Prognostic performance of the IABP-SHOCK II Risk Score among cardiogenic shock subtypes in the critical care cardiology trials network registry.

BACKGROUND: Risk stratification has potential to guide triage and decision-making in cardiogenic shock (CS). We assessed the prognostic performance of the IABP-SHOCK II score, derived in Europe for acute myocardial infarct-related CS (AMI-CS), in a contemporary North American cohort, including different CS phenotypes. METHODS: The critical care cardiology trials network (CCCTN) coordinated by the TIMI study group is a multicenter network of cardiac intensive care units (CICU). Participating centers annually contribute ≥2 months of consecutive medical CICU admissions. The IABP-SHOCK II risk score includes age > 73 years, prior stroke, admission glucose > 191 mg/dl, creatinine > 1.5 mg/dl, lactate > 5 mmol/l, and post-PCI TIMI flow grade < 3. We assessed the risk score across various CS etiologies. RESULTS: Of 17,852 medical CICU admissions 5,340 patients across 35 sites were admitted with CS. In patients with AMI-CS (n = 912), the IABP-SHOCK II score predicted a >3-fold gradient in in-hospital mortality (low risk = 26.5%, intermediate risk = 52.2%, high risk = 77.5%, P < .0001; c-statistic = 0.67; Hosmer-Lemeshow P = .79). The score showed a similar gradient of in-hospital mortality in patients with non-AMI-related CS (n = 2,517, P < .0001) and mixed shock (n = 923, P < .001), as well as in left ventricular (<0.0001), right ventricular (P = .0163) or biventricular (<0.0001) CS. The correlation between the IABP-SHOCK II score and SOFA was moderate (r2 = 0.17) and the IABP-SHOCK II score revealed a significant risk gradient within each SCAI stage. CONCLUSIONS: In an unselected international multicenter registry of patients admitted with CS, the IABP- SHOCK II score only moderately predicted in-hospital mortality in a broad population of CS regardless of etiology or irrespective of right, left, or bi-ventricular involvement.

Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams.

BACKGROUND: Single-center studies suggest that implementation of multidisciplinary cardiogenic shock (CS) teams is associated with improved CS survival. OBJECTIVES: The aim was to characterize practice patterns and outcomes in the management of CS across multiple centers with versus without shock teams. METHODS: The Critical Care Cardiology Trials Network is a multicenter network of cardiac intensive care units (CICUs) in North America. All consecutive medical admissions to each CICU (n = 24) were captured during annual 2-month collection periods (2017-2019; n = 6,872). Shock management and CICU mortality among centers with versus without shock teams were compared using inverse probability weighting. RESULTS: Ten of the 24 centers had shock teams. Among 1,242 CS admissions, 44% were at shock team centers. The groups were well-balanced with respect to demographics, shock etiology, Sequential Organ Failure Assessment score, biochemical markers of end organ dysfunction, and invasive hemodynamics. Centers with shock teams used more pulmonary artery catheters (60% vs 49%; adjusted odds ratio [OR]: 1.86; 95% CI: 1.47-2.35; P < 0.001), less overall mechanical circulatory support (MCS) (35% vs 43%; adjusted OR: 0.74; 95% CI: 0.59-0.95; P = 0.016), and more advanced types of MCS (53% vs 43% of all MCS; adjusted OR: 1.73; 95% CI: 1.19-2.51; P = 0.005) rather than intra-aortic balloon pumps. The presence of a shock team was independently associated with lower CICU mortality (23% vs 29%; adjusted OR: 0.72; 95% CI: 0.55-0.94; P = 0.016). CONCLUSIONS: In this multicenter observational study, centers with shock teams were more likely to obtain invasive hemodynamics, use advanced types of MCS, and have lower risk-adjusted mortality. A standardized multidisciplinary shock team approach may improve outcomes in CS.

Comparative Analysis of Radial Versus Femoral Diagnostic Cardiac Catheterization Procedures in a Cardiology Training Program.

OBJECTIVES: This study was conducted to evaluate the differences in the procedural variables between transradial and transfemoral access for coronary angiography, with cardiology fellows as the primary operators. METHODS: This was a retrospective study of 163 radial and 180 femoral access diagnostic cardiac catheterization procedures, and involved cardiology fellowship trainees as primary operators. RESULTS: The radial approach was associated with significantly higher fluoroscopy time (8.0 ± 6.97 min vs 4.25 ± 3.01 min; P<.001), dose area product (10775 ± 6724 µGy/m² vs 7952 ± 4236 µGy/m²; P<.001), procedure time (38.31 ± 12.25 min vs 27 ± 17.56 min; P<.001), procedure start to vascular access time (8.24 ± 6.31 min vs 5.31 ± 4.59 min; P<.001), and vascular access to procedure end time (30 ± 15.34 min vs 21.2 ± 9.57 min; P<.001). These differences persisted after adjusting for patients with bypass grafts and additional imaging (P<.001). The contrast amount was not significantly different between the two groups (P=.12). Procedure start to vascular access time improved significantly with fellowship training year in both the radial (9.57 ± 6.96 min vs 8.23 ± 6.08 min vs 5.57 ± 4.82 min) and femoral groups (6.17 ± 5.07 min vs 5.47 ± 4.75 min vs 4.01 ± 3.31 min). Fluoroscopy time showed significant difference in only the femoral access group (P=.01). Dose area product did not improve with training in either access group. CONCLUSION: Radial procedures were associated with higher radiation dose and longer procedure time. Despite decrease in total procedural time for radial cases with the level of training, total radiation dose did not decrease.

