Advertisement

Early Risk Stratification of Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction Who Undergo Percutaneous Coronary Intervention

      The mortality rate of patients with cardiogenic shock complicating acute myocardial infarction remains exceedingly high despite early mechanical revascularization. Early risk stratification is of great importance to identify patients who could benefit from ventricular assist devices and urgent heart transplantation (UHT). All consecutive patients with cardiogenic shock complicating acute myocardial infarction admitted from June 2001 to December 2007 were prospectively included. Clinical, hemodynamic, and echocardiographic variables were registered on admission and patients were followed for a median of 297 days. A total of 74 patients were included. One-year mortality was 55% and 7 patients (9%) underwent UHT. One-year mortality or need for UHT for patients with postprocedural Thrombolysis In Myocardial Infarction (TIMI) grade 3, 2, and 0 or 1 flows were 38%, 92%, and 90%, respectively (p <0.001). After adjustment by multivariate analysis, the most important predictors of mortality or need for UHT were age >75 years (hazard ratio [HR] 3.56, 95% confidence interval [CI] 1.07 to 11.80), left main coronary artery occlusion (HR 3.75, 95% CI 1.09 to 12.84), left ventricular ejection fraction <25% (HR 2.70, 95% CI 1.17 to 6.22), and postprocedural TIMI grade <3 flow (HR 3.37, 95% CI 1.48 to 7.72). A simple risk score constructed with these 4 variables effectively predicted 1-year survival without the need for UHT (83% for score 0, 19% for score 1, and 6% for score 2, p <0.001). In conclusion, age >75 years, left main coronary artery occlusion, left ventricular ejection fraction <25%, and postprocedural TIMI grade <3 flow were significantly associated with worse prognosis. A simple risk score rapidly available in the catheterization laboratory can efficiently estimate prognosis.
      To read this article in full you will need to make a payment

      References

        • The TIMI Study Group
        Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction.
        N Engl J Med. 1989; 320: 618-627
        • Chodek A.
        • Angioi M.
        • Fajraoui M.
        • Moulin F.
        • Chouihed T.
        • Maurer P.
        • Mejean C.
        • Carteaux J.P.
        • Popovic B.
        • Piquemal R.
        • Ethevenot G.
        • Aliot E.
        Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention.
        Ann Cardiol Angeiol (Paris). 2005; 54: 74-79
        • Hochman J.S.
        • Sleeper L.A.
        • Webb J.G.
        • Dzavik V.
        • Buller C.E.
        • Aylward P.
        • Col J.
        • White H.D.
        Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction.
        JAMA. 2006; 295: 2511-2515
        • Jeger R.V.
        • Harkness S.M.
        • Ramanathan K.
        • Buller C.E.
        • Pfisterer M.E.
        • Sleeper L.A.
        • Hochman J.S.
        Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry.
        Eur Heart J. 2006; 27: 664-670
        • Quigley R.L.
        • Milano C.A.
        • Smith L.R.
        • White W.D.
        • Rankin J.S.
        • Glower D.D.
        Prognosis and management of anterolateral myocardial infarction in patients with severe left main disease and cardiogenic shock.
        Circulation. 1993; 88: 1165-1170
        • Webb J.G.
        • Lowe A.M.
        • Sanborn T.A.
        • White H.D.
        • Sleeper L.A.
        • Carere R.G.
        • Buller C.E.
        • Wong S.C.
        • Boland J.
        • Dzavik V.
        • et al.
        Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial.
        J Am Coll Cardiol. 2003; 42: 1380-1386
        • Singh M.
        • White J.
        • Hasdai D.
        • Hodgson P.K.
        • Berger P.B.
        • Topol E.J.
        • Califf R.M.
        • Holmes Jr, D.R.
        Long-term outcome and its predictors among patients with ST-segment elevation myocardial infarction complicated by shock: insights from the GUSTO-I trial.
        J Am Coll Cardiol. 2007; 50: 1752-1758
        • Antman E.M.
        • Anbe D.T.
        • Armstrong P.W.
        • Bates E.R.
        • Green L.A.
        • Hand M.
        • Hochman J.S.
        • Krumholz H.M.
        • Kushner F.G.
        • Lamas G.A.
        • et al.
        ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction).
        Circulation. 2004; 110: e82-e292
        • Arzamendi D.
        • Garcia-Alvarez A.
        • Roig E.
        • Benito B.
        • Kiamco R.
        • Perez-Villa F.
        • Loma-Osorio P.
        • Bosch X.
        • Pomar J.L.
        • Cartana R.
        • et al.
        New insights in the management of cardiogenic shock complicating myocardial infarction: role of urgent heart transplantation.
        J Heart Lung Transplant. 2008; 27: 984-989
        • Tayara W.
        • Starling R.C.
        • Yamani M.H.
        • Wazni O.
        • Jubran F.
        • Smedira N.
        Improved survival after acute myocardial infarction complicated by cardiogenic shock with circulatory support and transplantation: comparing aggressive intervention with conservative treatment.
        J Heart Lung Transplant. 2006; 25: 504-509
        • Webb J.G.
        • Sanborn T.A.
        • Sleeper L.A.
        • Carere R.G.
        • Buller C.E.
        • Slater J.N.
        • Baran K.W.
        • Koller P.T.
        • Talley J.D.
        • Porway M.
        • Hochman J.S.
        Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry.
        Am Heart J. 2001; 141: 964-970
        • Urban P.
        • Stauffer J.C.
        • Bleed D.
        • Khatchatrian N.
        • Amann W.
        • Bertel O.
        • van den Brand M.
        • Danchin N.
        • Kaufmann U.
        • Meier B.
        • Machecourt J.
        • Pfisterer M.
        A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction.
        Eur Heart J. 1999; 20: 1030-1038