Biomarkers predictive of late cardiogenic shock development in patients with suspected ST-elevation myocardial infarction

Abstract

Background: Cardiogenic shock complicating ST-elevation myocardial infarction is characterised by progressive left ventricular dysfunction causing inflammation and neurohormonal activation. Often, cardiogenic shock develops after hospital admission. Whether inflammation and a neurohormonal activation precede development of clinical cardiogenic shock is unknown. Methods and results: In 93% of 2247 consecutive patients with suspected ST-elevation myocardial infarction admitted at two tertiary heart centres, admission plasma levels of pro-atrial natriuretic peptide, copeptin, mid-regional pro-adrenomedullin and stimulation-2 were measured on hospital admission. Patients were stratified according to no cardiogenic shock development and cardiogenic shock developed before (early cardiogenic shock) or after (late cardiogenic shock) leaving the catheterization laboratory. In total, 225 (10%) patients developed cardiogenic shock, amongst these patients late cardiogenic shock occurred in 64 (2.9%). All four biomarkers were independently associated with the development of late cardiogenic shock (odds ratio per two-fold increase in risk: 1.19–3.13) even when adjusted for the recently developed Observatoire Régional Breton sur l’Infarctus risk score for prediction of late cardiogenic shock development. Furthermore, pro-atrial natriuretic peptide, copeptin and mid-regional pro-adrenomedullin, but not stimulation-2, added significant predictive information, when added to the Observatoire Régional Breton sur l’Infarctus risk score (area under the receiver-operating characteristic curve, pro-atrial natriuretic peptide: 0.87, p=0.0008; copeptin: 0.86, p<0.05; mid-regional pro-adrenomedullin: 0.88, p=0.006). Conclusions: Pro-atrial natriuretic peptide, copeptin, mid-regional pro-adrenomedullin and stimulation-2 admission plasma concentration were associated with late cardiogenic shock development in patients admitted with suspected ST-elevation myocardial infarction. Pro-atrial natriuretic peptide, mid-regional pro-adrenomedullin and copeptin had independent predictive value for late cardiogenic shock development.

Elevated Plasma Bioactive Adrenomedullin and Mortality in Cardiogenic Shock: Results from the OptimaCC Trial

“…The present study showed that high bio-ADM at ICU admission in patients with CS complicating AMI was associated with increased mortality at 30 days. There have been several studies investigating the prognostic impact of adrenomedullin in patients with CS [ 30 , 31 , 32 ]. However, the majority of these studies used a stable fragment of the precursor molecule, mid-regional pro-ADM (MR-proADM) [ 21 ].…”

Copeptin and Stress

“…Conversely, assessing copeptin in patients with STEMI could be of prognostic importance: findings from a cohort of 401 patients with STEMI undergoing primary percutaneous coronary intervention showed copeptin levels at admission were significantly higher in non-survivors than in survivors (154.8 vs. 30.3 pmol/L) [104]. Moreover, in a cohort of more than 2000 patients with suspected STEMI, copeptin levels at admission were significantly higher in those complicating with cardiogenic shock (444 and 141 pmol/L in patients with early and late cardiogenic shock, respectively, vs. 55 pmol/L, p < 0.0001) and were independent predictors for late cardiogenic shock development, although with the lowest performance among the considered biomarkers (AUC 0.660 at cut-off values > 138 pmol/L) [105]. Data from a recent metaanalysis including 2269 patients from six studies indicate copeptin may be of prognostic importance in overall acute coronary syndrome, since it has been associated to mortality with acceptable predictive performance (AUC 0.730) [106].…”

Which patients with acute coronary syndrome need the cardiac intensive care unit: tuning the tools for risk stratification

“…In this issue of the European Heart Journal: Acute Cardiovascular Care, three reports help illustrate a path towards refined risk stratification in this population. [5][6][7] A focused clinical history and basic physical and laboratory findings remain remarkably useful for risk stratification of patients with suspected ACSs. Previously, the thrombolysis in myocardial infarction (TIMI) simple risk index (heart rate (HR) × (age/(10)) 2 /systolic blood pressure (SBP)) was developed to stratify early mortality risk in ST-segment elevation myocardial infarction (STEMI) patients.…”

“…In another important report from this issue, Frydland et al demonstrate the application of novel biomarkers to enhance the performance of the ORBI score. 6 In particular, Frydland et al found that in 2247 initially stable patients with STEMI, copeptin, mid-regional pro-adrenomedullin (MRproADM) and pro-atrial natriuretic peptide (proANP) added to the ORBI score for predicting late-onset cardiogenic shock. 6 Each of these biomarkers had a negative predictive value of 98% or greater and, when adjusted for the ORBI risk score, were associated with late-onset shock (e.g.…”

“…A low simple shock index, ORBI risk score, or hemodynamic biomarker measurements can help identify STEMI patients who are at low risk of major complications and may not need monitoring in a CICU (Figure 1). 6 In NSTEMI, a low ACTION ICU risk score or GRACE risk score might help to select a low-risk group. 11 Future advances may include the integration of novel biomarkers, multimarker profiling and advanced imaging to help direct the right patient to the right bed.…”