Immediate in-hospital outcomes after percutaneous revascularization of acute myocardial infarction complicated by cardiogenic shock

BACKGROUND Cardiogenic shock(CS)is a life-threatening complication of acute myocardial infarction with high morbidity and mortality rates.Primary percutaneous coro-nary 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,Pak-istan,between January 2018 and December 2022.The primary outcome was immediate mortality,defined as mortality within index hospitalization.Uni-variate 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%co-nfidence 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.

Application of pulse index continuous cardiac output system in elderly patients with acute myocardial infarction complicated by cardiogenic shock: A prospective randomized study

BACKGROUND Cardiogenic shock (CS) secondary to acute myocardial infarction (AMI) complicates management of the condition, and often leads to poor prognosis. Prompt and accurate monitoring of cardiovascular and accompanying hemodynamic changes is crucial in achieving adequate management of the condition. Advances in technology has availed procedures such as pulse index continuous cardiac output (PiCCO), which can offer precise monitoring of cardiovascular functions and hemodynamic parameters. In this study, PiCCO is evaluated for its potential utility in improving management and clinical outcomes among elderly patients with AMI complicated by CS. AIM To assess whether use of the PiCCO system can improve clinical outcomes in elderly patients with AMI complicated by CS.METHODS Patients from emergency intensive care units (EICU) or coronary care units (CCU) were randomized to receive PiCCO monitoring or not. The APACHE II score, SOFA score, hs-TnI, NT-proBNP, PaO2/FiO2 ratio and lactate levels on day 1, 3 and 7 after treatment were compared. The infusion and urine volume at 0-24 h, 24-48 h and 48-72 h were recorded, as were the cardiac index (CI), extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) at similar time intervals. RESULTS Sixty patients with AMI complicated by CS were included in the study. The PiCCO group had a significantly lower APACHE II score, SOFA score, hs-TnI and NT-proBNP levels on day 1, 3 and 7 after treatment. The infusion and urine volume during 0-24 h in the PiCCO group were significantly greater, and this group also showed significantly higher ADL scores. Furthermore, the PiCCO group spent lesser days on vasoactive agents, mechanical ventilation, and had a reduced length of stay in EICU/CCU. Additionally, the CI was significantly higher at 48 h and 72 h in the PiCCO group compared with that at 24 h, and the EVLWI, ITBVI and GEDVI were significantly decreased at 48 h and 72 h. CONCLUSION Applying the PiCCO system could improve the clinical outcomes of elderly patients with AMI complicated by CS.

The Utility of B-type Natriuretic Peptide to Predict Prognosis of Acute Myocardial Infarction Patients Complicated With Cardiogenic Shock Treated With Intra-aortic Ballon Counterpulsation

Objectives To assess the prognostic value of B-type natriuretic peptide （BNP） in severe AMI patients treated with intra-aortic ballon counterpulsation（IABP）. Methods A total of 42 AMI patients with cardiogenic shock were retrospectively studied. BNP plasma level was recorded in the 24th hour and 4th day after myocardial infarction. The different mortality were compared among patients with different BNP levels. Results With aggressive treatment, 20 patients survived short term hospitalization. Plasma concentration of BNP in dying patients is much higher than in survivals（1369 ± 353 vs 651 ± 302 pg/ml. P〈 0.01）.Patients with BNP higher than 1474 pg/mL had a mortality of 92.9 %. Conclusions Elevated BNP level in AMI patients with cardiogenic shock treated with IABP is highly associated with poor prognosis.

Diabetes mellitus, revascularization and outcomes in elderly patients with myocardial infarction-related cardiogenic shock

