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.

Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis

AIM: To assess the impact of percutaneous cardiac support in cardiogenic shock(CS) complicating acute myocardial infarction(AMI), treated with percutaneous coronary intervention. METHODS: We selected all of the studies published from January 1st, 1997 to May 15 st, 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization:(1) intra-aortic balloon pump(IABP) vs Medical therapy;(2) percutaneous left ventricular assist devices(PLVADs) vs IABP;(3) complete extracorporeal life support with extracorporeal membrane oxygenation(ECMO) plus IABP vs IABP alone; and(4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 moof follow-up. RESULTS: One thousand two hundred and seventytwo studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was:(1) significantly higher with IABP support vs medical therapy(RR = +15%, P = 0.0002);(2) was higher, although not significantly, with PLVADs compared to IABP(RR = +14%, P = 0.21); and(3) significantly lower in patients treated with ECMO plus IABP vs IABP(RR =-44%, P = 0.0008) or ECMO(RR =-20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP. CONCLUSION: Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.

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.

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.

Concurrent implantation of intra-aortic balloon pumping with extracorporeal membrane oxygenation improved survival of patients with postcardiotomy cardiogenic shock

Background Extra-corporeal membranous oxygenation (ECMO)and intra-aortic balloon pumping (IABP) are widely used in patients with severe circulatory failure. The decision to initiate ECMO and IABP on optimal occasion in postcardiotomy cardiogenic shock (PCS) remains controversial in the absence of guidelines.

Reversible cardiogenic shock caused by atrioventricular junctional rhythm after percutaneous coronary intervention

An 82-year-old female patient undergoing cardiogenic shock caused by atrioventficular junctional rhythm immediately after percutaneous coronary intervention （PCI） is described. Pharmacotherapy was invalid, and subsequent application of atrial pacing reversed the cardiogenic shock. PCI-related injury of sinuatrial nodal artery leading to acute atrial contractility loss, accompanied by atrioventricular junctional arrhythmia, was diagnosed. We recommend that preoperative risk evaluation be required for multi-risk patients. Likewise, emergent measures should to be established in advance. This case reminds us that atrial pacing can be an optimal management technique once cardiogenic shock has occurred.

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.

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.

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.

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.

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.

Thyrotoxicosis induced cardiogenic shock rescued by extracorporeal membrane oxygenation

Cardiomyopahty is one of complications of thyrotoxicosis. About 6% of thyrotoxic patients develop heart failure, but less than 1% of the patients progress dilated cardiomyopathy with systolic left ventricular dysthnction.

Use of Impella cardiac axial flow pump for cardiogenic shock(A newer alternative)-How good is the evidence?

The adverse outcomes of a ventricular heart failure(left,right or biventricular)caused by cardiogenic shock are aggravated by lung oedema and organ mal perfusion.Despite advances in medical sciences,revascularisation and mechanical hemodynamic support have proved ineffective in reducing the mortality rate in such patients.A thorough study of the data available about cardio-vascular diseases reveals that the application of conventional methods of treatment are least helpful to practically restore normal functions of heart when it experiences end-stage systolic ventricular failure.Thus,to overcome the challenges and find alternatives to address this issue,percutaneous ventricular support devices/machines were designed and successfully introduced.These devices have revolutionized the treatment of ventricular heart failures and are now in use all over the world.In this review paper a newer mechanical circulatory support(MCS)device,Impella,has been discussed and compared with a few other devices like Intra-aortic Balloon Pump(IABP),Extracorporeal Circulation(ECLS)and Veno-arterial Extracorporeal Membrane Oxygenation(VA-ECMO).This article studies the challenges being faced during the treatment of cardiogenic shock,and thoroughly discusses the use and effectiveness of Impella Cardiac Axial Pump in each emergency.It can be said that mechanical circulatory support(MCS)device use during percutaneous coronary intervention(PCI)should be individualized based on multiple factors with a recommended use in patients with the greatest potential benefit and a relatively low risk of device-related complications.The current literature suggests that the outcomes of use of Impella and other mechanical circulatory support devices like IABP and VA-ECMO are comparable.Though there seem to be a few advantages of Impella over the others,sufficiently powered,multi-centric,randomised control trials are needed to establish its superiority.

