Impact of Center Volume on Outcomes in Myocardial Infarction Complicated by Cardiogenic Shock: A CULPRIT‐SHOCK Substudy

Background Little is known about the impact of center volume on outcomes in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to investigate the association between center volume, treatment strategies, and subsequent outcome in patients with acute myocardial infarction complicated by cardiogenic shock. Methods and Results In this subanalysis of the randomized CULPRIT‐SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) trial, study sites were categorized based on the annual volume of acute myocardial infarction complicated by cardiogenic shock into low‐/intermediate‐/high‐volume centers (<50; 50–100; and >100 cases/y). Subjects from the study/compulsory registry with available volume data were included. Baseline/procedural characteristics, overall treatment, and 1‐year all‐cause mortality were compared across categories. n=1032 patients were included in this study (537 treated at low‐volume, 240 at intermediate‐volume, and 255 at high‐volume centers). Baseline risk profile of patients across the volume categories was similar, although high‐volume centers included a larger number of older patients. Low‐/intermediate‐volume centers had more resuscitated patients (57.5%/58.8% versus 42.2%; P <0.01), and more patients on mechanical ventilation in comparison to high‐volume centers. There were no differences in reperfusion success despite considerable differences in adjunctive pharmacological/device therapies. There was no difference in 1‐year all‐cause mortality across volume categories (51.1% versus 56.5% versus 54.4%; P =0.34). Conclusions In this study of patients with acute myocardial infarction complicated by cardiogenic shock, considerable differences in adjunctive medical and mechanical support therapies were observed. However, we could not detect an impact of center volume on reperfusion success or mortality.

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Sample Timing, Diagnosis of Subclinical Thyroid Dysfunction and Mortality in Acute Myocardial Infarction: ThyrAMI1 Study

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgz143 ◽

2019 ◽

Vol 105 (4) ◽

pp. e1299-e1306 ◽

Cited By ~ 3

Author(s):

Salman Razvi ◽

Owain Leng ◽

Avais Jabbar ◽

Arjola Bano ◽

Lorna Ingoe ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Thyroid Function ◽

Thyroid Dysfunction ◽

Reference Interval ◽

Reference Ranges ◽

Diagnosis And Prognosis ◽

Time Period ◽

All Cause Mortality ◽

The Impact

Abstract Objective The objective of this study was to determine the impact of blood sample timing on the diagnosis of subclinical thyroid dysfunction (SCTD) and mortality in patients with acute myocardial infarction (AMI). Patients, Design, and Main Outcome Measures Patients with AMI had thyroid function evaluated on admission between December 2014 and December 2016 and those with abnormal serum thyrotropin (TSH) had repeat thyroid function assessed at least a week later. The association between sample timing and SCTD was evaluated by logistic regression analysis. Secondary outcomes were confirmation of SCTD on repeat testing and all-cause mortality up to June 2018. Results Of the 1806 patients [29.2% women, mean (± standard deviation) age of 64.2 (±12.1) years] analyzed, the prevalence of subclinical hypothyroidism (SCH) was 17.2% (n = 311) and subclinical hyperthyroidism (SHyper) was 1.2% (n = 22) using a uniform TSH reference interval. The risk of being diagnosed with SCTD varied by sample timing in fully-adjusted models. The risk of SCH was highest between 00.01 and 06.00 hours and lowest between 12.01 and 18.00 hours, P for trend <.001, and risk of SHyper was highest between 12.01 hours and 18.00 hours and lowest between 00.01 hours and 06.00 hours. Furthermore, time of the initial sample was associated with the risk of remaining in a SCH state subsequently. Mortality in SCH patients was not elevated when a uniform TSH reference interval was utilized. However, when time period–specific TSH reference ranges were utilized, the mortality risk was significantly higher in SCH patients with HR (95% CI) of 2.26 (1.01–5.19), P = .04. Conclusions Sample timing impacts on the diagnosis and prognosis of SCH in AMI patients. If sample timing is not accounted for, SCH is systemically misclassified, and its measurable influence on mortality is lost.