Background The prognostic role of diabetes mellitus(DM)in elderly patients with myocardial infarction-related cardiogenic shock(MI-CS)remains controversial.Little information exists about the impact of intensive cardiac care unit(ICCU)and revascularization on outcomes of elderly patients with MI-CS.We aimed to assess the prognostic impact of DM according to age in patients with MI-CS,and to analyze the impact ICCU management and revascularization on in-hospital mortality in MI-CS patients at older ages.Methods Discharge episodes with diagnosis of CS associated with MI were selected from the Spanish National Health System’s Basic Data Set.Centers were classified according to their availability of ICCU.Main outcome measured was in-hospital mortality.Results A total of 23,590 episodes of MI-CS were identified,of whom 12,447(52.8%)were in patients aged≥75 years.The impact of DM on in-hospital mortality was different among age subgroups.While in younger patients,DM was associated to a higher mortality risk(0.52 vs.0.47,OR=1.12,95%CI:1.06–1.18,χ^2<0.001),this association became non-significant in older patients(0.76 vs.0.81,χ^2=0.09).Adjusted mortality rate of MI-CS aged≥75 years was lower in patients admitted to hospitals with ICCU(adjusted mortality rate:74.2%vs.77.7%,P<0.001)and in patients undergoing revascularization(74.9%vs.77.3%,P<0.001).Conclusions Prognostic impact of DM in patients with MI-CS was different according to age,with a significantly lower impact at older ages.The availability of ICCU and revascularization were associated with better outcomes in these complex patients.

Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock:A review of contemporary literature

Acute myocardial infarction(AMI)with left ventricular(LV)dysfunction patients,the most common cause of cardiogenic shock(CS),have acutely deteriorating hemodynamic status.The frequent use of vasopressor and inotropic pharmacologic interventions along with mechanical circulatory support(MCS)in these patients necessitates invasive hemodynamic monitoring.After the pivotal Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial failed to show a significant improvement in clinical outcomes in shock patients managed with a pulmonary artery catheter(PAC),the use of PAC has become less popular in clinical practice.In this review,we summarize currently available literature to summarize the indications,clinical relevance,and recommendations for use of PAC in the setting of AMI-CS.

Cardiogenic shock in the setting of acute myocardial infarction:Another area of sex disparity?

Cardiogenic shock in the setting of acute myocardial infarction(AMI)carries significant morbidity and mortality,despite advances in pharmacological,mechanical and reperfusion therapies.Studies suggest that there is evidence of sex disparities in the risk profile,management,and outcomes of cardiogenic shock complicating AMI.Compared with men,women tend to have more comorbidities,greater variability in symptom presentation and are less likely to receive timely revascularization and mechanical circulatory support.These factors might explain why women tend to have worse outcomes.In this review,we highlight sex-based differences in the prevalence,management,and outcomes of cardiogenic shock due to AMI,and discuss potential ways to mitigate them.

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.

An unusual case of renal calculi leading to myocardial infarction and cardiogenic shock

INTRODUCTION The presentation of cardiogenic shock(CS)is usually straightforward,and includes hypotension,absence of hypovolemia,and clinical signs of poor tissue perfusion such as oliguria,cyanosis,cool extremities and altered mentation.^([1])

Dobutamine Infusion and Absence of Pulmonary Hypertension Are Associated with Decreased Mortality in a Cohort of 249 Patients with Cardiogenic Shock

Objective: Prognostic analysis of 249 patients admitted for cardiogenic shock (CS) of various origins. Background: Little is known about prognosis of CS from non-ischemic cardiomyopathy. Methods: Retrospective monocentric study of patients referred to an ICU during 2 years. Results: Despite aggressive management including intra-aortic balloon pump (31%), extra-renal replacement therapy (36%), extra-corporeal life support (8%), and catecholamine infusion (97%), in-hospital mortality was 46%. Toxic CS or CS related to deficiency carried a better outcome (mortality 5%). Post-myocardial infarction or post-cardiac arrest CS was associated with higher mortality. In the multivariate analyses, only SAPS II (OR 1.037;1.013 - 1.056;p = 0.0001), pulmonary hypertension (OR 4.8;1.3 - 17;p = 0.02), extra-renal replacement therapy (OR 2.9;1.3 - 6;p = 0.006), and dobutamine infusion (OR 0.44;0.2 - 0.96;p = 0.04) were significantly associated with in-hospital mortality. Conclusion: Dobutamine infusion was associated with a better outcome. Higher SAPS II, pulmonary hypertension, and extra-renal replacement therapy were associated with increased in-hospital mortality.

