Implications of Myocardial Infarction on Management and Outcome in Cardiogenic Shock

Background The randomized DOREMI (Dobutamine Compared to Milrinone) clinical trial evaluated the efficacy and safety of milrinone and dobutamine in patients with cardiogenic shock. Whether the results remain consistent when stratified by acute myocardial infarction remains unknown. In this substudy, we sought to evaluate differences in clinical management and outcomes of acute myocardial infarction complicated by cardiogenic shock (AMICS) versus non‐AMICS. Methods and Results Patients in cardiogenic shock (n=192) were randomized 1:1 to dobutamine or milrinone. The primary composite end point in this subgroup analysis was all‐cause in‐hospital mortality, cardiac arrest, non‐fatal myocardial infarction, cerebrovascular accident, the need for mechanical circulatory support, or initiation of renal replacement therapy (RRT) at 30‐days. Outcomes were evaluated in patients with (n=65) and without (n=127) AMICS. The primary composite end point was significantly higher in AMICS versus non‐AMICS (hazard ratio [HR], 2.21; 95% CI, 1.47–3.30; P =0.0001). The primary end point was driven by increased rates of all‐cause mortality, mechanical circulatory support, and RRT. No differences in other secondary outcomes including cardiac arrest or cerebrovascular accident were observed. AMICS remained associated with the primary composite outcome, 30‐day mortality, and RRT after adjustment for age, sex, procedural contrast use, multivessel disease, and inotrope type. Conclusions AMI was associated with increased rates of adverse clinical outcomes in cardiogenic shock along with increased rates of mortality and initiation of mechanical circulatory support and RRT. Contrast administration during revascularization likely contributes to increased rates of RRT. Heterogeneity of outcomes in AMICS versus non‐AMICS highlights the need to study interventions in specific subgroups of cardiogenic shock. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03207165.

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Early Impella support in post-cardiac arrest cardiogenic shock complicating acute myocardial infarction improves short and long term survival

European Heart Journal ◽

10.1093/ehjci/ehaa946.1860 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

G Hatzis ◽

B Markus ◽

U Luesebrink ◽

H Ahrens ◽

D Divchev ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiac Arrest ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Coronary Intervention ◽

Circulatory Support ◽

Survival Outcomes ◽

Optimal Timing ◽

Term Survival

Abstract Background Early mechanical circulatory support with Impella may improve survival outcomes in the setting of post-cardiac arrest cardiogenic shock (CS) after out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). However, the optimal timing to initiate mechanical circulatory support (MCS) in this particular setting remains unclear. Purpose We aimed to compare survival outcomes of patients supported with Impella 2.5 before percutaneous coronary intervention (PCI) (pre-PCI) to those supported after PCI (post-PCI). Methods Single center study of patients resuscitated from OHCA due to AMI with post-cardiac arrest CS between September 2014 and June 2018. Survival outcomes were compared between those with Impella support before and after PCI. Results A total of 65 consecutive patients with infarct-related post-cardiac arrest shock supported with Impella 2.5 during admission coronary angiogram were included. All patients were in profound CS requiring catecholamines on admission. Overall survival to discharge and at 12-months was 44.6% and 41.5%, respectively. Patients in the pre-PCI group had a higher survival to discharge and at 12-months as compared to patients of the post-PCI group (60.7% versus 32.4%, p=0.03 and 57.1% versus 29.7%, p=0.04, respectively). Moreover, the patients in the early support group demonstrated a greater functional recovery of the left ventricle when Impella support was initiated prior to PCI. Conclusions Our results suggest that the early initiation of MCS with Impella 2.5 prior to PCI is associated with improved hospital and 12-month survival in patients with post-cardiac arrest CS complicating AMI. Figure 1 Funding Acknowledgement Type of funding source: None

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Faculty Opinions recommendation of Mechanical circulatory support with the Impella® LP5.0 pump and an intra-aortic balloon pump for cardiogenic shock in acute myocardial infarction: The IMPELLA-STIC randomized study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.736961014.793576620 ◽

2020 ◽

Author(s):

Navin Kapur

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Randomized Study ◽

Circulatory Support ◽

Intra Aortic Balloon Pump

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Mechanical circulatory support with impella in patients with non-acute myocardial infarction related cardiogenic shock

European Heart Journal ◽

10.1093/ehjci/ehaa946.1231 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Haurand ◽

S Bueter ◽

C Jung ◽

M Kelm ◽

R Westenfeld ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Apache Ii Score ◽

Hemodynamic Parameters ◽

Clinical Scores ◽

Lactate Levels

Abstract Background Percutaneous left ventricular assist devices such as the Impella pump, are used to hemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI) until cardiac function has recovered after revascularization. Whether Impella mechanical circulatory support (MCS) is effective in stabilizing patients with CS not caused by AMI has so far not been thoroughly investigated. Purpose The aim of this study is to analyze whether MCS with Impella is effective to stabilize patients with non-AMI related CS compared to patients with AMI related CS. Method We retrospectively analyzed 106 patients with CS and Impella support in the years from 2011 to 2018. Efficacy to stabilize the patient was assessed by laboratory values such as lactate, hemodynamic parameters and clinical scores. The difference in mortality was calculated with the Log-Rank-Test, comparing Kaplan-Meier curves. Results 36 patients suffered from non-AMI CS and in 70 patients CS was caused by AMI. Regarding the clinical scores and hemodynamic parameters, both groups were severely ill, with no significant difference in APACHE II score, with a mean score of 17.9 in the non-AMI group compared to 20.5 in the AMI-group (p=0.103), the SOFA score (mean score of 6.3 in non-AMI group vs 6.8 in AMI group, p=0.467) and cardiac index (mean CI of 1.9 l/min/m2 in non-AMI group vs 2.2 l/min/m2 in AMI group, p=0.176). There was a comparable mean decrease in lactate levels in both groups 48 hours after initiation of MCS, from initially 4.1 mmol/l to 1.7 mmol/l (p<0.001) in the non-AMI group and from initially 3.6 mmol/l to 2.2 mmol/l (p=0.025) in the AMI group. The non-ACS group exhibited a trend of lower mortality compared to the AMI group, with 47% in the non-AMI group and 57% in the AMI group (p=0.067). In multivariate analysis, age, lactate levels, cardiopulmonary resuscitation, low platelets and higher doses of inotropes and vasopressors were independent predictors for mortality. An upgrade to LVAD was performed for 22% of the non-AMI group and for 6% of the AMI group (p=0.020). Conclusion Impella support is effective to hemodynamically stabilize patients with non-AMI related CS. Therefore, MCS can be used as bridge to recovery or enables further treatment options as upgrade to longterm mechanical support devices. Funding Acknowledgement Type of funding source: None

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