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Abstract 429: First-Line Vasopressor Agent for Cardiogenic Shock Due to Acute Myocardial Infarction: Results From Tokyo CCU Network Registry

Circulation ◽

10.1161/circ.140.suppl_2.429 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Tadashi Ashida ◽

Tsukasa Yagi ◽

Ken Nagao ◽

Norihiro Kuroki ◽

Tadateru Takayama ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Renal Function ◽

Mortality Rate ◽

Cardiogenic Shock ◽

First Line ◽

Poor Renal Function ◽

Vasopressor Agent ◽

Significant Difference ◽

All Cause Mortality

Background: In the guidelines for cardiogenic shock, norepinephrine, as compared with dopamine, was associated with fewer cases of arrhythmia and may be a better first-line vasopressor agent. However, few clinical studies have investigated the effects of optimal first-line vasopressor agents for patients with poor renal function. Methods: From a multicenter, prospective, cohort registry of emergency cardiovascular patients in Tokyo between 2013 and 2016, we identified adult patients with cardiogenic shock due to acute myocardial infarction (AMI) who received either norepinephrine, dopamine or both as a vasopressor agent without mechanical circulatory supports. Study patients were divided into 4 groups according to estimated glomerular filtration rate (eGFR). The primary endpoint was all-cause mortality at 30 days after admission. Results: Of the 4,034 patients with cardiogenic shock due to AMI, 665 were eligible for this study; 419 received norepinephrine (N group), 154 dopamine (D group), and 92 both agents (B group). There was a significant difference in the all-cause mortality rate between the three groups in the whole cohort (16.0% in the N group, 9.7% in the D group and 40.2% in the B group, P<0.001). In addition, there was a significant difference in the all-cause mortality rate between the three groups in the subgroups of patients with eGFR stage 3a and 3b. (Figure). After adjustment of independent factors for mortality, the odds ratio of the D group (reference, the N group) was 0.51 (95%CI 0.26-0.99, p=0.049). Conclusion: Compared with norepinephrine, dopamine was associated with a lower all-cause mortality rate for patients with cardiogenic shock due to AMI, especially patients with poor renal function.

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Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

Open Heart ◽

10.1136/openhrt-2018-000987 ◽

2019 ◽

Vol 6 (1) ◽

pp. e000987 ◽

Cited By ~ 16

Author(s):

Brunilda Alushi ◽

Andel Douedari ◽

Georg Froehlig ◽

Wulf Knie ◽

Thomas H Wurster ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Primary Outcome ◽

Left Ventricular ◽

Cox Proportional Hazards ◽

Left Ventricular Ejection ◽

Bleeding Complications ◽

Ventricular Ejection Fraction ◽

All Cause Mortality

ObjectiveWe investigated the benefit of Impella, a modern percutaneous mechanical support (pMCS) device, versus former standard intra-aortic balloon pump (IABP) in acute myocardial infarction complicated by cardiogenic shock (AMICS).MethodsThis single-centre, retrospective study included patients with AMICS receiving pMCS with either Impella or IABP. Disease severity at baseline was assessed with the IABP-SHOCK II score. The primary outcome was all-cause mortality at 30 days. Secondary outcomes were parameters of shock severity at the early postimplantation phase. Adjusted Cox proportional hazards models identified independent predictors of the primary outcome.ResultsOf 116 included patients, 62 (53%) received Impella and 54 (47%) IABP. Despite similar baseline mortality risk (IABP-SHOCK II high-risk score of 18 % vs 20 %; p = 0.76), Impella significantly reduced the inotropic score (p < 0.001), lactate levels (p < 0.001) and SAPS II (p =0.02) and improved left ventricular ejection fraction (p = 0.01). All-cause mortality at 30 days was similar with Impella and IABP (52 % and 67 %, respectively; p = 0.13), but bleeding complications were more frequent in the Impella group (3 vs 4 units of transfused erythrocytes concentrates due to bleeding complications, p = 0.03). Previous cardiopulmonary resuscitation (HR 3.22, 95% CI 1.76 to 5.89; p < 0.01) and an estimated intermediate (HR 2.77, 95% CI 1.42 to 5.40; p < 0.01) and high (HR 4.32 95% CI 2.03 to 9.24; p = 0.01) IABP-SHOCK II score were independent predictors of all-cause mortality.ConclusionsIn patients with AMICS, haemodynamic support with the Impella device had no significant effect on 30-day mortality as compared with IABP. In these patients, large randomised trials are warranted to ascertain the effect of Impella on the outcome.