Impact of liver cirrhosis on ST-elevation myocardial infarction related shock and interventional management,a nationwide analysis

BACKGROUND Critical care is rapidly evolving with significant innovations to decrease hospital stays and costs.To our knowledge,there is limited data on factors that affect the length of stay and hospital charges in cirrhotic patients who present with STelevation myocardial infarction-related cardiogenic shock(SRCS).AIM To identify the factors that increase inpatient mortality,length of stay,and total hospital charges in patients with liver cirrhosis(LC)compared to those without LC.METHODS This study includes all adults over 18 from the National Inpatient Sample 2017 database.The study consists of two groups of patients,including SRCS with LC and without LC.Inpatient mortality,length of stay,and total hospital charges are the primary outcomes between the two groups.We used STATA 16 to perform statistical analysis.The Pearson's chi-square test compares the categorical variables.Propensity-matched scoring with univariate and multivariate logistic regression generated the odds ratios for inpatient mortality,length of stay,and resource utilization.RESULTS This study includes a total of 35798453 weighted hospitalized patients from the 2017 National Inpatient Sample.The two groups are SRCS without LC(n=758809)and SRCS with LC(n=11920).The majority of patients were Caucasian in both groups(67%vs 72%).The mean number of patients insured with Medicare was lower in the LC group(60%vs 56%)compared to the other group,and those who had at least three or more comorbidities(53%vs 90%)were significantly higher in the LC group compared to the non-LC group.Inpatient mortality was also considerably higher in the LC group(28.7%vs 10.63%).Length of Stay(LOS)is longer in the LC group compared to the non-LC group(9 vs 5.6).Similarly,total hospital charges are higher in patients with LC($147407.80 vs$113069.10,P≤0.05).Inpatient mortality is lower in the early percutaneous coronary intervention(PCI)group(OR:0.79<0.11),however,it is not statistically significant.Both early Impella(OR:1.73<0.05)and early extracorporeal membrane oxygenation(ECMO)(OR:3.10 P<0.05)in the LC group were associated with increased mortality.Early PCI(-2.57 P<0.05)and Impella(-3.25 P<0.05)were also both associated with shorter LOS compared to those who did not.Early ECMO does not impact the LOS;however,it does increase total hospital charge(addition of$24717.85,P<0.05).CONCLUSION LC is associated with a significantly increased inpatient mortality,length of stay,and total hospital charges in patients who develop SRCS.Rural and Non-teaching hospitals have significantly increased odds of extended hospital stays and higher adjusted total hospital charges.The Association of LC with worse outcomes outlines the essential need to monitor these patients closely and treat them early on with higher acuity care.Patients with early PCI had both shorter LOS and reduced inpatient mortality,while early Impella was associated with increased mortality and shorter LOS.Early ECMO is associated with increased mortality and higher total hospital charges.This finding should affect the decision to follow through with interventional management in this cohort of patients as it is associated with poor outcomes and immense resource utilization.

IABP-SHOCKⅡ评分联合动脉血乳酸、RDW对心肌梗死并发心源性休克患者预后的预测价值

目的探讨IABP-SHOCKⅡ评分联合动脉血乳酸水平、红细胞分布宽度(RDW)对心肌梗死并发心源性休克患者预后的预测价值。方法选取2019年10月至2021年10月于该院就诊的心肌梗死并发心源性休克患者68例,按患者28 d后的生存情况分为良好组(49例)和死亡组(19例)。比较两组患者IABP-SHOCKⅡ评分、动脉血乳酸水平、红细胞计数(RBC)、白细胞计数(WBC)、红细胞分布宽度(RDW)、血小板计数(PLT),采用Logistic回归模型分析心肌梗死并发心源性休克患者死亡的影响因素,并采用受试者工作特征(ROC)曲线分析IABP-SHOCKⅡ评分联合动脉血乳酸和RDW对心肌梗死并发心源性休克患者死亡的预测效能。结果良好组的IABP-SHOCKⅡ评分、动脉血乳酸水平、WBC、RDW及PLT均显著低于死亡组,差异均有统计学意义(P<0.05)。Logistic回归分析显示,WBC和PLT不是心肌梗死并发心源性休克患者死亡的影响因素(P>0.05),IABP-SHOCKⅡ评分、动脉血乳酸水平和RDW是心肌梗死并发心源性休克患者死亡的独立影响因素(P<0.05)。IABP-SHOCKⅡ评分、动脉血乳酸水平、RDW预测心肌梗死并发心源性休克患者死亡的AUC分别为0.834(95%CI:0.724~0.913)、0.800(95%CI:0.685~0.887)、0.793(95%CI:0.677~0.882),IABP-SHOCKⅡ评分、动脉血乳酸水平、RDW联合预测心肌梗死并发心源性休克患者死亡的AUC为0.943(95%CI:0.859~0.985),联合检测的预测效能高于单项检测。结论IABP-SHOCKⅡ评分联合动脉血乳酸水平、RDW对心肌梗死并发心源性休克患者的死亡有一定的预测价值。

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.

