Multiple stenting in acute myocardial infarction with double vessel occlusion, complicated with cardiogenic shock

Stenting of the infarct-related artery during the acute phase of myocardial infarction is a controversial issue. We report a case of primary multiple stent implantation in 2 vessels in a patient with AMI, double vessel total occlusion and cardiogenic shock. No intracoronary thrombotic therapy was given. Stenting provides an optimal angiographic result which may decrease the need for repeat interventions. Primary stenting in AMI deserves further investigation.     

Thrombolysis in acute myocardial infarction complicated by cardiogenic shock

The adverse impact of the development of cardiogenic shock in the setting of acute myocardial infarction was first described by Killip and Kimball in 1967. While the inhospital mortality rate in patients with myocardial infarction and no evidence of heart failure was only 6%, the mortality rate in those patients who developed cardiogenic shock was 81%. Despite advances in cardiovascular care and therapy since that initial report, including universal institution of cardiac care units, advances in hemodynamic monitoring, new inotropic and vasodilating agents, and even increasing utilization of thrornbolytic therapy, the mortality from acute myocardial infarction, when complicated by cardiogenic shock, remains disturbingly high, and cardiogenic shock remains the leading cause of death of hospitalized patients following acute myocardial infarction.The grave prognosis associated with this condition has resulted in increased interest in potential therapeutic interventions, particularly in the area of reperfusion therapy. Several studies suggest that, in contrast to the beneficial effects of thrombolytic therapy in most patient populations suffering acute myocardial infarction, mortality rates are not decreased in those patients with cardiogenic shock at the time of lytic administration. Thrombolytic administration does, however, appear to lead to a modest reduction in the percent of patients with myocardial infarction who will subsequently develop cardiogenic shock during hospitalization.Reperfusion rates with lytic therapy in patients with cardiogenic shock are disappointingly low, in the range of 42–48%, significantly lower than those achieved in patients without cardiogenic shock. These low perfusion rates may, in part, be explained by decreased coronary blood flow and perfusion pressure in patients with left ventricular pump failure.Although promising as adjunctive therapy, it is unclear whether institution of balloon counterpulsation has any long-term benefit in patients with cardiogenic shock treated with thrombolytic therapy. Whether other or additional interventions, such as coronary angioplasty and coronary artery bypass graft (CABG), decrease mortality rates in patients with cardiogenic shock remains to be determined.     

Revascularization,stenting, and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.     

急性心肌梗死并发心源性休克的干预进展

心源性休克是急性心肌梗死（AMI）最严重的并发症之一,其发病率为7％～10％。近些年,随着经皮冠状动脉介入术（PCI）、冠状动脉旁路移植术（CABG）等血运重建技术的熟练应用和多巴胺、主动脉球囊反搏技术（IABP）的有效配合,以及新型药物左西孟坦和心室辅助装置（VAD）、体外膜氧合（ECMO）的应用,其病死率由70年代的70％～80％下降到50％。本文综述了急性心肌梗死并发的心源性休克的诊断标准、病理生理机制、尤其是干预手段的应用进展。     

急性心肌梗死并发心源性休克的临床特征

目的分析急性心肌梗死并发心源性休克患者的临床特征。方法连续收集我院1995年2005年初发急性ST段抬高心肌梗死患者资料,按照是否有心源性休克分为两组。分析患者一般情况、化验指标、危险因素、并发症和病死率的差异。结果休克组年龄显著高于非休克组[（70±9）岁vs（63±12）岁,P<0.01];两组间血清磷酸激酶同工酶（CK-MB）、WBC和电解质水平无显著差异;休克组吸烟者明显少于非休克组（19%vs52%,P<0.01）,其他危险因素无显著差异;休克组心律失常和心脏破裂的发生率显著增高,病死率明显高于非休克组（83%vs8%,P<0.01）。结论高龄是心肌梗死并发心源性休克的关键因素之一,心源性休克患者临床情况更为凶险,预后不良。     

Treatment options for acute myocardial infarction complicated by cardiogenic shock

Hospital survival of patients with acute myocardial infarction complicated by cardiogenic shock has improved during recent years. Before the 1990s, emphasis on a medical and supportive approach to treatment of these high-risk patients (including thrombolytic therapy) was not clearly associated with improving outcomes. However, in the past decade, the interventional approach to treatment of acute myocardial infarction complicated by cardiogenic shock (mainly acute infarct angioplasty) has led to an improving prognosis across a broad spectrum of patients with cardiogenic shock.     

