Management of cardiogenic shock complicating acute myocardial infarction: A review

Despite advances in percutaneous coronary interventions and their widespread use, mortality in patients presenting with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) has remained very high, and treatment options are limited. Limited evidences exist, supporting many of the routinely used therapies in treating these patients. In the present article, we discuss CS complicating MI in general and an update on the currently available treatment options, including inotropes and vasopressor, coronary revascularization, mechanical circulatory support devices, mechanical complications, and long‐term outcomes.     

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.     

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。     

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。     

早期发生急性肾衰竭与急性心肌梗死后心源性休克患者预后的关系

目的了解急性心肌梗死后心源性休克患者早期发生急性肾衰竭与其预后的关系.方法回顾性分析解放军总医院1993～2003年间,因急性心肌梗死或冠心病心绞痛住院,并出现心源性休克的病例,以24h内是否出现急性肾衰竭为标准,比较其住院期间死亡率,并采用多元Logistic回归分析,评估早期发生急性肾衰竭对患者预后的影响.结果符合统计分析标准的患者共172例,其中51例(30%)于24h内出现急性肾衰竭.有无早期发生急性肾衰竭的患者,其住院死亡率分别为90%(46/51)和56%(68/121).逐步回归分析表明,早期发生急性肾衰竭是影响急性心肌梗死后心源性休克患者预后的独立因素(OR=6.7,95%可信限2.5～18;P＜0.001).结论急性心肌梗死后心源性休克患者,早期发生急性肾衰竭,与其住院死亡率显著相关,可作为判断患者不良预后的指标.     

Primary cardiogenic shock during acute myocardial infarction: results of emergency cardiac transplantation

Fifteen patients with acute myocardial infarction and cardiogenicshock underwent emergency cardiac transplantation after medicaltreatment failed to improve their haemodynamic status. Theirmean age was 49 ± 7 years. The infarction was anteriorin 12 cases, inferoposterior in two cases, and septal in one.Shock occurred within 3 days after the onset of chest pain innine patients, and during the first day in six of them. Mechanicalcirculatory assistance was used in six patients as a bridgeto transplantation when their haemodynamic status could notbe stabilized pharmacologically. Orthotopic cardiac transplantationwas performed an average of 15.6 ± 14 days after onsetof infarction. Three patients died during the early post-operativeperiod. Another died 7 months after transplantation. Duringthe mean follow-up period of 30.6 ± 20.3 months, therewere three acute rejections, all successfully treated, and onechronic rejection. The survival rate for this series is 70%.Thus, emergency cardiac transplantation may be the best optionfor selected patients with acute myocardial infarction and cardiogenicshock refractory to conventional therapy.     

Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction-a single centre experience

BackgroundMortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 – 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS.MethodsForty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival.ResultsThere were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12–72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status.ConclusionMortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.     

Intra-aortic balloon counterpulsation improves survival in cardiogenic shock complicating acute myocardial infarction

The impact of intra-aortic balloon counterpulsation (IABC) onsurvival of patients with acute myocardial infarction (AMI)complicated by cardiogenic shock (CS) has been evaluated inthis study of 85 patients. IABC was available for the 24 groupA patients (and used in 20 patients). IABC was not availablefor the 21 group B patients who presented simultaneously withsimilar clinical characteristics and received identical pharmacologicaltreatment. In-hospital and one year survival was significantlyhigher in group A (46% and 38% vs 19% and 10%, P <0·001).Sixteen out of the 20 (group Al) IABC patients received earlycoronary revascularization. During 1980–1984, 35 patients with AMI and CS receivedIABC (group C) but none underwent early revascularization. Therewas no difference in in-hospital or one-year survival betweengroup AI (50% and 40%) and group C (45% and 40%). We concludethat early IABC improves survival of patients with AMI complicatedby CS.     

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.     

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

OBJECTIVE—To 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.
METHODS—Patients 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).
RESULTS—Of 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 < 0.001), angioplasty (21% v 4%, p = 0.002), and intra-aortic balloon counterpulsation (28% v 4%, p < 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).
CONCLUSIONS—The 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.


