Predictive value of outcome scores in patients suffering from cardiogenic shock complicating AMI

Abstract

Acute myocardial infarction (AMI) is complicated by cardiogenic shock (CS) in 7-10% of cases and the mortality rate is about 60-70% [13,16]. Early revascula rization by percutaneous coronary inter vention (PCI) and intensive care includ ing positive inotropic agents, vasopres sors, and circulatory assist devices are routinely used to improve cardiac output and to prevent multiorgan failure [1,5,16]. Intraaortic balloon pump (IABP) is a commonly used mechanical support sys tem for patients with CS [25,33]. Despite intensive therapy, these patients often de velop a systemic inflammatory response syndrome (SIRS) progressing to multiple organ dysfunction syndrome (MODS) and subsequent death due to multiple or gan failure [6,39]. Identification of these patients in the ICU is clinically important [34]. Previous studies of patients with MODS or sepsis have shown the rele vance of several scoring systems such as the APACHE II [22,42,43] Originalien culation is more complex and laborious. However, a scoring system is only valid for a special group of patients when it has been validated on this group. The objec tive of the present study was to evaluate the predictive value of the APACHE II, APACHE III, Elebute-Stoner, SOFA, and SAPS II scores on mortality, determined on the day of diagnosis/admission of infarctionrelated CS patients and at the point of maximum value. Methods Inclusion and exclusion criteriaPatients treated with primary PCI for CS secondary to AMI, who required inotro pic and/or vasopressor support despite appropriate volume filling, were includ ed in the study. For the diagnosis of CS, the definitions of Hochman et al. [16] and Reynolds et al. [36] were used. The inclu sion and exclusion criteria are shown in . Tab. 1. Study designIn this prospective observational study, carried out in a medical intensive care unit of a university hospital from 2004 to 2005, we consecutively enrolled 45 pa tients in CS. Patients underwent regu lar clinical assessment, complete inva sive monitoring, and frequent blood sam pling for laboratory markers. Datasets for the APACHE II, APACHE III, ElebuteStoner, SOFA, and SAPS II scores and for the patient parameters were calcu lated. Written informed consent was ob tained from all patients or their relatives. The trial was approved by the local eth ics committee. Primary endpointsThe primary endpoint was the value of the initial and the maximum value of the APACHE II, APACHE III, ElebuteStoner, SOFA, and SAPS II scores in pre dicting mortality. Scores were collected at enrollment and then daily for 4 days. Demographic data, admission diagnosis, mechanical ventilation, IABP use, hemo dynamic parameters, survivors, and non survivors were recorded. The APACHE II, APACHE III, Elebute-Stoner, SOFA, and SAPS II scores were determined by the worst value found during the initial 24 h after ICU admission and also by the max imum value during the following 96 h.A flowchart of the study is shown in . Fig. 1. Coronary angiography and PCICoronary angiography and PCI were per formed using...

Clinical picture and risk prediction of short‐term mortality in cardiogenic shock

“…It derives from increased lactate production in hypoperfusion states or decreased lactate clearance that may also be secondary to liver dysfunction. Indeed, multiorgan damage and failure, or systemic pathways activated in the state of cardiogenic shock, have been suggested to contribute to the detrimental prognosis …”

Ventricular Assist Device in Acute Myocardial Infarction

“…Early outcomes may be improved by optimizing hemodynamics and perfusion with MCS and vasoactive agents. However, once there is a systemic inflammatory state and multisystem organ failure, even full mechanical support and normalization of cardiac output may not improve survival, which is no longer mediated by hypoperfusion alone (19,20). Further studies are therefore needed to address several questions, including the ideal timing of MCS, the role of TCS, and identification of patients who do not derive benefits from MCS.…”

Predictors of mortality in patients with cardiogenic shock treated with primary percutaneous coronary intervention and intra-aortic balloon counterpulsation

“…Risk scores have gained increasing importance for decision making in critically ill patients. Currently, the APACHE II and the SAPS II scores are the most useful ICU assessment tools for the prognostic outcome of critically ill patients (Knaus et al, 1985;LeGall et al, 1984), but for CS patients these scores are less useful, since a recent study reported sensitivity and specificity rates below 80% in a contemporary CS cohort (Kellner et al, 2013).…”

“…Moreover, currently available ICU outcome scores appear to be inappropriate to guide the management of CS patients (Kellner et al 2013).…”