Functional Status and Quality of Life After Emergency Revascularization for Cardiogenic Shock Complicating Acute Myocardial Infarction

Sleeper, Lynn A.; Ramanathan, Krishnan; Picard, Michael H.; LeJemtel, Thierry H.; White, Harvey D.; Džavík, Vladimir; Tormey, Deborah; Avis, Nancy E.; Hochman, Judith S.; Investigators, Shock

doi:10.1016/j.jacc.2005.01.061

Cited by 90 publications

(41 citation statements)

References 11 publications

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“…Functional status in the SHOCK trial. 60 The majority of patients who survived 2 weeks after discharge had good functional status (and quality of life) at that time point. Functional status continued to be good up to 1 year after the event.…”

Section: Disclosuresmentioning

confidence: 93%

“…Already at 2 weeks after discharge, 75.9% of patients assigned to revascularization and 62.5% of patients assigned to medical stabilization in the SHOCK trial were in New York Heart Association functional class I to II ( Figure 6). 60 Among patients who were in functional class III to IV at 2 weeks, 55% of survivors improved to class I to II by 1 year. Similarly, in a series of CS patients treated with early revascularization, 80% of survivors were completely asymptomatic at a median of 18 months, and all were in functional class I to II.…”

Section: Long-term Survival and Quality Of Lifementioning

confidence: 99%

“…59 Despite a higher prevalence of triple-vessel or left main disease and diabetes mellitus in patients who underwent CABG compared with PCI, survival and quality of life were similar. 59,60 The rate of emergency CABG in CS is much lower in the community (Ͻ10%). 4 Survival in patients with CS who have CABG may improve further with advancing surgical techniques.…”

Section: Circulation February 5 2008mentioning

confidence: 99%

“…ERV indicates early revascularization; IMS, initial medical stabilization. Reprinted from Sleeper et al, 60 copyright © 2005, with permission from The American College of Cardiology Foundation. Figure 5.…”

Section: Disclosuresmentioning

confidence: 99%

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Cardiogenic Shock

2008

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ardiogenic shock (CS) occurs in Ϸ5% to 8% of patients hospitalized with ST-elevation myocardial infarction (STEMI). Recent research has suggested that the peripheral vasculature and neurohormonal and cytokine systems play a role in the pathogenesis and persistence of CS. Early revascularization for CS improves survival substantially. New mechanical approaches to treatment are available, and clinical trials are feasible even in this high-risk population. Most importantly, hospital survivors have an excellent chance for long-term survival with good quality of life. This review will outline the causes, pathophysiology, and treatment of CS with a focus on CS complicating myocardial infarction (MI.) The case will be made for viewing CS as a serious disorder with a high early death rate, but one that is treatable and that, if approached aggressively, can result in full recovery. The diagnosis is usually made with the help of pulmonary artery (PA) catheterization; however, Doppler echocardiography may also be used to confirm elevation of LV filling pressures. 1 Hypoperfusion may be manifest clinically by cool extremities, decreased urine output, and/or alteration in mental status. Hemodynamic abnormalities form a spectrum that ranges from mild hypoperfusion to profound shock, and the short-term outcome is directly related to the severity of hemodynamic derangement. MI with LV failure remains the most common cause of CS. It is critical to exclude complicating factors that may cause shock in MI patients. Chief among these are the mechanical complications: ventricular septal rupture, contained free wall rupture, and papillary muscle rupture. Mechanical complications must be strongly suspected in patients with CS complicating nonanterior MI, particularly a first MI. Echocardiography is the technique of choice to rule out these entities and should be performed early unless the diagnosis is extensive anterior MI and the patient is undergoing prompt percutaneous coronary intervention (PCI). In addition, the detection of valvular disease before angiography may alter the revascularization approach. Diagnosis and CausesHemorrhage, infection, and/or bowel ischemia may contribute to shock in the setting of MI. As with mechanical complications, a high index of suspicion is required to make these diagnoses in MI patients, and survival may depend on timely recognition and treatment.Any cause of acute, severe LV or RV dysfunction may lead to CS. Acute myopericarditis, tako-tsubo cardiomyopathy, and hypertrophic cardiomyopathy may all present with ST elevation, release of cardiac markers, and shock in the absence of significant coronary artery disease. Stress-induced cardiomyopathy, also known as apical ballooning or takotsubo cardiomyopathy, is a syndrome of acute LV dysfunction after emotional or respiratory distress that leads to CS in 4.2% of cases. 2 Acute valvular regurgitation, typically caused by endocarditis or chordal rupture due to trauma or degenerative disease, may also cause CS. Aortic dissection may lead to CS via acute,...