Temporary coronary sinus pacing to improve ventricular dyssynchrony with cardiogenic shock: A case report

BACKGROUND Temporary transvenous pacing through the coronary sinus is a novel approach rarely used in treating unstable bradycardia.This modality could provide cardiac pacing while achieving better ventricular synchrony.We present a case who received cardiac pacing through the coronary sinus and provide a summary of evidence in the current literature.CASE SUMMARY A 55-year-old woman with a history of advanced heart failure was admitted to the rehabilitation ward after a recent stroke.During hospitalization,she had paroxysmal atrial fibrillation with rapid ventricular response resulting from fluid overload.While atrial fibrillation was spontaneously reversed to sinus rhythm after diuresis,she developed multiple episodes of polymorphic ventricular tachycardia along with sinus bradycardia and prolonged QTc interval.She became hypotensive despite appropriate medical management.Pacing through her implantable cardioverter-defibrillator was attempted but worsened her hypotension.Ventricular dyssynchrony was suspected.Temporary transvenous atrial pacing through the coronary sinus was performed,which stabilized her blood pressure and improved end-organ perfusion.A permanent biventricular pacemaker was later implanted,and she was safely discharged to a nursing home.CONCLUSION Temporary transvenous pacing through the coronary sinus,a novel approach to treat unstable bradycardia,may reduce ventricular dyssynchrony.

Interventional Cardiology Management of a Cardiogenic Shock Induced by Takotsubo Cardiomyopathy at the Hospital Center of Montlucon: A Case Report

Background: Takotsubo cardiomyopathy is frequently considered as a benign disorder. We present an atypical form with cardiogenic shock that was managed by interventional cardiology measures. Case presentation: A 58 years old female patient with a past history of hypertension, obesity and multiple sclerosis was admitted at the Hospital Center of Montlucon for septic shock of urinary origin. During hospitalization in intensive care unit, the patient presented a markedly increasing of troponin levels with a diffused ST-segment elevation. Transthoracic Echocardiography showed an altered left ventricular ejection fraction at 35% with hypokinesia of apex and lateral ventricular segments in conjunction with compensatory hyperkinesis of the base;these findings were strongly suggestive of a diagnosis of Takotsubo cardiomyopathy. Despite concomitant anemia, renal failure and sepsis, all adequately treated with complete remission, the patient developed frequent episodes of ventricular tachycardia that prompted an emergency coronarography. During this procedure, the patient presented a cardiogenic shock and bradyasystole that were successfully managed by intra-aortic balloon pumping and temporary transvenous pacing. Finally, there were no coronary lesions and ventriculography confirmed a Takotsubo cardiomyopathy. Given the unstable hemodynamic status of this patient, she was addressed to the University Teaching Hospital of Clermont-Ferrand for more specialized care. Conclusion: This case alerts the physician to be more vigilant when managing all patients with Takotsubo cardiomyopathy, because some cases could be fatal. In severe cases, intra-aortic balloon pumping and temporary epicardial pacing can be life-saving.

Hypoglycemic myocardial stunning as cause of cardiogenic shock in a patient with ischemic cardiomyopathy: A case report and review of literature

Hypoglycemia is a common complication seen in patients with diabetes mellitus and has been proven to have adverse effects on cardiovascular mortality. Hypoglycemia can potentially lead to worsening of cardiac function in patients with ischemic heart disease. We present a case of cardiogenic shock in a patient with hypoglycemia secondary to insulin accumulation due to worsening renal function with dramatic recovery of shock once his sugars normalized.

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.

Results of 50 adult patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock

Objective Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. Since 2004,our institution has adopted venoarterial ECMO for adult patients who otherwise could not be weaned from cardiopulmonary bypass and patients experiencing postcardiotomy cardiogenic shock and / or pulmonary dysfunction

The 6-hour lactate clearance rate in predicting 30-day mortality in cardiogenic shock

