Adrenal Insufficiency in Cardiogenic Shock: Incidence and Prognostic Implication

Introduction: Functional integrity of the hypothalamic pituitary axis is disrupted during severe infection or stress. The observed blunted response to corticotropin was interpreted as impaired secretory reserve of the adrenal glands and was termed as relative adrenocortical insufficiency. Aim of the work: To study the incidence of adrenal insufficiency in patients developed cardiogenic shock complicating ST segment elevation myocardial infarction. Materials and methods: Prospective cohort study was done for 90 patients admitted to Algalaa Hospital for whom basal cortisol and ACTH level were measured immediately before a standard-dose (250 μg) ACTH stimulation test (SST) and 60 minutes after SST Δmax is defined as the difference between the maximal value after the test and basal level of serum cortisol. Results: Baseline ACTH and total cortisol showed positive correlation to clinical severity scores (APACHE II and Lactate), LVEF as well as vasoactive inotrope score, all with significant p value (0.000). The higher baseline cortisol level was co-related to increased mortality (Baseline serum cortisol level was significantly lower in survivors (30.6 ± 6.1 vs 45.0 ± 16.3) p value: 0.000) while the better response of the adrenal gland to short stimulation test was co-related more to survival as detected by Δmax TC (difference of cortisol level before and after SST) (13.8 ±3.8 in survivors vs 8.5 ± 4.42 in non survivors) p value 0.000. Conclusion: A high baseline plasma TC was associated with increased mortality in patients with cardiogenic shock post acute myocardial infarction. Patients with lower baseline TC, but with a better adrenal response, appeared to have a survival benefit.

The Incidence of Myocardial Diastolic Dysfunction in Patients with Decompensated Liver Disease

Introduction: There is a debate about whether the occurrence is of systolic, diastolic dysfunction, or both in patients with liver cirrhosis. Aim of the work was to investigate the diastolic and systolic function changes prevalence in Acute decompensated on top of chronic liver disease. Patients and methods: The studywas performed on three hundred patients with Hepatitis C virus (HCV) associated liver cirrhosis;patients with a history of cardiac disease were excluded from the study about complete liver function tests. Abdominal ultrasound and echo-doppler were done for all patients and control. They were subdivided according to compensation into two groups: Group A was 150 patients with Compensated Liver Cirrhosis Disease (child A), and Group B was 150 patient with Decompensate Liver Cirrhosis (child B & C) and Control group of twenty, with no hepatic abnormality and no cardiac dysfunction. Echocardiography was done to all patients to detect left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), ejection fraction (EF%) and E/A ratio to detect the presence of diastolic dysfunction. Results: In this study, reversed E/A ratio as an indicator for diastolic dysfunction was found in 120 (40%) patients while patients had standard E/A rate was 180 (60%). E/A ratio decreased and decreased in the LVESD and EF% in patients with decompensated liver cirrhosis more than those with compensated liver cirrhosis. Conclusion: Decompensated liver cirrhosis is associated with diastolic and systolic dysfunctions.