Keywords: percutaneous transluminal coronary angioplasty; heart failure; myocardial infarction; cardiogenic shock     

A risk-predictive score for cardiogenic shock after acute myocardial infarction in Chinese patients

BACKGROUND: Cardiogenic shock after acute myocardial infarction (AMI) remains a poor prognosis. Although numerous studies discussed the predictors of cardiogenic shock complicating AMI, the data in Chinese patients is still absent. The goal of this study is to develop a risk-predictive score for cardiogenic shock after AMI, among Chinese patients, so as to guide clinicians to prevent cardiogenic shock. METHODS: Patients with ST-segment elevated AMI were provided by two Chinese hospitals from 1994 to 2004. Baseline characteristics of each case were documented. Multivariable logistic regression modeling techniques were used to develop a model to predict the occurrence of cardiogenic shock within 72 h after admission. On the basis of the coefficients in the model, a risk score was developed for the probability of cardiogenic shock. To test its viability, another population, which was consistent with the original population, confirmed the scoring. RESULTS: Among 2,077 patients, 184 cases developed cardiogenic shock within 72 h. Age, gender, BMI, killip class, MI location, multivessel disease, previous MI, family history of CAD, and thrombolytic therapy were strong predictors for shock after AMI. A risk-predictive score for shock was developed. It predicted cardiogenic shock accurately in another Chinese population. CONCLUSIONS: A predictive model is developed in Chinese patients with AMI for the first time. It is based on some simple parameters, which can be easily obtained by clinicians. The risk score derived from the model can predict cardiogenic shock accurately.     

Echocardiographic findings in cardiogenic shock due to right ventricular myocardial infarction

The echocardiographic findings in a patient with cardiogenic shock secondary to acute right ventricular myocardial infarction based on typical clinical, electrocardiographic, and hemodynamic features are described. The echocardiogram demonstrated a large RV/LV minor axis ratio caused by a volume overload of the right ventricle and an underfilled left ventricle. The interventricular septum showed abnormal movement, presumably due to right ventricular overload or severe disease of the left anterior descending coronary artery. Diminished septal systolic thickening, as seen in our patient, may be explained by extension of the infarct from the right ventricle to the adjacent part of the septum. Predominant right ventricular involvement can be a cause for a correctable hypotension in patients with acute myocardial infarction and should therefore be recognized early. The echocardiographic picture demonstrated in our patient, when considered in conjunction with the clinical status, can be useful for early diagnosis.     

脉搏指数连续心输出量监测在急性心肌梗死合并心源性休克患者中的应用

目的探讨脉搏指数连续心输出量监测(PICCO)在急性心肌梗死(AMI)合并心源性休克(CS)患者中的应用价值。方法入选2012年1月至2013年1月因AMI合并心源性休克(CS)入住南京鼓楼医院集团宿迁市人民医院心血管内科重症监护病房(CCU)患者56例。其中男性35例,女性21例,年龄28~75岁,平均(56.5±2.3)岁。随机分成PICCO组(27例)及对照组(29例)。对照组入CCU后立即监测血压,心率,呼吸次数,血氧饱和度及心电图,记录体温变化,深静脉穿刺监测中心静脉压(CVP)。PICCO组在此基础上,进行深静脉置管+股动脉置管+PICCO模块连接。监测心脏指数(CI),血管外肺水指数(EVLWI)及血清N-末端脑钠肽前体(NT-pro BNP)变化情况。结果与PICCO治疗24 h比较,治疗48 h EVLWI[(8.85±0.73)ml/kg vs.(7.41±1.36)ml/kg]下降,CI[(2.21±0.45)L/min·m2 vs.(2.60±0.17)L/min·m2]增加,NT-pro BNP[(4069.48±65.32)pg/ml vs.(3721±20.32)pg/ml]下降,差异具有统计学意义(P0.05)。随着时间延长,EVLWI下降,CI增加,NT-pro BNP呈降低的趋势。同时,EVLWI与NT-pro BNP呈直线正相关(r=0.78,P0.05)。PICCO组患者血管活性药物使用时间,入住CCU时间,机械通气时间,病死率以及出院时血清NT-pro BNP水平明显低于对照组,差异有统计学意义(P均0.05)。结论 PICCO对于AMI合并CS患者的治疗具有重要价值。     

An early revascularization strategy is associated with a survival benefit for diabetic patients in cardiogenic shock after acute myocardial infarction

