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.     

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。     

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.     

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.     

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。     

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.     

Elevated random glucose levels at admission are associated with all-cause mortality and cardiogenic shock during hospitalisation in patients with acute myocardial infarction and without diabetes: A retrospective cohort study

Background

Elevated glucose levels at admission are associated with a worse prognosis in patients with acute myocardial infarction (AMI); additionally, such elevation has a higher prognostic value for patients without diabetes.

Methods

We retrospectively recruited 2412 AMI patients without diabetes from 1 August 2011 to 10 January 2022. The primary outcome was all-cause mortality during hospitalisation, and the secondary outcomes were cardiogenic shock, ventricular tachycardia, ventricular fibrillation, atrioventricular block and new stroke.

Results

The mean age of participants was 65 years and 78.6% were male. Of the 2412 patients, all-cause mortality occurred in 236 patients (9.8%) during hospitalisation. In multivariate-adjusted models that corrected for variable weights, the risk of all-cause mortality increased with an increase in random glucose levels at admission; specifically, the risk of all-cause mortality increased per 1 mg/dL (odds ratio [OR] 1.006, 95% confidence interval [CI]: 1.004–1.008), per 9 mg/dL (OR: 1.06, 95% CI: 1.04–1.08), and per 18 mg/dL (OR: 1.12, 95% CI: 1.07–1.16) increases in admission glucose levels. When admission glucose levels were expressed as a categorical variable, increased levels of glucose (relative to the reference glucose value <140 mg/dL) led to an increased risk of all-cause mortality; specifically, the OR of all-cause mortality for 140–200 mg/dL glucose was 1.55 (95% CI: 1.09–2.17) and the OR for glucose >200 mg/dL was 3.08 (95% CI: 2.00–4.62) (P for trend <0.001). The risk of cardiogenic shock also increased with glucose levels with an OR of 1.68 (95% CI: 1.21–2.31) for 140–200 mg/dL glucose and an OR of 3.72 (95% CI: 2.50–5.46) for >200 mg/dL, compared with that of glucose <140 mg/dL. In multivariate-adjusted spline regression models, an increased risk of all-cause mortality was observed in patients with glucose ≥122 mg/dL (OR: 1.81, 95% CI: 1.38–2.38, p < 0.001) compared with the reference cohort. Furthermore, patients with glucose ≥111 mg/dL (OR: 2.36, 95% CI: 1.80–3.12) had a higher risk of cardiogenic shock than patients with glucose <111 mg/dL.

Conclusions

Patients with AMI and without diabetes who had elevated random glucose levels at admission had a higher risk of all-cause mortality and cardiogenic shock during hospitalisation. In particular, patients with glucose ≥122 mg/dL had an increased risk of all-cause mortality, and those with glucose ≥111 mg/dL had an increased risk of cardiogenic shock.     

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.     

急性心肌梗死并发心源性休克的住院死亡率危险因素分析

目的探讨急性心肌梗死并发心源性休克患者住院死亡率的危险因素,为临床识别高危患者提供依据。方法回顾性分析89例急性心肌梗死合并心源性休克的患者资料,应用单变量及多变量logistic回归分析其基线特征因素和治疗因素与住院死亡率的关系。结果急性心肌梗死并发心源性休克患者的住院死亡率为51.7％（46例）。其中病死组平均年龄[（74.1±10.1）岁]高于非病死组平均年龄[（66.8±11.4）岁],急诊PCI比例[10例（21.7%）]低于非病死组[26例（60.5%）],差异均有统计学意义（均P＜0.05）。多因素logistic回归分析显示年龄（OR=2.109,95％CI：1.29～3.44）、持续性室性心动过速/心室颤动（OR=4.831,95％CI：1.05～22.26）及急诊冠状动脉血运重建（OR=0.171,95％CI：0.06～0.48）与住院死亡率显著相关（均P＜0.05）。结论高龄、持续性室性心动过速/心室颤动是急性心肌梗死合并心源性休克患者住院死亡率增加的危险因素,而急诊冠状动脉血运重建则是保护性因素。     

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.     

