急性心肌梗死合并心源性休克的血运重建策略

尽管早期血运重建的广泛开展,急性心肌梗死合并心源性休克仍是治疗的重点和难点。另外,急性心肌梗死伴心源性休克患者往往合并多支血管病变,其最佳血运重建策略尚无定论。本文就心源性休克定义及病因,急性心肌梗死合并心源性休克早期血运重建的重要性及血运重建策略选择方面做一综述。     

Identifying cardiogenic shock in the emergency department

IntroductionCardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early.ObjectiveThis review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician.DiscussionThe most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound.ConclusionsThe emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.     

Management of cardiogenic shock attributable to acute myocardial infarction in the reperfusion era

Cardiogenic shock is the leading cause of death among patients hospitalized with acute myocardial infarction. It is defined as tissue hypoperfusion resulting from ventricular pump failure in the presence of adequate intravascular volume. Rapid assessment and triage of patients presenting in cardiogenic shock followed by appropriate institution of supportive therapies including vasopressor and inotropic agents, mechanical ventilatory support, and intra-aortic balloon pump counterpulsation are critical for effective management of these patients. However, emergency percutaneous coronary intervention or coronary artery bypass graft surgery is required to decrease mortality rates. Novel approaches, including inhibition of nitric oxide synthase and new mechanical support devices, may further decrease mortality rates, which remain high despite reperfusion therapy.     

Plasma concentrations of interleukin-6, organ failure, vasopressor support, and successful coronary revascularization in predicting 30-day mortality of patients with cardiogenic shock complicating acute myocardial infarction

OBJECTIVE: Inflammation may play an important role in the pathogenesis, persistence, and prognosis of cardiogenic shock. We analyzed whether elevated plasma concentrations of inflammatory markers are independently associated with an adverse prognosis (increased 30-day mortality rate) in patients with cardiogenic shock. DESIGN: Retrospective study. SETTING: Single-center study, eight-bed intensive care unit at a university hospital. PATIENTS: Retrospective study on stored plasma samples from 38 patients with cardiogenic shock complicating acute myocardial infarction. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-day nonsurvivors (n = 23, 61%) had been less frequently successfully revascularized, exhibited more frequently renal failure, needed higher vasopressor doses, and presented with significantly higher interleukin-6 plasma concentrations on intensive care unit admission than 30-day survivors. Univariate hazard ratios (95% confidence interval) for 30-day mortality were 1.49 (1.24-1.80) for every 50 pg/mL increase in the interleukin-6 plasma concentration (p = .00003), 1.06 (1.02-1.10) for every 0.1 microg x kg x min increase in the total vasopressor dose (p = .007), 1.14 (1.04-1.25) for every mmol/L increase in serum lactate (p = .006), 2.47 (1.06-5.73) for acute renal failure (p = .036), and 0.34 (0.14-0.82) for successful revascularization (p = .016). However, interleukin-6 plasma concentrations were correlated with vasopressor need and were significantly higher in patients with acute renal failure and in patients without or unsuccessful revascularization. In a multivariate Cox-proportional hazard model, interleukin-6 was the only significant predictor of 30-day mortality with a hazard ratio of 1.42 (1.12-1.80, p = .004). Accordingly, interleukin-6 concentrations > or =200 pg/mL (the point of maximum interest by receiver operating characteristic analysis with a specificity of 87% and a sensitivity of 74%) were associated with a significantly increased 30-day mortality rate in both patients with and patients without successful revascularization. CONCLUSIONS: Interleukin-6 concentrations are an independent predictor of 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock.     

Clinical review: mechanical circulatory support for cardiogenic shock complicating acute myocardial infarction

Acute myocardial infarction is one of the 10 leading reasons for admission to adult critical care units. In-hospital mortality for this condition has remained static in recent years, and this is related primarily to the development of cardiogenic shock. Recent advances in reperfusion therapies have had little impact on the mortality of cardiogenic shock. This may be attributable to the underutilization of life support technology that may assist or completely supplant the patient's own cardiac output until adequate myocardial recovery is established or long-term therapy can be initiated. Clinicians working in the intensive care environment are increasingly likely to be exposed to these technologies. The purpose of this review is to outline the various techniques of mechanical circulatory support and discuss the latest evidence for their use in cardiogenic shock complicating acute myocardial infarction.     

