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BACKGROUND: In patients with ST-elevation myocardial infarction (STEMI), either with or without cardiogenic shock, mechanical circulatory support with an intra-aortic balloon pump (IABP) is not associated with lower mortality. However, in STEMI patients undergoing urgent coronary artery bypass grafting (CABG), preoperative insertion of an IABP has been suggested to reduce mortality. In this study, the effect of preoperative IABP use on mortality in STEMI patients undergoing urgent CABG was investigated. METHODS: All consecutive STEMI patients undergoing urgent CABG in a single centre between 2000 and 2018 were studied. The primary outcome, 30-day mortality, was compared between patients with and without a preoperative IABP. Subgroup analysis and multivariable analysis using a propensity score and inverse probability treatment weighting were performed to adjust for potential confounders. RESULTS: A total of 246 patients were included, of whom 171 (69.5%) received a preoperative IABP (pIABP group) and 75 (30.5%) did not (non-pIABP group). In the pIABP group, more patients suffered from cardiogenic shock, persistent ischaemia and reduced left ventricular function. Unadjusted 30-day mortality was comparable between the pIABP and the non-pIABP group (13.3% vs 12.3%, pâ¯= 0.82). However, after correction for confounders and inverse probability treatment weighting preoperative IABP was associated with reduced 30-day mortality (relative risk 0.52, 95% confidence interval 0.30-0.88). CONCLUSION: In patients with STEMI undergoing urgent CABG, preoperative insertion of an IABP is associated with reduced mortality.
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BACKGROUND: Cardiogenic shock (CS) is a strong predictor of mortality in patients with ST-elevation myocardial infarction (STEMI), but there is evidence that shock index (SI), taking into account both blood pressure and heart rate, is a more sensitive and powerful predictor. We investigated the independent impact of SI and CS on 30-day and 1-year mortality in patients with STEMI, treated by primary percutaneous coronary intervention (PCI).MethodsâandâResults:In 7,412 consecutive patients with STEMI treated with primary PCI, the predictive value of either SI or CS on 1-year mortality was assessed. Best cut-off value of SI, determined using receiver operating characteristic (ROC) curve, was 0.7, with an ROC AUC of 0.66 (95% CI: 0.65-0.67), compared with an ROC AUC of 0.60 (95% CI: 0.59-0.61) for CS (P<0.001). At admission, 387 patients (5.2%) had CS and 1,567 patients (21.1%) had SI ≥0.7. The adjusted hazard ratio of mortality in patients with SI ≥0.7 and in CS patients was, respectively, 3.3 (95% CI: 2.4-4.6) and 3.1 (95% CI: 2.1-4.6) after 30 days, and 2.3 (95% CI: 1.8-2.9) and 3.1 (95% CI: 2.2-4.2) after 1 year. CONCLUSIONS: SI identifies more patients with increased risk of mortality, and seems to be a more sensitive prognostic predictor than CS in patients with STEMI treated by primary PCI.
Assuntos
Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Índice de Gravidade de Doença , Choque Cardiogênico/mortalidade , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , Estudos de Coortes , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidadeRESUMO
Vasopressors and inotropes are routinely used in acute myocardial infarction (AMI) related cardiogenic shock (CS) to improve hemodynamics. We aimed to investigate the effect of routinely used vasopressor and inotropes on mortality in AMI related CS. A systematic search of MEDLINE, EMBASE and CENTRAL was performed up to 20 February 2019. Randomized and observational studies reporting mortality of AMI related CS patients were included. At least one group should have received the vasopressor/inotrope compared with a control group not exposed to the vasopressor/inotrope. Exclusion criteria were case reports, correspondence and studies including only post-cardiac surgery patients. In total, 19 studies (6 RCTs) were included, comprising 2478 CS patients. The overall quality of evidence was graded low. Treatment with adrenaline, noradrenaline, vasopressin, milrinone, levosimendan, dobutamine or dopamine was not associated with a difference in mortality between therapy and control group. We found a trend toward better outcome with levosimendan, compared with control (RR 0.69, 95% CI 0.47-1.00). In conclusion, we found insufficient evidence that routinely used vasopressors and inotropes are associated with reduced mortality in patients with AMI related CS. Considering the limited evidence, this study emphasizes the need for randomized trials with appropriate endpoints and methodology.