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Prognostic Analysis for Cardiogenic Shock in Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention

BioMed Research International ◽

10.1155/2017/8530539 ◽

2017 ◽

Vol 2017 ◽

pp. 1-8 ◽

Cited By ~ 3

Author(s):

Mao-Jen Lin ◽

Chun-Yu Chen ◽

Hau-De Lin ◽

Han-Ping Wu

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Cardiogenic Shock ◽

Systolic Pressure ◽

Coronary Intervention ◽

Syntax Score ◽

Long Term Outcome ◽

Percutaneous Coronary ◽

All Cause Mortality

Cardiogenic shock (CS) is uncommon in patients suffering from acute myocardial infarction (AMI). Long-term outcome and adverse predictors for outcomes in AMI patients with CS receiving percutaneous coronary interventions (PCI) are unclear. A total of 482 AMI patients who received PCI were collected, including 53 CS and 429 non-CS. Predictors for AMI patients with CS including recurrent MI, cardiovascular (CV) mortality, all-cause mortality, and repeated-PCI were analyzed. The CS group had a lower central systolic pressure and central diastolic pressure (both P<0.001). AMI patients with hypertension history were less prone to develop CS (P<0.001). Calcium channel blockers and statins were less frequently used by the CS group than the non-CS group (both P<0.05) after discharge. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, CV mortality, and all-cause mortality were higher in the CS group than the non-CS group (all P<0.005). For patients with CS, stroke history was a predictor of recurrent MI (P=0.036). CS, age, SYNTAX score, and diabetes were predictors of CV mortality (all P<0.05). CS, age, SYNTAX score, and stroke history were predictors for all-cause mortality (all P<0.05). CS, age, and current smoking were predictors for repeated-PCI (all P<0.05).

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Prasugrel vs clopidogrel in cardiogenic shock patients undergoing primary PCI for acute myocardial infarction

Thrombosis and Haemostasis ◽

10.1160/th14-06-0489 ◽

2014 ◽

Vol 112 (12) ◽

pp. 1190-1197 ◽

Cited By ~ 12

Author(s):

Tanja Morath ◽

Isabell Bernlochner ◽

Martin Hadamitzky ◽

Siegmund Braun ◽

Stefanie Schulz ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Primary Pci ◽

Bleeding Events ◽

All Cause Mortality ◽

Clopidogrel Therapy ◽

Function Testing ◽

Lower Mortality Risk ◽

High Risk Cohort

SummaryThere is limited clinical data comparing different P2Y12-receptor inhibitors in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. The aim of the ISAR-SHOCK registry was to compare the clinical outcome of patients treated with clopidogrel vs prasugrel in this setting. Patients (n=145) with AMI complicated by cardiogenic shock and undergoing primary PCI in two centres (Deutsches Herzzentrum München and Klinikum rechts der Isar, Technical University Munich) between January 2009 and May 2012 were included in this registry. The use of prasugrel for patients within this registry reflected co-morbidities and platelet function testing results during the acute AMI phase. Early outcome at 30-days was reported with regard to all-cause mortality, myocardial infarction (MI), stent thrombosis (ST) and bleeding events. With regard to antiplatelet treatment in the 145 cardiogenic shock patients, 50 patients were initially treated or immediately switched to prasugrel while 95 patients were treated with clopidogrel. All-cause mortality was lower in prasugrelvs clopidogrel-treated patients (30 % vs 50.5%, HR: 0.51, 95% CI [0.29–0.92], p=0.025). No significant differences in prasugrel- vs clopidogrel-treated patients were observed for the occurrence of MI (p=0.233), ST (p=0.306) or TIMI major bleedings (p=0.571). Results of the ISAR-SHOCK registry suggest that the use of prasugrel in AMI patients complicated by cardiogenic shock might be associated with a lower mortality risk as compared to clopidogrel therapy without increasing the risk of bleeding. These findings, however, need confirmation from specifically designed randomised studies in this high-risk cohort of patients.

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P3122Complete versus culprit-vessel only revascularization for patients with acute coronary syndromes and multivessel disease

European Heart Journal ◽

10.1093/eurheartj/ehz745.0197 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J Ferreira ◽

S Monteiro ◽

R Baptista ◽

F Goncalves ◽

P Monteiro ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Left Ventricular ◽

