, p = 0.001), and had higher 30-day mortality from shock (77.2% vs. 52.7%, p = 0.001). Randomization to eptifibatide did not affect the occurrence of shock (p = 0.71, adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.72–1.25). However, shock patients treated with eptifibatide had significantly reduced adjusted odds of 30-day death (p = 0.03, adjusted OR = 0.51, 95% CI = 0.28–0.94).CONCLUSIONSPatients with shock treated with eptifibatide had significantly reduced adjusted odds of death, suggesting a salutary effect of antiplatelet therapy on shock. This finding warrants verification in specifically designed studies.

Correlation of clinical and hemodynamic findings and outcome in Cardiogenic Shock

Correlation of clinical and hemodynamic findings and outcome in Cardiogenic Shock

Prognosis in cardiogenic shock after acute myocardial infarction in the intervencional era

Objectives. The purpose of this study is to describe the outcome in cardiogenic shock treated with aggressive reperfusion therapy and to identify factors predictive of in-hospital and long-term mortality.Background. Cardiogenic shock is the most common cause of death in patients admitted to the coronary care unit. Although studies have reported lower mortality rates in shock treated with angioplasty, few studies have described a cohort of patients with shock who were not selected because they were most likely to benefit from reperfusion therapy.Methods. A consecutive series of 200 patients admitted with acute myocardial infarction complicated by cardiogenic shock were studied.Results. The in-hospital mortality rate was 53%. Variables with significant univariable association with in-hospital death included patency of the intarct-related artery, patient age, lowest cardiac index, highest arteriovenous oxygen difference and left main coronary artery disease. The most important independent predictors of in-hospital death were patency of the Infarct-related artery, cardiac Index and peak creatine kinase, MB fraction. The mortality rate in patients with patent infarct-related arteries was 33% versus 75% in those with closed arteries and 84% in those in whom arterial patency was unknown. Patients who survived to hospital discharge were followed up for a median of 2 years, with a mortality rate of 18% after 1 year. The best descriptors of the relation between these variables and postdischarge mortality included age, peak creatine kinase, ejection fraction and patency of the infarct-related artery.Conclusions. In a large consecutive series of patients with cardiogenic shock with complete follow-up, patency of the infarclrelated artery was most strongly associated with in-hospital and long-term mortality. This finding supports an aggressive Interventional strategy in patients with cardiogenic shock.