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BACKGROUND: The association between chronic beta-blocker treatment and haemodynamics at admission in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention is not well studied. We investigated the impact of chronic beta-blocker treatment on the risk of cardiogenic shock and pre-shock at admission in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention. METHODS AND RESULTS: A total of 4907 patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention were included in the study. A total of 1148 patients (23.3%) were on chronic beta-blocker treatment. Cardiogenic shock was observed in 264 patients (5.3%). Pre-shock was defined as a shock index (the ratio of heart rate and systolic blood pressure) of 0.7 or greater, and was observed in 1022 patients (20.8%). The risk of cardiogenic shock in patients with chronic beta-blocker treatment was not increased (adjusted hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.65-1.46, P=0.90). Chronic beta-blocker treatment was also not associated with an increased risk of pre-shock (adjusted HR 0.86, 95% CI 0.68-1.07, P=0.19). Also after propensity score matched analysis, there was no increased risk of cardiogenic shock or pre-shock in patients with chronic beta-blocker treatment (respectively HR 0.97, 95% CI 0.61-1.51, P=0.88 and HR 0.82, 95% CI 0.65-1.06, P=0.12). CONCLUSION: In ST-segment elevation myocardial infarction, chronic beta-blocker treatment is not associated with an increased risk of cardiogenic shock or pre-shock.
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Antagonistas Adrenérgicos beta/administração & dosagem , Angioplastia Coronária com Balão/métodos , Hemodinâmica/fisiologia , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Esquema de Medicação , Eletrocardiografia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Pontuação de Propensão , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
BACKGROUND: In selected patients with an acute myocardial infarction (AMI) complicated by Cardiogenic shock (CS), mechanical circulatory support with Impella may be beneficial, although conclusive evidence is still lacking. Nevertheless, it has been suggested that Impella initiation prior to primary PCI might improve survival. OBJECTIVE: To investigate the effect pre-PCI versus immediate post-PCI Impella initiation on short term mortality. METHODS: A prospective, single center, observational study, was performed including all patients with STEMI complicated by CS, treated with primary PCI and Impella. Thirty day mortality was compared between patients with Impella initiation pre-PCI and immediately post-PCI. RESULTS: A total of 88 patients were included. In the pre-PCI group (n = 21), admission heart rate was lower (84 versus 94 bpm, p = 0.04) and no IABP was implanted before Impella initiation, versus 17.9% in post-PCI group (n = 67), p = 0.04. Total 30-day all-cause mortality was 58%, and was lower in pre-PCI group, 47.6% versus 61.2% in the post-PCI group, however not statistically significant (HR 0.7, 95% CI 0.3-1.3, p = 0.21). Thirty-day cardiac mortality was significantly lower in the pre-PCI group, 19% versus 44.7% in the post-PCI group (HR 0.3, 95% CI 0.09-0.96, p = 0.042). CONCLUSION: Pre-PCI Impella initiation in AMICS patients was not associated with a statistically significant difference in 30-day all-cause mortality, compared to post-PCI Impella initiation.
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Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Intervenção Coronária Percutânea/métodos , Recuperação de Função Fisiológica , Choque Cardiogênico/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/terapia , Prognóstico , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) has a poor prognosis. Recently published data suggested, however, that CS does not affect long-term mortality in hospital survivors of STEMI. We investigated whether this could be confirmed in a larger cohort. HYPOTHESIS: STEMI complicated by CS leads to worse long-term survival. METHODS: A prospective cohort study was performed in 7412 consecutive patients with STEMI treated by primary percutaneous coronary intervention (angioplasty). The predictive value of CS on long-term mortality was assessed in hospital survivors. Multivariate analysis, adjusting for differences in baseline variables, was performed to assess the independent prognostic value of CS. RESULTS: Cardiogenic shock was observed in 387 patients (5.2%). The total in-hospital mortality was 254 (3.4%), and mortality was significantly higher in patients with CS (20.0% vs 2.6%; P < 0.001). The 1-year mortality in hospital survivors was 10.3% in patients with CS and 3.9% in patients without CS (P < 0.001). After multivariate analysis, CS was still a significant predictor of long-term mortality in hospital survivors (hazard ratio: 2.6, 95% confidence interval: 1.64-4.01). CONCLUSIONS: Cardiogenic shock remains a strong predictor of long-term mortality in hospital survivors of STEMI treated by primary percutaneous coronary intervention.