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Section: Disclosuresmentioning

confidence: 93%

Section: Long-term Survival and Quality Of Lifementioning

confidence: 99%

Section: Circulation February 5 2008mentioning

confidence: 99%

Section: Disclosuresmentioning

confidence: 99%

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Cardiogenic Shock

2008

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“…Informações recentes sobre a evolução mais tardia de pacientes com choque cardiogênico na fase aguda do infarto e que sobreviveram demonstram que na fase mais tardia, após um ano do quadro agudo, a maioria apresenta-se em classe funcional I ou II (NYHA), mantendo uma qualidade de vida bastante adequada 402 .…”

Section: -Insuficiência Cardíacaunclassified

Diretrizes

2009

Arq. Bras. Cardiol.

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-Atendimento pré-hospitalarO interesse no atendimento pré-hospitalar do infarto agudo do miocárdio (IAM) teve início na década de 1960, devido ao grande número de óbitos que ocorriam antes que os paciente chegassem ao hospital.A maioria das mortes por IAM ocorre nas primeiras horas de manifestação da doença, sendo 40%-65% dos casos na primeira hora e, aproximadamente, 80% nas primeiras 24 horas [1][2][3] . Assim, a maior parte das mortes por IAM acontece fora do ambiente hospitalar, geralmente desassistidas pelos médicos 4 . A modalidade mais frequente de parada cardiorrespiratória nas primeiras horas do IAM é a fibrilação ventricular 3 . -Período pré-hospitalar.O período pré-hospitalar compreende dois momentos: a) do início dos sintomas (geralmente dor torácica aguda) até a decisão de procurar atendimento; b) da decisão de procurar atendimento até a chegada ao hospital.No infarto agudo do miocárdio com elevação do segmento ST (IAMCST), o tempo desde o início dos sintomas (oclusão da artéria coronária) até a instituição do tratamento (reperfusão química ou mecânica) é diretamente proporcional à ocorrência de eventos clinicamente relevantes. Esse tempo é fator fundamental para o benefício do tratamento, tanto imediato quanto tardio 5 .No entanto, sabe-se que a fase pré-hospitalar (em ambos os momentos descritos) é caracterizada por ser demorada, especialmente em pacientes idosos, do sexo feminino e com baixa condição socioeconômica 4 . Alguns fatores estão relacionados ao aumento desse tempo tão precioso (Quadro 1.1.1.1) 6 . O componente pré-hospitalar no atraso do atendimento ao paciente com dor torácica é de tal magnitude que, na prática clínica, apenas cerca de 20% destes pacientes chegam ao setor de emergência com até duas horas após o início dos sintomas 7 . -Medidas na fase pré-hospitalarApesar da significativa redução da mortalidade hospitalar do IAM nas últimas décadas 8,9 , houve pouco avanço no conhecimento sobre a epidemiologia e o tratamento na fase pré-hospitalar. É notória a necessidade de mudanças nesse cenário, embora poucas sejam as evidências geradas para este fim.A abordagem do paciente com suspeita de síndrome coronária aguda em ambiente extra-hospitalar deve, idealmente, ser feita por profissional de saúde, com realização de uma história clínica direcionada, investigando as características dos sintomas atuais (momento do início, tempo de duração, qualidade, intensidade, relação com o esforço e repouso) e a presença de doença coronária estabelecida (angina prévia). Algumas características são reconhecidamente determinantes para a manifestação atípica de um evento coronariano e devem ser lembradas quando um indivíduo for abordado na fase pré-hospitalar, por mascararem o quadro de IAM (Tabela 1.1.2.1) [10][11][12] .O eletrocardiograma executado no local de atendimento e interpretado por um médico habilitado (na ambulância ou em local remoto) mostrou ser um método que reduz em 34% o tempo porta-agulha e em 18% o tempo porta-balão, além de proporcionar maiores taxas de tempo porta-balão ideal (men...

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