Cardiogenic shock complicating myocardial infarction

Cardiogenic shock is the primary cause of death among patients hospitalized with acute myocardial infarction. It is defined as tissue hypoperfusion resulting from ventricular pump failure in the presence of adequate intravascular volume. These patients need rapid assessment and appropriate institution of supportive therapies including vasopressor and inotropic agents, ventilatory support, and intra-aortic balloon pump counterpulsation. Emergency coronary artery revascularization is the only therapy that reduces mortality, and this should be provided early to patients to achieve maximal benefit, unless further care is deemed futile. Whereas newer support devices can provide better hemodynamic augmentation, their impact on mortality is limited. Novel therapies are needed to further decrease mortality rates, which remain high despite reperfusion therapy.     

Mechanical and electrical complications of acute myocardial infarction

Although much of the current enthusiasm in the management of acute myocardial infarction is related to revascularization strategies, mechanical and electrical complications continue to pose a major threat to recovery in some patients. Some of the major complications of acute myocardial infarction are cardiogenic shock, rupture of the free wall and pseudoaneurysm, rupture of the ventricular septum, acute mitral regurgitation, right ventricular myocardial infarction, infarct expansion or extension, pericarditis and tamponade, peri-infarction hypertension, and tachyarrhythmias and bradyarrhythmias. For each of these complications, general guidelines for diagnosis and management are offered. Early, aggressive, and judicious treatment of these complications may substantially decrease the morbidity and mortality associated with acute myocardial infarction.     

主动脉内球囊反搏在急性心肌梗死并发心源性休克中的应用

目的　评价主动脉内球囊反搏 (IABP)对急性心肌梗死合并心源性休克患者在不同血管再通治疗中的疗效和短期生存的影响。方法　回顾性分析了 10 8例接受IABP治疗的急性心肌梗死合并心源性休克患者 ,分别分析了溶栓治疗组、介入治疗组和冠脉搭桥 (CABG)手术治疗组患者的基本特征和血流动力学情况 ,并比较IABP治疗对住院病死率和 30d病死率的影响。结果　患者的基本特征包括年龄、冠心病的危险因子等在各组间差异无显著性意义 (P >0 0 5 ) ,但手术治疗组的男性患者显著少于其它两组 (P <0 0 5 ) ;IABP治疗前血流动力学状态各组间也无显著性意义 ,住院病死率和 30d病死率手术治疗组均显著低于溶栓组和介入组 ,分别为 18 9%、 6 2 8%和 6 0 7% ,16 2 %、 6 0 5 %和 6 0 7% ,P值均 <0 0 0 1。结论　IABP支持下进行CABG治疗可显著减低心肌梗死合并心源性休克患者的近期死亡率 ,且显著优于溶栓治疗和介入治疗     

床边紧急置入主动脉内球囊反搏治疗心源性休克的围术期护理

目的总结床边紧急置入主动脉内球囊反搏（IABP）辅助治疗急性心肌梗死合并心源性休克的围术期护理。方法对15例急性心肌梗死合并心源性休克患者床边置入IABP的围术期护理要点进行总结,包括术前准备,术中配合,术后生命体征、尿量、心电图、球囊导管、反搏压力、并发症等的监测。结果患者在应用IABP辅助治疗后,血流动力学趋于稳定,表现为心率减慢,舒张压、平均动脉压、尿量明显增加,血管活性药物剂量明显减少（P〈0.01）;住院期间存活11例,死亡4例。结论对于急性心肌梗死合并心源性休克早期床旁应用IABP的患者,积极的术中配合和有效的术后监护能为冠脉血运重建提供稳定的血流动力学支持,提高救治成功率。     

