Acute myocardial infarction and cardiogenic shock Interventional approach to management in the cardiac catheterization laboratories

2021 ◽  
Vol 17 ◽  
Author(s):  
Behnam N Tehrani ◽  
Abdulla A Damluji ◽  
Wayne B Batchelor
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Cardiac Catheterization ◽  
Management Strategies ◽  
Multidisciplinary Care ◽  
Circulatory Support ◽  
Early Reperfusion ◽  
Catheterization Laboratory ◽  
Cardiac Catheterization Laboratory

: Despite advances in early reperfusion and a technologic renaissance in the space of mechanical circulatory support (MCS), cardiogenic shock (CS) remains the leading cause of in-hospital mortality following acute myocardial infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patient without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated in the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trial designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.

scholarly journals Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association

Circulation ◽  
2021 ◽  
Author(s):  
Timothy D. Henry ◽  
Matthew I. Tomey ◽  
Jacqueline E. Tamis-Holland ◽  
Holger Thiele ◽  
Sunil V. Rao ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
American Heart Association ◽  
American Heart ◽  
Heart Association ◽  
Circulatory Support ◽  
Cardiac Catheterization Laboratory ◽  
Wide Range ◽  
Scientific Statement

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

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

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

scholarly journals Admission biomarkers among patients with acute myocardial-infarction related cardiogenic shock with or without out-of-hospital cardiac arrest

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
M Thoegersen ◽  
M Frydland ◽  
O Helgestad ◽  
LO Jensen ◽  
J Josiassen ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Cardiogenic Shock ◽  
Plasma Concentrations ◽  
Endothelial Damage ◽  
Soluble Thrombomodulin ◽  
Catheterization Laboratory ◽  
Hospital Cardiac Arrest

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Lundbeck Foundation OnBehalf Critical Cardiac Care Research Group Background Approximately half of all patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) present with out-of-hospital cardiac arrest (OHCA). Cardiogenic shock due to OHCA is caused by abrupt cessation of circulation, whereas AMICS without OHCA is due to cardiac failure with low cardiac output. Thus, there may also be differences between the two conditions in terms of blood borne biomarkers. Purpose To explore the potential differences in the admission plasma concentrations of biomarkers reflecting tissue perfusion (lactate), neuroendocrine response (mid-regional proadrenomedullin [MRproADM], Copeptin, pro-atrial natriuretic peptide [proANP]), endothelial damage (Syndecan-1, soluble thrombomodulin [sTM]), inflammation (soluble suppression of tumorigenicity 2 [sST2]) and kidney injury (neutrophil gelatinase-associated lipocalin [NGAL]), in patients with AMICS presenting with or without OHCA. Method Consecutive patients admitted for acute coronary angiography due to suspected ST-elevation myocardial infarction (STEMI) were enrolled during a 1-year period. A total of 2,713 patients were screened. In the present study 86 patients with confirmed STEMI and CS at admission were included. Results Patients with OHCA (had significantly higher median admission concentrations of Lactate (6,9 mmol/L vs. 3.4 mmol/L p <0.001), NGAL (220 ng/ml  vs 150 ng/ml p = 0.046), sTM (10 ng/ml vs. 8.0  ng/ml p = 0.026) and Syndecan-1 (160 ng/ml vs. 120 ng/ml p= 0.015) and significantly lower concentrations of MR-proADM (0.85 nmol/L  vs. 1.6 nmol/L p <0.001) and sST2 (39 ng/ml vs. 62 ng/ml p < 0.001).  After adjusting for age, sex, and time from symptom onset to coronary angiography, lactate (p = 0.008), NGAL (p = 0.03) and sTM (p = 0.011) were still significantly higher in patients presenting with OHCA while sST2 was still significantly lower (p = 0.029). There was very little difference in 30-day mortality between the OHCA and non-OHCA groups (OHCA 37% vs. non-OHCA 38%). Conclusion Patients with STEMI and CS at admission with or without concomitant OHCA had similar 30-day mortality but differed in terms of Lactate, NGAL, sTM and sST2 levels at the time of admission to catheterization laboratory. These findings propose that non-OHCA and OHCA patients with CS could be considered as two individual clinical entities. Abstract Figure. Level of biomarkers OHCA vs. non-OHCA

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