Effect of early revascularisation in cardiogenic shock complicating acute myocardial infarction. A single center experience

BACKGROUND: Five to 10% of patients with acute myocardial infarction develop cardiogenic shock and the majority of these patients are expected to die within the first few weeks. In this study, we review our recent experience in the management of patients with cardiogenic shock complicating MI and examine the effect of early invasive revascularisation on mortality. METHODS: Thirty-six consecutive patients who developed cardiogenic shock less than 48 h after MI were retrospectively evaluated and divided into two treatment groups. One group received early invasive revascularisation (n=24) and the other group had no early invasive revascularisation, but received similar conventional intensive care medical treatment (n=12). RESULTS: Baseline characteristics and hemodynamic variables were similar in both groups. Apart from invasive revascularisation and the use of intra aortic balloon counterpulsation (IABP), treatment strategies did not differ between the two groups. Thirty-day mortality was 21% in the revascularised group of patients and 58% in the non-revascularised group (P<0.05). CONCLUSIONS: Our data support previous observations suggesting that an aggressive treatment strategy including early invasive revascularisation and IABP is associated with improved short and long-term survival in patients with cardiogenic shock. Since early revascularisation appears safe with a considerable treatment benefit, this approach must be considered in patients with short shock duration early after MI.     

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.     

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。     

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.     

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.     

Impella 2.5 initiated prior to unprotected left main PCI in acute myocardial infarction complicated by cardiogenic shock improves early survival

Objectives

To assess post‐procedural outcomes when Impella 2.5 percutaneous left ventricular assist device (pLVAD) support is initiated either prior to or after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULMCA) culprit lesion in the context of acute myocardial infarction cardiogenic shock (AMICS).

Background

Initiation of Impella 2.5 pLVAD prior to PCI is associated with significant survival benefit in the setting of AMICS. Outcomes of those presenting with a ULMCA culprit lesion in this setting have not been well characterized.

Methods

Thirty‐six consecutive patients in the cVAD Registry supported with Impella 2.5 pLVAD for AMICS who underwent PCI on ULMCA culprit lesion were included in our multicenter study.

Results

The average age was 69.8 ± 14.2 years, 77.8% were male, 72.7% were in CS at admission, 44.4% sustained one or multiple cardiac arrests, and 30.6% had anoxic brain injury. Baseline characteristics were comparable between the Pre‐PCI group (n = 20) and Post‐PCI group (n = 16). Non‐ST segment elevation myocardial infarction and greater coronary disease burden were significantly more frequent in the Pre‐PCI group but they had significantly better survival to discharge (55.0% vs 18.8%, P = 0.041). Kaplan‐Meier 30‐day survival analysis showed very poor survival in Post‐PCI group (48.1% vs 12.5%, Log‐Rank P = 0.004).

Conclusions

Initiation of Impella 2.5 pLVAD prior to as compared with after PCI of ULMCA for AMICS culprit lesion is associated with significant early survival. As previously described, patients supported after PCI appear to have very poor survival at 30 days.

     

The ability to achieve complete revascularization is associated with improved in‐hospital survival in cardiogenic shock due to myocardial infarction: Manitoba cardiogenic shock registry investigators

Objectives: To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort. Background: Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization. Methods: A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in‐hospital survival were identified utilizing logistic regression. Results: ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09–0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002–1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04–11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73–39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1–6.2)) and peak lactate (P = 0.02). Conclusions: The ability to achieve complete revascularization may be strongly associated with improved in‐hospital survival in patients with cardiogenic shock. © 2011 Wiley‐Liss, Inc.     

体外膜肺氧合在急性心肌梗死合并重症心源性休克治疗中的应用

目的:总结体外膜肺氧合(ECMO)对急性心肌梗死(AMI)合并心源性休克(CS)患者进行支持治疗的结果。方法:2009年8月到2013年3月,我院对5例AMI合并CS的患者进行了ECMO辅助支持治疗。回顾分析这5例患者的临床资料,包括基本情况,辅助原因,辅助时间及预后。结果:5例患者中男性4例,女性1例。平均辅助时间(121.2±40.6)h,全部脱机,4例存活出院。结论:ECMO可以为AMI合并CS的患者提供有效的支持治疗。