Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.
Objectives: We applied the cardiovascular angiography and interventions (SCAI) shock staging system to patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) who were enrolled in the National Cardiogenic Shock Initiative (NCSI). Background: The SCAI shock staging system provides a framework for evaluation of patients with CS based on clinical and hemodynamic parameters, but has not been validated in patients with AMI-CS managed with a contemporary treatment algorithm that incorporates early use of Impella. Methods: Consecutive patients enrolled in NCSI were identified, all of whom were managed with invasive hemodynamic guidance and supported with Impella. Patients were retrospectively categorized into appropriate SCAI shock stages, and outcomes were assessed accordingly. Results: A total of 300 patients were included in the analysis; 182 patients (61%) presented in Stage C shock, 25 (8%) in Stage D, and 93 (31%) in Stage E. Survival to hospital discharge was 76, 76, and 58%, respectively (p = .006). Survival was <20% among patients in Stage E at 24 hr, regardless of baseline stage. There was near perfect agreement in shock staging between two independent clinicians at baseline (kappa = 0.975, 95% CI, 0.95-1.00, p < .001) and at 24 hr (kappa = 0.985, 95% CI, 0.77-1.00, p < .001). Conclusion: In patients with AMI-CS enrolled in NCSI, SCAI Shock classification was reproducible, and predicted survival when applied at presentation and at 24 hr.
Background:
Invasive fractional flow reserve (FFR
INV
) is the standard technique for assessing myocardial ischemia. Pressure distortions and measurement location may influence FFR
INV
interpretation. We report a technique for performing invasive fractional flow reserve (FFR
INV
) by minimizing pressure distortions and identifying the proper location to measure FFR
INV
.
Methods:
FFR
INV
recordings were obtained prospectively during manual hyperemic pullback in 100 normal and diseased coronary arteries with single stenosis, using 4 measurements from the terminal vessel, distal-to-the-lesion, proximal vessel, and guiding catheter. FFR
INV
profiles were developed by plotting FFR
INV
values (
y
-axis) and site of measurement (
x
-axis), stratified by stenosis severity. FFR
INV
≤0.8 was considered positive for lesion-specific ischemia.
Results:
Erroneous FFR
INV
values were observed in 10% of vessels because of aortic pressure distortion and in 21% because of distal pressure drift; these were corrected by disengagement of the guiding catheter and re-equalization of distal pressure/aortic pressure, respectively. There were significant declines in FFR
INV
from the proximal to the terminal vessel in normal and stenotic coronary arteries (
P
<0.001). The rate of positive FFR
INV
was 41% when measured from the terminal vessel and 20% when measured distal-to-the-lesion (
P
<0.001); 41.5% of positive terminal measurements were reclassified to negative when measured distal-to-the-lesion. Measuring FFR
INV
20 to 30 mm distal-to-the-lesion (rather than from the terminal vessel) can reduce errors in measurement and optimize the assessment of lesion-specific ischemia.
Conclusions:
Meticulous technique (disengagement of the guiding catheter, FFR
INV
pullback) is required to avoid erroneous FFR
INV
, which occur in 31% of vessels. Even with optimal technique, FFR
INV
values are influenced by stenosis severity and the site of pressure measurement. FFR
INV
values from the terminal vessel may overestimate lesion-specific ischemia, leading to unnecessary revascularization.
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