An Unusual Presentation of Cardiogenic Shock in the Emergency Department

A 51-year old female with a history of multiple sclerosis presented to the emergency department with hypotension and fatigue. She was found to be in cardiogenic shock. Her initial EKG was concerning for STEMI and her troponin was positive. She was eventually diagnosed with spontaneous coronary artery dissection. This case report discusses her presentation, management, and clinical course. We emphasize the need for emergency medicine physicians to be concerned for SCAD, especially in women with a history of fibromuscular dysplasia, connective tissue disorders, or peri-partum status.

急性缺血性二尖瓣反流的缘对缘治疗

急性缺血性二尖瓣反流(AIMR)是一种严重危及生命的心血管疾病,常常由急性心肌梗死引起二尖瓣腱索或乳头肌断裂或室壁运动异常导致二尖瓣瓣叶栓系引起。其症状包括呼吸急促、心悸和肺水肿、心原性休克等,治疗极具挑战性,传统的治疗方法包括药物治疗和外科手术干预,但药物治疗对部分患者效果不佳,而外科手术干预对部分患者风险较高而无法实施。随着介入心脏病学的进步,经导管二尖瓣缘对缘修复(TEER)对慢性二尖瓣反流患者的治疗进行了诸多的探索,在缓解症状和提高生活质量方面有很大获益。TEER为AIMR提供了一种全新的选择。本综述将深入探讨TEER在治疗AIMR中的手术策略、器械选择、临床探索以及其面临的挑战与前景。

乳酸对ECMO支持下急性心肌梗死合并心源性休克患者预后的影响

目的分析血乳酸对体外膜肺氧合(ECMO)支持下治疗急性心肌梗死(AMI)合并心源性休克(CS)患者预后的影响,从而指导临床以期改善预后。方法回顾性分析2018年12月至2021年12月于河北医科大学第二医院急诊医学科就诊的ECMO支持下行冠脉造影及经皮冠状动脉介入(PCI)治疗AMI合并CS患者临床资料。患者均在就诊后经充分评估行VA-ECMO支持治疗,24 h内行冠脉造影及PCI,期间多次测量患者动脉血乳酸值,收集上ECMO前最高血乳酸值、上ECMO后行急诊PCI之前最低血乳酸值、乳酸清除率。根据发病30 d预后情况将患者分为存活组和死亡组。比较ECMO前后血乳酸值的变化,比较存活组、死亡组上ECMO前、后血乳酸值的差异,并绘制ROC曲线评价上机前、后血乳酸对患者预后的预测价值。结果39例患者中30 d存活21例(53.8%),死亡18例(46.2%);上ECMO后最低乳酸值较上ECMO前最高血乳酸值明显下降(均P<0.05);与存活组比较,死亡组上ECMO前最高血乳酸值、上ECMO后最低乳酸值均明显升高,乳酸清除率明显降低(均P<0.05)。ROC曲线分析显示上ECMO前最高血乳酸值、上ECMO后最低乳酸值对ECMO支持下行治疗AMI合并CS患者预后有预测价值,上ECMO前最高血乳酸值对应的ROC曲线下面积(AUC)为0.756,95%CI为0.601~0.911,P值为0.007,当截断值为5 mmol/L时,敏感度为94.1%,特异度为57.1%;上ECMO后最低乳酸值对应的AUC为0.870,95%CI为0.761~0.979,P值为0.000,当截断值为2.45 mmol/L时,敏感度为100%,特异度为61.9%。结论ECMO可以有效降低AMI合并CS患者血乳酸水平;上ECMO前最高血乳酸值、上ECMO后最低血乳酸值对ECMO支持下行治疗AMI合并CS患者预后有预测价值;上ECMO前最高血乳酸值≥5 mmol/L,上ECMO后PCI前最低乳酸值≥2.45 mmol/L提示不良预后;ECMO支持的患者在PCI前降低血乳酸水平可能改善患者预后。