Free-radical lipid peroxidation in acute myocardial infarction complicated by cardiogenic shock

The pattern of variation in primary and end products of erythrocyte lipid peroxidation (LPO) was examined in 131 patients with acute myocardial infarction. The levels of LPO products were found to be increased dramatically, the magnitude and duration of the increase being dependent on the severity of cardiogenic shock complicating myocardial infarction. The changes were particularly marked in true cardiogenic shock. The level of LPO products fell significantly on day 2-3 of myocardial infarction where it stabilized until the end of the study in patients with uncomplicated infarction treated with alpha-tocopherol acetate in addition to a symptomatic therapy. This pattern is attributed to an inhibitory effect this antioxidant may have on LPO.     

主动脉内球囊反搏在急性心肌梗死合并心源性休克中的应用

目的:探讨主动脉内球囊反搏(IABP)在急性心肌梗死(AMI)合并心源性休克中的应用价值。方法:收集88例AMI合并心源性休克患者的临床资料,其中50例行IABP,38例药物治疗,回顾性分析88例患者的治疗效果及安全性。结果:对于AMI并心源性休克患者,应用IABP后可改善血流动力学,使患者的收缩压、心率趋于稳定,左心室射血分数(LVEF)有明显改善,与非IABP组比较,差异有统计学意义(P<0.05);IABP组住院生存时间优于非IABP组(RR=0.402,95%CI:0.175~0.921,P=0.031)。肢体缺血与出血的发生率2组无统计学差异(P>0.05)。结论:对于AMI合并心源性休克的患者,行IABP辅助循环,可改善血流动力学,改善住院生存时间,且相对安全。     

Left main coronary artery stenting in a patient with acute myocardial infarction and cardiogenic shock

Acute total occlusion of left main coronary artery (LMCA) is rarely found in patients presenting with acute coronary syndromes. It is a grave condition with poor prognosis. We present a case of successful stenting of a LMCA lesion in a patient presenting with acute myocardial infarct and cardiogenic shock.     

急诊介入治疗对老年急性心肌梗死并心原性休克的疗效观察

目的探讨急诊冠状动脉介入治疗对老年急性心肌梗死(AMI)并心原性休克的近期及中期疗效.方法对20例平均年龄(71.4±6.4)岁的老年AMI患者的21支梗死相关动脉(IRA)的29处靶病变行急诊介入治疗.术前IRA平均狭窄(99.9±0.4)%,心肌梗死溶栓试验(TIMI)血流 0级15例,1～2级5例.对其中15处靶病变置入支架15枚.结果病例、IRA及靶病变的介入治疗成功率分别为95.0%、 95.2% 及96.6%,成功者94.7%恢复TIMI 血流3级.无因手术并发症及术中死亡发生者.平均开通时间(19.8±3.9)min,术后住院期间8例(40%)死亡.发病距治疗≤6h的10例全部存活,>6h者仅存活2例(P<0.01).对出院的12例患者随访7个月以上全部存活,无任何不良心脏事件发生.结论急诊介入治疗(尤其是急诊冠状动脉支架术)对高龄AMI并心原性休克高危患者有显著疗效,其主要优势为再通快、TIMI血流 3级率高、近期及中期病死率降低,发病≤6h者介入治疗疗效更为显著.     

主动脉内球囊反搏对急性心肌梗死合并心源性休克患者的疗效观察

目的探讨主动脉内球囊反搏（IABP）在急性心肌梗死（AMI）合并心源性休克患者中的应用价值。方法 2007年5月至2009年3月给予13例AMI合并心源性休克的患者急诊行IABP循环支持治疗,以同时期同一疾病未经IABP治疗的15例患者作为对照组进行比较,观察其循环复苏前后的基础心率、血压（收缩压、舒张压、平均动脉压）、心功能、尿量、多脏器衰竭、恶性心律失常、30d病死率等指标的变化。结果 2组间年龄、性别、院前时间、冠状动脉病变支数、再发心梗次数及IABP治疗前心功能分级（Killips分级）、收缩压、舒张压差异无统计学意义,而患者的心功能恢复情况、30d病死率、恶性心律失常发生率、多器官功能衰竭发生率、循环支持药物的应用等有显著性差异（P〈0.01）,IABP治疗组较对照组明显获益（P〈0.01）。与治疗前比较,IABP循环支持治疗后患者收缩压、舒张压、平均动脉压、心功能分级、尿量明显提高,心率明显下降（P〈0.01）。结论对AMI合并心源性休克患者尽早进行IABP治疗具有明显的循环支持疗效,可以为下一步的治疗争取时间并能明显减少并发症、降低病死率。     

