Echocardiographic and angiographic correlations in patients with cardiogenic shock secondary to acute myocardial infarction

In patients with cardiogenic shock (CS) complicating acute myocardial infarction, echocardiographic and angiographic findings are used to aid diagnosis, determine prognosis, and guide management. The purpose of this analysis from the Should we emergently revascularize Occluded Coronary arteries for Cardiogenic ShocK (SHOCK) trial is to identify relations between the angiographic and echocardiographic features of patients with CS. Such an analysis of the correlations between echocardiographic and angiographic findings in patients with CS may provide insights into the etiology and treatment of CS. In 302 randomized patients, an echocardiogram and an angiogram before revascularization were available in 127 patients. Although the median ejection fraction derived by echocardiography and left ventricular angiography was identical (30%), the positive correlation was weak (R2 = 0.209, p = 0.019). Patients with a larger number of diseased vessels had worse mitral regurgitation (MR) by echocardiography (p = 0.005). There was a significant but weak association between left ventricular angiographic MR grade and echocardiographic MR severity (R2 = 0.162, p = 0.015), but there was no association between culprit vessel and degree of MR. In conclusion, worse coronary artery disease is associated with more severe MR. Echocardiography and angiography are valuable and result in similar estimated ejection fractions in a large cohort, but there is wide variation between the techniques in patients.     

急性心肌梗死合并心原性休克患者的血运重建治疗

心源性休克是急性心肌梗死患者最严重的并发症。虽然已经有了多种药物治疗、综合的监护管理以及先进的器械辅助,但急性心肌梗死合并心源性休克患者依旧保持着较高的死亡率。多项研究表明,尽早进行血运重建治疗是目前唯一可以明显改善急性心肌梗死合并心源性休克患者预后的治疗措施。因此尽早进行血运重建治疗是急性心肌梗死合并心源性休克患者治疗中最重要的一环。该文综述了其研究进展。     

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.     

Diabetes mellitus and cardiogenic shock in acute myocardial infarction

AIMS: Cardiogenic shock is the leading cause of in-hospital mortality after acute myocardial infarction (MI). This study investigates the importance of age and preexisting diabetes mellitus on the incidence and prognosis of cardiogenic shock in a large group of consecutive patients with MI. METHODS AND RESULTS: Baseline characteristics and in-hospital complications to the infarction were prospectively recorded in 6676 patients with MI. Ten-year mortality was collected. Diabetes was present in 10.8% of the total population. A total of 443 developed cardiogenic shock with an incidence of 6.2% among nondiabetics and 10.6% among diabetics. Age, wall motion index, reinfarction, and the absence of thrombolytic treatment were significant independent predictors of mortality in patients with cardiogenic shock. Intriguingly, diabetes was not a significant predictor for short- and long-term mortality in this population. The 30-day and 5-year mortality rate was equally poor in both diabetic and nondiabetic patients with cardiogenic shock (diabetics: 30-day 63%, 5-year 91%; nondiabetics: 30-day 62%, 5-year 86%; p>0.05). CONCLUSIONS: Cardiogenic shock develops approximately twice as often among diabetics as among nondiabetic patients with acute MI. The prognosis of diabetics with cardiogenic shock is similar to the prognosis of nondiabetic patients with cardiogenic shock.     

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.     

Salbutamol in cardiogenic shock complicating acute myocardial infarction.

Intravenous salbutamol (13 microgram/min) has been given to 31 patients with cardiogenic shock complicating acute myocardial infarction. Haemodynamic measurements were made in nine of these patients. Salbutamol increased cardiac index by 41 per cent from 1.25 +/- 0.06 l/min per m2 to 1.76 +/- 0.19 l/min per m2 and decreased systemic vascular resistance by 16 per cent from 26.2 +/- 1.9 units to 21.9 +/- 2.1 units. Heart rate rose by 13 per cent from 95 +/- 4.5 beats/min to 106 +/- 6.0 beats/min. Pulmonary artery end-diastolic pressure fell from 20.6 +/- 1.7 mmHg to 16.9+/- 1.9 mmHg. Of the 31 patients, eight survived to leave hospital (27%). Five of the survivors had initial low heart rates and in these patients the clinical improvement was probably attributable to the positive chronotropic action of salbutamol. In the remaining three survivors clinical improvement was probably a result of salbutamol mediated afterload reduction. Salbutamol may be useful in the treatment of cardiogenic shock and pump failure complicating acute myocardial infarction.     

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.     

Coronary stenting in acute myocardial infarction complicated with cardiogenic shock

AIM: To assess immediate and long-term results of urgent coronary stenting in patients with cardiogenic shock. MATERIAL AND METHODS: Twenty three patients (15 men, 8 women mean age 58-/+12 years) with myocardial infarction and cardiogenic shock treated with vasopressors and intraaortic balloon pumping (IABP). Culprit lesions were localized in left anterior descending and right coronary arteries in 16 and 7 cases, respectively. Prior to stenting 18 and 5 patients had TIMI grade 0 and 1 flow, respectively. RESULTS: Stents (n=26, Seaquence and Ephesos, length 12-28 mm, diameter 2-3.5 mm) were successfully implanted in all patients after balloon predilation. After stenting TIMI grade 3 flow was achieved in 15 patients, 8 patients had TIMI-2 flow without angiographic signs of dissection or residual stenosis. There were 4 inhospital deaths and 19 patients (83%) were discharged. One angioplasty and 2 coronary artery bypass grafting procedures because of restenosis and reocclusion were successfully performed during first 4 months of follow-up. CONCLUSION: Urgent stenting combined with IABP was effective method of treatment of cardiogenic shock with 83% inhospital survival and 61% freedom from repeat revascularization.     

Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock

OBJECTIVES: We sought to determine whether or not inhaled nitric oxide (NO) could improve hemodynamic function in patients with right ventricular myocardial infarction (RVMI) and cardiogenic shock (CS). BACKGROUND: Inhaled NO is a selective pulmonary vasodilator that can decrease right ventricular afterload. METHODS: Thirteen patients (7 males and 6 females, age 65 +/- 3 years) presenting with electrocardiographic, echocardiographic, and hemodynamic evidence of acute inferior myocardial infarction associated with RVMI and CS were studied. After administration of supplemental oxygen (inspired oxygen fraction [F(i)O(2)] = 1.0), hemodynamic measurements were recorded before, during inhalation of NO (80 ppm at F(i)O(2) = 0.90) for 10 min, and 10 min after NO inhalation was discontinued (F(i)O(2) = 1.0). RESULTS: Breathing NO decreased the mean right atrial pressure by 12 +/- 3%, mean pulmonary arterial pressure by 13 +/- 2%, and pulmonary vascular resistance by 36 +/- 8% (all p < 0.05). Nitric oxide inhalation increased the cardiac index by 24 +/- 11% and the stroke volume index by 23 +/- 12% (p < 0.05). The NO administration did not change systemic arterial or pulmonary capillary wedge pressures. Contrast echocardiography identified three patients with a patent foramen ovale and right-to-left shunt flow while breathing at F(i)O(2) = 1.0. Breathing NO decreased shunt flow by 56 +/- 5% (p < 0.05) and was associated with markedly improved systemic oxygen saturation. CONCLUSIONS: Nitric oxide inhalation results in acute hemodynamic improvement when administered to patients with RVMI and CS.     

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.     

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。     

Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital mortality.     

Contemporary device management of cardiogenic shock following acute myocardial infarction

Heart Failure Reviews - Despite advances in the overall management of acute myocardial infarction (AMI), cardiogenic shock in the setting of AMI (CS-AMI) continues to be associated with poor...