急性心肌梗死合并心原性休克患者器械辅助支持下直接经皮冠状动脉介入治疗预后不良的因素分析

目的本研究旨在考察急性心肌梗死合并心原性休克患者直接经皮冠状动脉介入治疗(PPCI)术后预后不良的影响因素。方法入选2015年1月至2019年12月期间,河南中医药大学第一附属医院胸痛中心收治急性心肌梗死合并心原性休克并且行PPCI的患者,收集其临床基线特征、冠状动脉造影及PPCI相关参数、器械辅助支持信息等。根据1年内随访生存与否,分为生存组与死亡组,比较两组各项因素。结果共入选40例患者,其中生存组26例,死亡组14例。两组在基线资料、入院诊断、危险因素及合并症等方面差异均无统计学意义(均P>0.05);生存组较死亡组有入院时心率较低、血压较高的趋势;生存组心肌酶显著低于死亡组(肌酸激酶峰值:496.00(198.25,2830.00)U/L比3040.00(405.75,5626.53)U/L,P=0.003;肌酸激酶同工酶MB型峰值:52.65(31.75,219.50)U/L比306.00(27.25,489.63)U/L,P=0.006);两组间在冠状动脉造影及PPCI相关指标方面比较,生存组较对照组有更高的完全血运重建率(53.85%比21.43%,P=0.048);两组器械辅助支持方面比较,生存组较死亡组有更多的体外膜肺氧合(ECMO)联合主动脉内球囊反搏(IABP)支持的比例(38.46%比7.14%,P=0.034)。结论急性心肌梗死合并心原性休克行PPCI的患者的预后与心肌酶水平、ECMO联合IABP支持以及完全血运重建有关。

老年急性心肌梗死患者并发心源性休克的危险因素及预后分析

目的探讨老年急性心肌梗死患者并发心源性休克的危险因素及预后。方法回顾性分析2020年1月至2023年12月沈阳市第十人民医院重症医学科收治的急性心肌梗死患者398例,根据住院期间是否发生心源性休克分为心源性休克组99例和对照组299例。比较2组临床特征,分析心源性休克的危险因素,并探讨心源性休克对患者预后的影响。结果与对照组比较,心源性休克组年龄≥80岁、糖尿病、冠状动脉病变支数≥2支、冠状动脉左主干病变、既往心肌梗死病史比例显著增高(P<0.05,P<0.01)。年龄≥80岁、糖尿病、冠状动脉病变支数≥2支、冠状动脉左主干病变、既往心肌梗死病史是老年急性心肌梗死患者并发心源性休克的独立危险因素(OR=2.280,95%CI:1.294~4.017,P=0.004;OR=2.326,95%CI:1.281~4.225,P=0.006;OR=3.868,95%CI:2.145~6.975,P=0.000;OR=3.587,95%CI:1.868~6.886,P=0.000;OR=4.040,95%CI:1.951~8.365,P=0.000)。根据相关危险因素,构建预测模型,训练集ROC曲线下面积为0.799(95%CI:0.736~0.862),验证集ROC曲线下面积为0.737(95%CI:0.634~0.840)。对验证集模型进行Hosmer-Lemeshow拟合优度检验(χ^(2)=7.117,P=0.524),说明本模型具有较好的可信度。与对照组比较,心源性休克组院内病死率显著升高(12.12%vs 0.67%,P=0.000)。结论心源性休克可导致老年急性心肌梗死患者预后不良,年龄≥80岁、糖尿病、冠状动脉病变支数≥2支、冠状动脉左主干病变、既往心肌梗死病史是心源性休克的独立危险因素。

急诊经皮冠状动脉介入术联合体外肺膜氧合成功救治急性ST段抬高型心肌梗死1例报道

急性ST段抬高型心肌梗死(STEMI)是冠心病的严重类型之一,通过介入手段早期快速开通梗死相关动脉是改善预后的关键,部分急性STEMI患者易出现心源性休克,导致介入治疗无法实施。体外膜肺氧合(ECMO)技术通过呼吸和循环功能支持,使介入治疗的安全性和有效性得以提高。本文报告通过急诊经皮冠状动脉介入术联合ECMO成功救治1例STEMI患者的过程,并讨论如何提高急性STEMI尤其是合并心源性休克患者的救治成功率。