Background Early evaluation of prognosis in cardiogenic shock(CS)is crucial for tailored treatment selection.Both lactate clearance and lactate levels are considered useful prognostic biomarkers in patients with CS.However,there is yet no literature comparing the 6-hour lactate clearance rate(Δ6Lac)with lactate levels measured at admission(L1)and after 6 h(L2)to predict 30-day mortality in CS.Methods In this observational cohort study,95 patients with CS were treated at Department of Intensive Care Unit,Yiwu Central Hospital between January 2020 and December 2022.Of these,88 patients met the eligibility criteria.The lactate levels were measured after admission(L1)as the baseline lactate value,and were measured after 6 h(L2)following admission.The primary endpoint of the study was survival rate at 30 days.A receiver operating characteristic curve was used for data analysis.Univariate and multivariate Cox regression analyses were performed based onΔ6Lac.Kaplan–Meier(KM)survival curves were generated to compare the 30-day survival rates among L1,L2,andΔ6Lac.Results TheΔ6Lac model showed the highest area under the curve value(0.839),followed by the L2(0.805)and L1(0.668)models.TheΔ6Lac model showed a sensitivity of 84.2%and specificity of 75.4%.The L1 and L2 models had sensitivities of 57.9%each and specificities of 89.9%and 98.6%,respectively.The cut-off values forΔ6Lac,L1,and L2 were 18.2%,6.7 mmol/L,and 6.1 mmol/L,respectively.Univariate Cox regression analysis revealed a significant association betweenΔ6Lac and 30-day mortality.After adjusting for five models in multivariate Cox regression,Δ6Lac remained a significant risk factor for 30-day mortality in patients with CS.In our fifth multivariate Cox regression model,Δ6Lac remained a risk factor associated with 30-day mortality(hazard ratio[HR]=5.14,95%confidence interval[CI]:1.48 to 17.89,P=0.010)as well as L2(HR=8.42,95%CI:1.26 to 56.22,P=0.028).The KM survival curve analysis revealed that L1>6.7 mmol/L(HR=8.08,95%CI:3.23 to 20.20,P<0.001),L2>6.1 mmol/L(HR=25.97,95%CI:9.76 to 69.15,P<0.001),andΔ6Lac≤18.2%(HR=8.92,95%CI:2.95 to 26.95,P<0.001)were associated with a higher risk of 30-day mortality.ConclusionsΔ6Lac is a better predictor for 30-day mortality in CS than lactate levels at admission.It has a predictive value equivalent to that of lactate level at 6 h after admission,making it an important surrogate indicator for evaluating the suitability as well as poor prognosis after CS treatment.We found that a cut-off value of 18.2%forΔ6Lac provided the most accurate assessment of early prognosis in CS.

Effect of Shenfu injection on microcirculation effect index in early-and middle-stage of cardiogenic shock rats

OBJECTIVE Shenfu injection(SFI)is an effective treatment of cardiogenic shock,the pathology of the central link was microcirculation disturbance.However,whether the microcirculation status of the early-and mid-stage of cardiogenic shock has any difference is unclear.This study aimed to observe the effect of SFI on the microcirculatory disturbance in mesentery for early-and mid-stage of cardiogenic shock rat.METHODS The early-and mid-stage model of cardiogenic shock was established by ligating the ending or root of left anterior descending coronary arteries(LADCA).The rats were randomly divided into 9 groups,ie control group,early-stage model group,mid-stage model group,3 early medicated groups and 3 mid medicated groups(the dosage was 1,3.33,10 mL·kg^(-1) SFI for cardiogenic shock rats of early-and mid-stage,respectively).Parameters in mesenteric microcirculation,such as velocity of RBCs in venules,diameters of venules,the count of leukocyte adhesion and vascular permeability which calculated by FITC-dextran leakage were observed through an GeneandiM2 inverted intravital microscope and high-speed video camera system.RESULTS The cardiogenic shock induced by ligating the LADCA resulted in a number of responses in microcirculation,including a significant increase in the counts of adhesive leukocytes,narrowing of the vascular diameter,decrease in the velocity of RBCs and dextran efflux.All of the above parameters for early-stage cardiogenic shock rats were attenuated by the treatment with SFI,especially the dosage of 10 mL·kg^(-1).While SFI had no apparent time-effect on the vascular diameter and vascular permeability in mesentery for mid-stage cardiogenic shock rats.CONCLUSION The microcirculation status of the early-and mid-stage of cardiogenic shock rats were quite different.The efficacy of early treatment with SFI was more obvious than the mid administration,which could provide experimental and theoretical basis for the patients with cardiogenic shock in an earlier time.