Multivessel Disease ◽

Left Ventricular Ejection ◽

Great Loss ◽

Coronary Syndrome ◽

Propensity Matching ◽

All Cause Mortality ◽

The Impact

Abstract Background Recent randomized clinical trials have suggested that complete revascularization (CR) instead of culprit-vessel only revascularization (CVO) strategies may take a stand in the optimal management of patients admitted for acute myocardial infarction (AMI) with multivessel (MV) disease undergoing primary percutaneous coronary intervention (P-PCI). However, despite the 2017 ST-elevation acute coronary syndrome (STEMI) guidelines update with a new class of recommendation for CR, it remains controversial whether this strategy leads to better outcomes. Purpose To compare CR versus CV strategies during hospitalization in patients presenting with AMI with multivessel disease at P-PCI. Methods We analyzed data from all patients admitted with non-ST acute myocardial infarction (NSTEMI) and STEMI in a portuguese coronary care unit (CCU), between 2007 and 2016. We then evaluated potential differences of CR versus CVO with PCI during hospitalization in AMI patients with multivessel disease, defined by at least 2 different diseased main coronary vessels, saphenous vein or mammary artery conduits. We used 1:1 ratio propensity score matching to study the impact of CR on patient mortality and adjusted data for relevant risk factors at admission time. Results A total of 4758 patients were admitted for AMI, 2690 NSTEMI (56.5%) and 2068 STEMI (43.5%). Access to PCI records was possible in 3162 (66.5%) patients, of which 1707 (54%) underwent CR versus 1455 (46%) who underwent CVO. CVO patients were older (67.9±11.8 vs. 63.5±13.1 years, p<0.001), more diabetic (56.5% vs. 47.1%, p<0.001), hypertensive (78.4% vs. 72.2%, p<0.001), dyslipidemic (82.1% vs. 75%, p<0.001), had greater GRACE score at admission (mean score 143.4±37.2 vs. 131.2±131.2, p<0.001), had more severe coronary disease (mean number of diseased vessels – 2.56±0.6 vs. 2.18±0.4, p<0.004), reached higher Killip class (mean – 1.42±0.9 vs. 1.26±0.7, p<0.001) and had lower left ventricular ejection fraction (48.07±11.6 vs. 51.25±10.5, p<0.001). No significant differences were found in peak troponin-I release between CR and CV (44.7±69 vs. 46.9±76, respectively, p=0.468). After propensity matching, we obtained 130 CR and 133 CVO patients. In this cohort all-cause mortality was lower in CR group at 6-month (RR 0.262, CI 95% 0.071–0.962, p=0.031) and 1-year (RR 0.340, CI 95% 0.119–0.973, p=0.036) follow-up. When comparing STEMI versus NSTEMI all-cause mortality was nonsignificantly lower in CR (RR 0.394 vs. 0.226, p=0.12 vs. p=0.16). Conclusions In patients presenting with AMI and MV disease, CR strategy during hospitalization leads to greater 6-month and 1-year survival when compared with CVO strategy. Despite not having found significant differences when STEMI was directly compared to NSTEMI, we believe this was due to the great loss of patient numbers after propensity matching, requiring larger trials to prove the effect.

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Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

European Heart Journal ◽

10.1093/ehjci/ehaa946.1788 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

U Zeymer ◽

B Alushi ◽

A Lauten ◽

I Akin ◽

S Desch ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Coronary Intervention ◽

Funding Source ◽

National Budget ◽

Cardio Pulmonary Resuscitation ◽

Percutaneous Coronary ◽

Public Grant ◽

The Impact

Abstract Background There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock. Methods We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy. Results Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table. Conclusion Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK

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The Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing Coronary Revascularization with Percutaneous Ventricular Assist Device Support

Journal of Atrial Fibrillation ◽

10.4022/jafib.2179 ◽

2020 ◽

Vol 12 (5) ◽

Author(s):

Dhanunjaya Lakkireddy

Keyword(s):

Myocardial Infarction ◽

Atrial Fibrillation ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Ventricular Assist Device ◽

Coronary Revascularization ◽

Assist Device ◽

Hospital Outcomes ◽

Ventricular Assist ◽

The Impact

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P5738Multicenter analysis of left ventricular unloading on top of VA-ECMO for treatment of cardiogenic shock

European Heart Journal ◽

10.1093/eurheartj/ehz746.0678 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

B Schrage ◽

S Dabboura ◽

H Bezerra ◽

J M Sinning ◽

H Thiele ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiopulmonary Resuscitation ◽

Cardiogenic Shock ◽

Primary Endpoint ◽

Left Ventricular ◽

Predictors Of Outcome ◽

Severe Cardiogenic Shock ◽

All Cause Mortality ◽

Va Ecmo

Abstract Background Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population. Aim The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO. Material and methods We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables. Results A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD). Conclusion and outlook In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality. To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.

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