Systemic inflammatory response syndrome after acute myocardial infarction complicated by cardiogenic shock

BACKGROUND: The role of inflammation in patients with coronary artery disease is emerging. We sought to assess the profile and outcomes of patients with a clinical syndrome of severe systemic inflammation that led to a diagnosis of suspected sepsis in the setting of acute myocardial infarction complicated by cardiogenic shock (CS). METHODS: Patients enrolled in the randomized SHOCK (SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK) trial (n = 302) were divided into those with clinical signs of severe systemic inflammation (eg, fever [94%] or leukocytosis [72%]) that led to a diagnosis of suspected sepsis (n = 54 [18%]) and those without suspected sepsis (controls; n = 243 [80%]). The patients with suspected sepsis were then further subdivided into those who were considered to be potentially infectious (positive culture result ["culture-positive"]; n = 40) and those who were not (negative culture result ["culture-negative"]; n = 14). RESULTS: Severe systemic inflammation was diagnosed 4 and 2 days after the onset of CS in culture-positive and culture-negative patients, respectively. Patients who developed systemic inflammation tended to be younger (P = .05) and to have lower systemic vascular resistance (SVR) near the onset of CS (P = .006). Many culture-positive patients (40%) had undergone coronary artery bypass graft surgery. However, the lower the initial SVR, the higher the risk of developing culture-positive systemic inflammation (P = .01), even after controlling for age and coronary artery bypass graft surgery. A time-dependent model, adjusted for age, showed that culture-positive patients were at significantly higher risk for death than were controls (hazard ratio, 2.22; 95% confidence interval, 1.32-3.76; P = .008). CONCLUSIONS: Almost one fifth of patients with acute myocardial infarction complicated by CS showed clinical signs of severe systemic inflammation, and those who were culture-positive for sepsis had twice the risk of death. The observation of lower SVR at the onset of shock in patients who subsequently had culture-positive systemic inflammation suggests that inappropriate vasodilation may play an important role in the pathogenesis and persistence of shock and in the risk of infection.     

冠状动脉内支架术治疗急性心肌梗死并发心源性休克的临床评价

目的　观察急性心肌梗死并发心源性休克的状态下 ,紧急冠状动脉内支架术对挽救患者生命的疗效及安全性。方法　急性前壁心肌梗死患者 15例 ,平均年龄 (70 1± 8 4)岁 ,动脉血压 <85 / 6 0mmHg(1mmHg=0 133kPa) ,心动超声检查射血分数 (EF) <42 % ,伴有明确的急性泵衰竭征象。患者发病 2 4h内紧急行左前降支冠状动脉支架术 ,其中 4例同时行右冠状动脉内支架术 ,3例行回旋支冠状动脉内支架术。介入治疗术前及术后观察血压、心率 ,应用心动超声测定心功能变化情况。结果　 15例患者支架术后完全阻塞的左前降支血管再通良好 ,术后 30min血压与术前比较明显升高[收缩压 (10 6 0± 11 8)vs (76 2± 4 9)mmHg ,P <0 0 1;舒张压 (82 4± 9 7)vs (5 6 2± 6 1)mmHg ,P<0 0 1];心率明显下降 [(79 2± 8 4)vs (10 9 2± 9 1)次 /分 ,P <0 0 1]。术后 4h ,心动超声测定心功能明显改善 [EF(48 8± 4 7) %vs (34 3± 4 5 ) % ,P <0 0 1]。结论　急性心肌梗死并发心源性休克状态时 ,尤其是年老患者 ,治疗的关键是尽早使完全阻塞的血管再通 ,而冠状动脉内支架术是十分有效和较安全的治疗方法。     

COVID-19 complicated by acute myocardial infarction with extensive thrombus burden and cardiogenic shock

A patient with coronavirus disease 19 (COVID-19) developed acute myocardial infarction (AMI) complicated by extensive coronary thrombosis and cardiogenic shock. She underwent percutaneous coronary intervention and placement of a mechanical circulatory support device but subsequently died from shock. This report illustrates the challenges in managing patients with COVID-19, AMI, and cardiogenic shock.     