主动脉球囊反搏术后应用呼吸机辅助治疗急性心肌梗死合并心源性休克患者的护理

目的:探讨主动脉球囊反搏术后应用呼吸机辅助治疗急性心肌梗死合并心源性休克患者的效果及护理方法。方法:回顾分析我院21例急性心肌梗死合并心源性休克患者主动脉球囊反搏术后应用呼吸机辅助治疗的护理措施。结果:急性心肌梗死合并心源性休克患者经过积极的抢救治疗,16例患者好转出院,3例患者抢救无效死亡,2例患者家属签字放弃抢救,自动出院。救治成功率为76.19%。结论:急性心肌梗死患者应用主动脉球囊反搏治疗具有良好的近期疗效,及时使用呼吸机辅助治疗,给予积极有效的预防治疗护理措施,能降低死亡率,提高救治成功率,促进患者康复。     

Acute myocardial infarction. Treatment in the coronary care unit

Management of the patient with acute myocardial infarction is in flux. In the current "reperfusion era," many patients receive intravenous thrombolytic therapy and aspirin before admission to the coronary care unit. Appropriate use of drugs limits expansion of the infarct and reduces mortality rates in patients with uncomplicated myocardial infarction. Percutaneous transluminal coronary angioplasty may be necessary in those who are not candidates for drug treatment or who show recurrent ischemia after thrombolysis, while cardiac transplantation may be the only hope for patients with multivessel disease who are in cardiogenic shock. The "cocktail era," in which polypharmacy is both acceptable and effective, will likely be the next stage in management of acute myocardial infarction.     

IABP在急性心肌梗死并心源性休克救治中应用现状

急性心肌梗死作为临床上常见的疾病,起病急,易引起并发症,其中,心源性休克死亡率较高。临床上常规应用补液、扩血管、升压及溶栓、血管重建等。近年来,IABP被广泛应用于临床,它作为一种辅助装置可以增加血液灌流,降低心脏后负荷,降低心脏做功,从而快速改善循环灌注不足状态。本综述研究IABP作为血流动力辅助装置,应用于急性心肌梗死并发心源性休克患者的临床现状。     

Inflammation and cardiovascular diseases: lessons that can be learned for the patient with cardiogenic shock in the intensive care unit

PURPOSE OF REVIEW: In the past 12 years, atherosclerosis and the acute coronary syndromes have turned out to be thromboinflammatory diseases. Recent data suggest that inflammation also plays an important role in the pathogenesis and outcome of cardiogenic shock. This review will summarize recent advances in the understanding of the pathophysiology of cardiogenic shock related to the inflammatory network and will discuss recent findings in the treatment of patients with cardiogenic shock in relation to these new insights. RECENT FINDINGS: The glycoprotein IIb/IIIa antagonist abciximab has recently been found to be especially useful in the treatment of patients with cardiogenic shock undergoing coronary revascularization with stent implantation, reducing mortality in retrospective analyses from 40 to 50% down to 18 to 26%. Although it remains to be proved whether this is really due to their antiinflammatory effects, other drugs with clear antiinflammatory properties, like the nitric oxide synthase inhibitors L-NAME/L-NMMA, have recently been tested in small series of patients with refractory shock despite coronary revascularization based on the hypothesis that inflammation and impaired vasoreactivity are crucial for the pathogenesis and outcome of cardiogenic shock, with promising results. Other drugs, like a recently developed antibody fragment directed against C5 (pexelizumab) or high-dose statins, await testing in this population with a very high mortality rate. CONCLUSION: The promising results of studies that tested a potential benefit of drugs with clear or potential antiinflammatory/immunomodulatory properties in patients with cardiogenic shock underscores the importance of the inflammatory network in the pathogenesis and outcome of this devastating complication of cardiovascular disease.     

Prise en charge du choc cardiogénique d’origine ischémique : mise au point

Cardiogenic shock complicating myocardial infarction still remains a clinical challenge. Early revascularization represented the last major improvement aiming at the mortality reduction; however, despite optimal pharmacological treatments, mortality still exceeds 40%. Treatment with catecholamines is limited by arrhythmia, increases myocardial oxygen consumption, and is associated with worsened prognosis. Due to multiple beneficial hemodynamic and systemic effects, therapeutic hypothermia seems a promising tool. At least, life support aims to ensure adequate coronary and systemic circulation to limit multi-organ failure while preserving the myocardium and reducing the risk of ischemia. While intra-aortic balloon pump has been questioned recently in a large randomized controlled trial, other circulatory support devices have proved their effectiveness on early hemodynamic parameters without improving mortality, except for refractory shock. Large randomized trials are required to define the exact role of these devices according to patient’s hemodynamic status. Early diagnosis, coupled with the intensive management of shock based on effective reperfusion and adequate circulatory support, is the only way to limit or even better prevent multi-organ failure occurrence and thus improve outcome.     