NLR与MSI对急性NSTEMI短期预后判断价值

目的本研究旨在探讨校正休克指数(MSI)和中性粒细胞/淋巴细胞比值(NLR)在判断急性非ST段抬高型心肌梗死(NSTEMI)患者短期内可能出现不良预后的预测能力。方法研究组选择2020年3月到2021年9月期间,首次就诊急诊科明确诊断为急性非ST段抬高型心肌梗死的276例患者。通过快速急诊绿道监测血压与心率,并于急诊科10 min内抽取血常规、床旁心脏彩超等相关化验检查,依据监测及化验结果,研究小组计算了校正休克指数(MSI)和中性粒细胞/淋巴细胞比值(NLR),然后根据统计结果将患者分为2组:NLR≥5.0组(n=75)与NLR﹤5.0组(n=201);(2)MSI≥1.2组(n=57)与MSI<1.2组(n=219)。比较2组一般资料情况,发生不良心血管事件的比例,采用受试者ROC曲线下面积来评估NLR值和MSI值对NSTEMI院内不良心血管事件的预测能力。结果连续入选的276例NSTEMI患者中,发生不良心血管事件52例,占18.8%,心源性休克患者15例,占5.4%,恶性心律失常患者24例,占8.7%,死亡13例,占4.7%。NLR≥5.0与MSI≥1.2值组的心功能、收缩压(SBP)、舒张压(DBP)及心率(HR)分别与NLR<5.0与MSI<1.2组比较,差异有统计学意义(P<0.05);NLR≥5.0与MSI≥1.2组MACE发生率分别高于NLR<5.0组与MSI<1.2组(P<0.05)。此外,NLR和MSI的ROC曲线下面积分别为0.734和0.703,提示NLR和MSI均具有评价急性非ST段抬高型心肌梗死患者短期不良心血管事件发生能力。结论MSI与NLR是评估NSTEMI短期不良预后的两个简单的重要的易获得指标。

Efficacy of Intra-aortic Balloon Pump before versus after Primary Percutaneous Coronary Intervention in Patients with Cardiogenic Shock from ST-elevation Myocardial Infarction

Background： Previous studies showed that patients with cardiogenic shock （CS） from ST-elevation acute myocardial infarction （STEMI） supported by intra-aortic balloon pump （IABP） before primary percutaneous coronary intervention （PCI） decreased the risk of in-hospital mortality than patients who received IABP after PCI. However, little evidence is available on the optimal order of IABP insertion and primary PCI. The aim of this study was to investigate the impact of the sequence of IABP support and PC1 and its association with major adverse cardiac and cerebrovascular events （MACCEs）. Methods： Data were obtained from 218 consecutive patients with CS due to STEMI in Beijing Anzhen Hospital between 2008 and 2014% who were treated with 1ABP and PCI. The patients were divided into two groups： Group A in whom IABP received before PCI （n = 106） and Group B in whom IABP received after PCI （n = 112）. We evaluated the myocardial perfusion using myocardial blush grade and resolution of ST-segment elevation. The primary endpoint was 12-month risk of MACCE. Results： Most baseline characteristics were similar in patients between the two groups. However, patients received 1ABP before PCI were associated with a delay of door-to-balloon time （DBT） and higher troponin I level （P 〈 0.05）. However, myocardial perfusion was significantly improved in patients treated with IABP before PCI （P 〈 0.05）. Overall, IABP support before PCI was not associated with significantly lower risk of MACCE （P 〉 0.05）. In addition, risk of all-cause mortality, bleeding, and acute kidney injury （AKI） was similar between two groups （P 〉 0.05）. Multivariate analysis showed that DBT （odds ratio [OR] 2.5, 95% confidence interval [C/] 1.1-4.8, P=0.04）, lABP support after PCI （OR 5.7, 95% Cl 2.7-8.4, p〈0.01）, and AKI （OR 7.4, 95% CI 4.9 10.8, P- 0.01） were the independent predictors of mortality at 12-month follow-up. Conclusions： Early IABP insertion before primary PCI is associated with improved myocardial perfusion although DBT increases. IABP support before PCI does not confer a 12-month clinical benefit when used for STEMI with CS.