Efficacy of reperfusion therapy in acute myocardial infarction complicated by cardiogenic shock]

Efficacy of reperfusion therapy was studied in 40 patients with acute myocardial infarction complicated with cardiogenic shock. Among them, 27 were treated with intracoronary thrombolysis (ICT) and/or coronary angioplasty (Group I), and 13 were untreated by reperfusion therapy (Group II). In Group I, reperfusion was successful in 17 (Group Ia). It was unsuccessful in the other 10 (Group Ib). Patients' characteristics such as age, sex, infarct location, previous myocardial infarction, peak creatine kinase, and the extent of coronary artery disease were similar in Groups Ia and Ib. The in-hospital survival rate was significantly higher in Group Ia (76.5% vs 40.0%, p < 0.01). There was no significant difference in the average hospital and CCU stays, total or maximal dosage of catecholamines (dopamine and dobutamine), and duration of IABP treatment of the discharged patients between Groups Ia and Ib. Cardiac index under pressure support (IABP, catecholamines, etc) in both Groups did not differ significantly. One patient in Group Ia had re-infarction. However, no patient in either group died during a mean follow-up period of 747 days. Among the surviving patients, 3 (23%) of Group Ia and all (100%) of Group Ib suffered from congestive heart failure. These findings suggested that reperfusion therapy improves the in-hospital survival rate in patients with cardiogenic shock. Therefore, reperfusion therapy may be recommended for cardiogenic shock secondary to acute myocardial infarction.     

Coronary stenting with cardiogenic shock due to acute ascending aortic dissection

A 65-year-old man developed chest pain under cardiogenic shock. Coronary angiography revealed severe stenosis from the ostium of the left main coronary artery(LMCA) to the left anterior descending artery(LAD). Intravascular ultrasound(IVUS) identified a large hematoma that originated from the aorta and extended into the LAD, thereby compressing the true lumen. Type A aortic dissection(TAAD) that involved the LMCA was diagnosed by IVUS. Coronary stenting was performed via the LMCA to the proximal LAD, which resulted in coronary blood flow restoration and no further propagation of dissection. Elective surgical aortic repair was performed 2 wk after the stenting. LMCA stenting under IVUS guidance is effective for prompt diagnosis and precise stent deployment in patients with cardiogenic shock due to TAAD with LMCA dissection.     

急诊经皮冠状动脉介入治疗老年急性心肌梗死合并心源性休克的临床观察

目的探讨急诊PCI对老年急性心肌梗死(AMI)合并心源性休克(CS)的近期和中期疗效,并分析患者院内存活率的影响因素。方法选择行PCI的老年AMI合并CS患者共86例,按治疗结果分为院内病死组(病死组,32例)和院内存活组(存活组,54例),采用logistic回归分析死亡的预测因素,统计患者的临床特点、影像学特点、介入治疗成功率、院内病死率及存活时间。结果病死组既往有心肌梗死患者高于存活组(43.8%vs24.1%,P=0.049),存活组发病至PCI时间明显低于病死组[(9.8±3.2)hvs(12.7±5.9)h,P=0.004];病死组梗死发生部位为前降支,发生率明显高于存活组(59.4%vs35.2%,P=0.025);Kaplan-Meier生存分析显示1年生存率为51.2%。logistic多元回归分析显示,发病至PCI时间及梗死相关动脉与院内病死率显著相关(P<0.05)。结论急诊PCI对老年AMI合并CS患者有较好的近期和中期疗效。     

Prenalterol in cardiogenic shock following acute myocardial infarction

Eleven patients with cardiogenic shock following acute myocardial infarction (AMI) have been treated with prenalterol. This drug was administered in seven patients once dobutamine or dopamine proved to be ineffective or poorly effective, and it was the first inotropic drug employed in four patients. Therapeutic dose of intravenous infusion ranged from 2.2 to 18 μg/kg/min (mean dose: 7 μg/kg/min), and was maintained for 2 to 4 hours. Since two patients received the infusion on two different occasions, a total of 13 cases were considered for statistical analysis. Prenalterol produced an increase in cardiac index (p < 0.01), mean aortic pressure (p < 0.02), net work index (p < 0.01), net/stroke work index (p < 0.01), pressure rate product (p < 0.05), and myocardial perfusion gradient (p < 0.02). It decreased systemic (p < 0.02) and pulmonary (p < 0.01) vascular resistances, pulmonary artery (p < 0.01) and pulmonary capillary (p < 0.05) pressures. Heart rate and right atrial pressure were not significantly changed. The drug acted as a relatively selective inotropic agent without a chronotropic effect and with minimal peripheral actions. It was effective in seven patients and ineffective in four patients. Thus prenalterol appears to be a useful drug in cardiogenic shock and further studies are warranted.