Impact of a novel interventional platform and hospital design on the door-to-balloon time in patients presenting with ST-segment elevation myocardial infarction.

INTRODUCTION: Reducing door-to-balloon (DTB) time in ST-segment elevation myocardial infarction improves outcomes. Several hospital factors can delay DTB times and lead to increased morbidity and mortality. The effects of hospital design and an interventional platform (IP) on patient care, particularly on the DTB time, are unknown. METHODS: We performed a retrospective analysis of consecutive patients presenting to the emergency department of a medical center from September 2010 to February 2014 who met criteria for a ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention. Patients were divided into 2 groups based on whether they presented before or after the opening of the IP in our new hospital on January 6, 2012. Total DTB time and separate systematic intervals were tabulated. RESULTS: Fifty-two patients met our inclusion criteria, 21 pre-IP and 31 post-IP. Both groups had overall similar baseline characteristics. The mean DTB time significantly improved by 11.7 minutes after the opening of the IP (P = 0.016), and all cases had a DTB time 90 minutes or less as compared with 90.4% prior. Eighty-nine percent of the overall improvement in DTB happened before the patient reached the catheterization table. Important factors were the new emergency department (ED) design that facilitates rapid patient triage and the direct connection between the ED and cath lab. CONCLUSIONS: This study showed that the new hospital design had significant effects on immediate patient care by improving the DTB time at our institution. Further study regarding the long-term impact of hospital designs on patient care is needed.

Therapeutic angiogenesis in the management of critical limb ischemia: current concepts and review.

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease. Manifestations of CLI include rest pain, ischemic ulcers, and/or gangrene. The presence of CLI frequently leads to amputation, and furthermore, patients with CLI are at an increased risk of cardiovascular events including death. Treatment options for CLI when revascularization is not possible are extremely limited. Therapeutic angiogenesis is a promising new tool in the management of CLI. There is a growing body of evidence demonstrating the safety and efficacy of therapeutic angiogenesis with gene and cell therapy. Many factors must be considered in formulating clinically efficacious gene and/or cell therapies. The dosing regimen, route of delivery, and choice of growth factor or cell population must be decided. Although the optimal regimen of therapeutic angiogenesis has yet to be identified, building on the knowledge gained from the early pioneering studies may help to identify the best combination.

Myocardial infarction after taking zolmitriptan.

We report the case of a patient with mild non-obstructive coronary artery disease who sustained an inferior wall myocardial infarction shortly after taking zolmitriptan as abortive therapy for migraine headaches. A Medline search was performed to review all reported cases of myocardial infarction related to migraine therapy with zolmitriptan and related medications. Zolmitriptan may cause myocardial infarction (MI) even in the absence of significant coronary artery disease.

Clinical and angiographic outcomes of cardiac transplant patients treated with intracoronary beta-radiation for in-stent restenosis: a case series.

BACKGROUND: Vascular brachytherapy (VBT) is effective for the treatment of in-stent restenosis (ISR), however, the effect of VBT clinical and angiographic outcomes of patients with ISR who have undergone orthotopic heart transplantation (OHT) requires further study. METHODS: All OHT patients with ISR treated with VBT using the Novoste Beta-Cath System at Rush University Medical Center were identified, and the clinical and angiographic outcomes were evaluated. RESULTS: Four OHT patients with ISR who underwent VBT were identified. The mean age was 48.5 years, and the mean duration posttransplantation was 7.5 years. The mean reference coronary vessel diameter was 3.06 mm. The primary interventional device utilized prior to VBT was cutting balloon angioplasty (CBA) in 75% and percutaneous balloon angioplasty in 25%. The mean duration of follow-up after VBT was 11 months. There were no deaths attributable due to cardiac disease, no myocardial infarction, and no target vessel revascularization on follow-up. Overall survival during this period was 75%, with one mortality due to stroke 8 months after VBT. CONCLUSIONS: VBT for the treatment of ISR in patients who have undergone OHT appears safe and feasible and is associated with acceptable clinical and angiographic outcomes.