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      A Review of Cardiogenic Shock in Acute Myocardial Infarction

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          Abstract

          Cardiogenic shock continues to be the most common cause of death in patients hospitalized with acute myocardial infarction. It has also been frequently associated with ST-segment elevation myocardial infarction (STEMI) and patients with co-morbidities. Cardiogenic shock presents with low systolic blood pressure and clinical signs of hypoperfusion. Rapid diagnosis and supportive therapy in the form of medications, airway support and intra-aortic balloon counterpulsation is required. Initial stabilization can be followed by reperfusion by fibrinolytic therapy, emergent percutaneous intervention (PCI) or coronary artery bypass grafting (CABG). The latter two have been found to decrease mortality in the long term. Research is being carried out on the role of inflammatory mediators in the clinical manifestation of cardiogenic shock. Mechanical support devices also show promise in the future.

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          Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients.

          T Killip, J. Kimball (1967)
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            Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry.

            N Slater, Venu Menon, Ryan G. Webb … (2004)
            We sought to analyze clinical, angiographic, and outcome correlates of hemodynamic parameters in cardiogenic shock. The significance of right heart catheterization in critically ill patients is controversial, despite the prognostic importance of the derived measurements. Cardiac power is a novel hemodynamic parameter. A total of 541 patients with cardiogenic shock who were enrolled in the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial registry were included. Cardiac power output (CPO) (W) was calculated as mean arterial pressure x cardiac output/451. On univariate analysis, CPO, cardiac power index (CPI), cardiac output, cardiac index, stroke volume, left ventricular work, left ventricular work index, stroke work, mean arterial pressure, systolic and diastolic blood pressure (all p < 0.001), coronary perfusion pressure (p = 0.002), ejection fraction (p = 0.013), and pulmonary artery systolic pressure (p = 0.047) were associated with in-hospital mortality. In separate multivariate analyses, CPO (odds ratio per 0.20 W: 0.60 [95% confidence interval, 0.44 to 0.83], p = 0.002; n = 181) and CPI (odds ratio per 0.10 W/m(2): 0.65 [95% confidence interval, 0.48 to 0.87], p = 0.004; n = 178) remained the strongest independent hemodynamic correlates of in-hospital mortality after adjusting for age and history of hypertension. There was an inverse correlation between CPI and age (correlation coefficient: -0.334, p < 0.001). Women had a lower CPI than men (0.29 +/- 0.11 vs. 0.35 +/- 0.15 W/m(2), p = 0.005). After adjusting for age, female gender remained associated with CPI (p = 0.032). Cardiac power is the strongest independent hemodynamic correlate of in-hospital mortality in patients with cardiogenic shock. Increasing age and female gender are independently associated with lower cardiac power.
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              The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.

              S Broste, Frank E. Harrell, W Knaus … (1996)
              To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care. Prospective cohort study. Five US teaching hospitals between 1989 and 1994. A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories. Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results. By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17 000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful. In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Curr Cardiol Rev
                Journal ID (publisher-id): CCR
                Title: Current Cardiology Reviews
                Publisher: Bentham Science Publishers Ltd.
                ISSN (Print): 1573-403X
                ISSN (Electronic): 1875-6557
                Publication date (Print): February 2008
                Volume: 4
                Issue: 1
                Pages: 34-40
                Affiliations
                []Department of Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
                Author notes
                [* ]Address correspondence to this author at the Department of Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan; Tel: 92-21-4930051 Ext: 4700; Fax: 92-21-4934294; E-mail: sajid.dhakam@ 123456aku.edu
                Article
                Publisher ID: CCR-4-34
                DOI: 10.2174/157340308783565456
                PMC ID: 2774583
                PubMed ID: 19924275
                SO-VID: 28811177-fee8-48be-919f-5e96be2df145
                Copyright © ©2008 Bentham Science Publishers Ltd.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.5/), which permits unrestrictive use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 1 May 2007
                Date revision received : 10 January 2008
                Date accepted : 11 January 2007
                Categories
                Subject: Article

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: percutaneous coronary intervention,coronary artery bypass grafting.,fibrinolytic therapy,intra-aortic balloon counterpulsation,myocardial infarction,cardiogenic shock
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: percutaneous coronary intervention, coronary artery bypass grafting., fibrinolytic therapy, intra-aortic balloon counterpulsation, myocardial infarction, cardiogenic shock

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