阿替普酶与瑞替普酶治疗急性心肌梗死的疗效比较

目的：回顾性分析阿替普酶（rt-PA）和瑞替普酶（r-PA）治疗急性心肌梗死（AMI）患者的临床疗效。方法：观察使用阿替普酶全量加速给药或瑞替普酶静脉推注治疗的急性心肌梗死患者，分别统计两组胸痛至溶栓时间、再通率、出院前死亡率、治疗后并发症及再灌注心律失常发生率。结果：溶栓后，使用rt-PA的患者血管再通率84.6%，死亡率7.7%，出血率0%，再灌注心律失常发生率15.4%；使用r-PA的患者血管再通率90.9%，死亡率9.1%，出血率9.1%，再灌注心律失常发生率13.6%。结论：溶栓治疗急性心肌梗死rt-PA与r-PA两药比较疗效相当。     

Does intra-aortic balloon support for myocardial infarction with cardiogenic shock improve outcome?

Expanded abstract

Citation

Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators: Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012, 367:1287-1296.

Background

In the current international guidelines, intra-aortic balloon pump (IABP) counterpulsation is considered a class I treatment for acute myocardial infarction complicated by cardiogenic shock. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials.

Methods

Objective

To test the hypothesis that IABP counterpulsation, as compared with the best available medical therapy alone, results in a reduction in mortality among patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization is planned.

Design

Randomized, prospective, open-label, multicenter trial.

Setting

Thirty-seven centers in Germany.

Subjects

All adults had acute myocardial infarction complicated by cardiogenic shock and were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery).

Intervention

After enrollment, 600 patients were randomly assigned to intra-aortic balloon counterpulsation (IABP group, 301 patients) or no IABP counterpulsation (control group, 299 patients).

Outcomes

The primary efficacy endpoint is 30-day all-cause mortality.

Results

At 30 days, 119 patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) had died (relative risk with IABP, 0.96; 95% confidence interval, 0.79 to 1.17; P = 0.69). There were no significant differences in secondary endpoints or in process-of-care measures, including the time to hemodynamic stabilization, the length of stay in the intensive care unit, serum lactate levels, the dose and duration of catecholamine therapy, and renal function.

Conclusions

The use of IABP counterpulsation did not significantly reduce 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock for whom an early revascularization strategy was planned.     

急性心肌梗死后心源性休克患者早期发生急性肾功能衰竭与预后的关系

目的　了解急性心肌梗死后心源性休克患者中早期发生急性肾功能衰竭与预后的关系。方法回顾性分析解放军总医院 1993— 2 0 0 3年因急性心肌梗死或冠心病心绞痛住院、并出现心源性休克患者的临床资料。以 2 4 h内是否出现急性肾功能衰竭为标准 ,比较其住院期间病死率 ;并采用多元 logistic回归分析 ,评估早期发生急性肾功能衰竭对患者预后的影响。结果　 172例患者中 ,5 1例 ( 30 % )于 2 4 h内出现急性肾功能衰竭。早期是否发生急性肾功能衰竭患者的住院病死率分别为 90 % ( 4 6 / 5 1例 )和 5 6 % ( 6 8/ 12 1例 )。逐步回归分析表明 ,早期发生急性肾功能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 ,相对危险度 ( OR) =6 .7,95 %可信区间为 2 .5～ 18.0 ,P<0 .0 0 1。结论　急性心肌梗死后心源性休克患者 ,早期急性肾功能衰竭的发生与患者住院病死率显著相关 ,可作为判断患者预后不良的指标     