BACKGROUND: The role of diabetes mellitus (DM) in cardiogenic shock (CS) complicating an acute myocardial infarction (AMI) is not well understood. Previous studies have reported an in-hospital mortality rate for patients with DM and CS of about 60%. OBJECTIVES: This study compares the 1-year mortality rates of patients with DM and those without (NDM) and evaluates early revascularization (ERV) compared with initial medical stabilization (IMS) in patients with DM and CS. Methods: Baseline characteristics, clinical and hemodynamic measures, and management were compared for 90 patients (31%) with DM and 198 with NDM (69%) who were randomized to ERV or IMS in the SHOCK Trial. RESULTS: When compared with NDM, patients with DM were of similar age but had higher rates of prior MI (44.4 vs. 27.8%, p = 0.007) and hypertension (56.2 vs. 42.5%, p = 0.04). The DM group had a lower rate of fibrinolytic therapy (44.4 vs. 60.1%, p = 0.02). In patients randomized to ERV, patients with DM had a higher rate of coronary artery bypass grafting (CABG) (50.0 vs. 30.9%, p = 0.03) despite similar rates of triple-vessel disease. The 1-year mortality rates in both groups were equivalent (58.9%). One-year mortality was not associated with diabetes (hazard ratio [HR] 1.02, 95% CI, 0.73-1.42, p = 0.91). The benefit of an ERV strategy was similar (HR [DM] 0.62; HR [NDM] 0.75, p = 0.58). Even after adjusting for the imbalance in CABG rates, 1-year mortality was not associated with DM. CONCLUSION: Diabetes mellitus is not a predictor of 1-year mortality in CS after AMI. The benefit from an ERV strategy is similar for DM and NDM. The management strategies and influence of DM on mortality in CS deserve further evaluation.     

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty

BACKGROUND: Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines. AIM: To evaluate the in‐hospital and 30‐day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS. METHODS AND RESULTS: Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co‐morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In‐hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non‐cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48?hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age ?75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0–1.24, P = 0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95–1.0, P = 0.05), were independent predictors of all cause mortality at 30 days. CONCLUSION: Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.     

Cardiogenic shock complicating acute myocardial infarction in the elderly: predictors of long-term survival

Background: Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI), associated with a high mortality. A significant improvement in survival has been reported with immediate coronary revascularization. However, there is no clear evidence of such an improvement amongst older patients. The aim of our work was to evaluate in‐hospital and long‐term outcomes in the group of elderly AMI patients with CS (≥75 years old). Methods: We collected data of 157 consecutive AMI patients with CS who underwent percutaneous coronary intervention (PCI) and compared clinical and procedural characteristics and in‐hospital and long‐term outcomes between patients <75 years and patients ≥75 years old. Results: There were 58 patients (36.9%) with age ≥75 years and 99 patients (63.1%) with age <75 years. Patients were followed up for an average period of 34 months (range 5–69). In‐hospital and long‐term mortality was significantly higher in the older group (55 vs. 25%, P < 0.0001; and 62.1 vs. 37.3%, P = 0.005, respectively). Multivariate predictors of in‐hospital mortality were age ≥75 years (hazard ratio 1.81, 95% CI 1.006–3.27, P = 0.04) and PCI failure (hazard ratio 2.67, 95% CI 1.34–5.307, P = 0.005), whereas, the only multivariate predictor of long‐term mortality was PCI failure (hazard ratio 2.88, 95% CI 1.52–5.46, P = 0.001). Age ≥75 years showed only a trend toward statistical significance (hazard ratio 1.62, 95% CI 0.96–2.76, P = 0.07). Conclusions: In elderly AMI patients with CS, PCI can be performed with an acceptable risk that seems lower than that reported in most previous studies. © 2010 Wiley‐Liss, Inc.     

急性心肌梗死合并心原性休克47例治疗和死亡原因分析

目的 评价急性心肌梗死合并心原性休克47例患者的临床疗效,寻求降低病死率、改善预后的措施.方法 回顾性分析2002年1月至2007年5月共47例心肌梗死合并心原性休克患者,运用心血管活性药物、主动脉内球囊反搏(IABP)、介入手术或冠状动脉旁路移植术的治疗效果.结果 IABP治疗47例(100%),再血管化治疗41例(87.3%),死亡17例(36.2%).经药物和IABP治疗,在接受再血管化前死亡的患者占死亡数的35.3%(6/17),再血管化后死亡的患者占死亡数的64.7%(11/17).死于心功能衰竭者9例,死于肾功能衰竭和呼吸功能衰竭者8例.11例出现急性肾功能衰竭的患者全部死亡.急性肾功能衰竭(r=0.734,P=0.000)、急性呼吸功能衰竭(r=0.606,P=0.000)和糖尿病(r=0.372,P=0.012)与死亡有相关关系.结论 尽管急性心肌梗死合并心原性休克的治疗有了很大的发展,但病死率仍然较高,主要死因是急性心力衰竭、急性肾功能衰竭和急性呼吸功能衰竭.要进一步降低急性心肌梗死合并心原性休克患者住院病死率,可能需要更好的循环辅助装置及加强重要器官的保护.     

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。