Review of ventricular rupture: key concepts and diagnostic tools for success

Although a rare complication of acute myocardial infarction (AMI), ventricular rupture is a serious event associated with significant mortality and morbidity. Patients normally present with hemodynamic instability, often in cardiogenic shock. Despite improvements in surgical techniques and diagnostic tools, post-myocardial infarction ventricular rupture remains a difficult therapeutic challenge. There are three categories of ventricular rupture: free wall rupture (FWR), ventricular septal rupture (VSR), and papillary muscle rupture (PWR). The incidence of FWR occurs following up to 10% of myocardial infarctions. VSR and PWR have a lower incidence of 1-2% and 0.5-5%, respectively. Patients often present with single-vessel coronary artery disease and usually do not have a positive history for a previous myocardial infarction. The incidence of post infarction angina in these patients is significantly greater than in patients without ventricular rupture. Delay in treatment and continued physical activity post infarction increases the risk of ventricular rupture. Diagnostic tools such as two-dimensional echocardiography and cardiac catheterization confirm the diagnosis of ventricular rupture in only 45-88% of cases. Knowledge of the disease progression is necessary to insure accurate and timely diagnosis. Due to the rapid deterioration of these patients, there is a 50-80% mortality rate within the first week if untreated. With surgical correction, patients can extend their 5-year survival rates to 65%. A good example of the complex course of ventricular rupture is the case of a 71-year-old patient at our institution. The patient presented in cardiogenic shock following an AMI. Preoperative diagnosis was unsuccessful in determining the extent of the ventricular rupture. The correct diagnosis was determined in the operating room, and both a mitral valve replacement and closure of a ventricular septal defect were completed. The patient was successfully treated with this difficult pathology.     

Cardiogenic shock: thrombolysis or angioplasty?

Cardiogenic shock (CGS) occurs in 3 to 20% of patients presenting with acute myocardial infarction (MI), and it generally involves dysfunction of at least 40% of the total myocardial mass. Prior to the advent of balloon angioplasty and thrombolysis, in-hospital mortality was greater than 75%. This mortality rate has been consistent in reported series despite the advent of cardiac intensive care units, vasopressor, inotropic, and vasodilator therapy. Intra-aortic balloon counterpulsation therapy provides hemodynamic improvement, and it may provide some mortality benefit when used in conjunction with appropriate revascularization. Survival studies have shown that patency of the infarct-related artery is a strong predictor of survival. No randomized trials have been completed to examine which reperfusion therapy best treats this emergent situation. Subgroup analysis of large scale, multicenter trials, although underpowered, has shown no improvement in mortality with use of thrombolytic agents, leading many to advise use of mechanical intervention. In patients who present with acute MI with contraindications to thrombolysis, primary angioplasty is the treatment of choice. At selected centers, primary angioplasty is comparable to or better than thrombolytic therapy for patients presenting with acute MI, with or without CGS. Studies examining angioplasty in patients with CGS have shown high procedural success rates (75%) and reduced in-hospital mortality (44%), particularly in those patients with successful revascularization. Emergency bypass surgery may improve survival, but it is costly, unavailable to many, and often leads to excessive delays in therapy. If available, we believe that primary angioplasty is the treatment of choice for patients with CGS.     

Aortic counterpulsation in cardiogenic shock during acute myocardial infarction

Intra-aortic balloon counterpulsation is the most widely used form of mechanical hemodynamic support in the setting of cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI). Intra-aortic balloon pump (IABP) is also strongly recommended (class 1b) in the current European guidelines for treatment of STEMI. The evidence of a possible benefit of IABP in this setting is based mainly on registry data and a few randomized trials. Cardiogenic shock and subsequent death due to STEMI result from three factors: hemodynamic deterioration, occurrence of multiorgan dysfunction and systemic inflammatory response. IABP does not cause an immediate improvement in blood pressure, but the recent SHOCK II trial shows positive effects on multiorgan dysfunction. Some experimental and clinical studies have indicated that IABP results in hemodynamic benefits as a result of afterload reduction and diastolic augmentation with improvement of coronary perfusion. However, the effect on cardiac output is modest and may not be sufficient to reduce mortality. Furthermore we can say that the use of IABP before coronary revascularization in the setting of STEMI complicated with cardiogenic shock may make the interventional procedure safer by improving left ventricular unloading. The purpose of the present review is to clarify the state of the art on this topic.