Primary Angioplasty For Patients in Cardiogenic Shock: Optimal Management

Abstract

CoronaryCardiogenic shock is a clinical condition of inadequate end-organ perfusion due to cardiac dysfunction (see Table 1). It most commonly occurs in the setting of acute MI with left ventricular failure (~80 % cases), 1,2 but can also be caused by right ventricular infarction or late mechanical complications, such as acute mitral regurgitation or ventricular rupture (septal or free wall). Non-infarct-related cardiogenic shock is comparatively rare, and may result from decompensated valvular heart disease and arrhythmias, to name a few mechanisms.The pathophysiology of cardiogenic shock is complex. Myocardial ischaemia induces marked depression of myocardial contractility, this sets into motion a downward spiral of reduced cardiac output and hypotension, which in turn drives further myocardial ischaemia. Incidence and Prognosis of Cardiogenic ShockCardiogenic shock complicates 5-10 % of acute MI cases, and despite advances in acute care there remains the same incidence (~60,000-70,000 patients per year in Europe). 2,4 Historically, MI complicated by cardiogenic shock was associated with a mortality rate of 80-90 %. 5 However, with advances in coronary reperfusion techniques over the past few decades, especially with the introduction of primary percutaneous coronary intervention (PCI), the mortality rate has improved to below 50 %. 4,[6][7][8][9][10][11][12] The trend towards better outcomes may also be due to greater awareness of the need for timely treatment, improvements in the medical care of haemodynamically unstable patients as well as the use of mechanical support devices, although this has not yet been clearly demonstrated.Despite this high mortality rate, it is important to note that patients with cardiogenic shock who survive to discharge have a long-term outcome similar to that of patients without cardiogenic shock, with a good functional outcome at 1 year. 13,14 This highlights the importance of improving the chance of early survival among patients in cardiogenic shock. Management Myocardial ReperfusionThere is evidence that the high mortality rates associated with cardiogenic shock have improved over time. 7,9,11,15,16 This benefit is thought to be due to increased use of coronary revascularisation strategies, which, by restoring flow to the ischaemic myocardium, can limit infarct size as well as interrupt the downward spiral that characterises cardiogenic shock. 7,9,15 As such, the cornerstone of the management of cardiogenic shock complicating acute MI is prompt revascularisation, as highlighted in AbstractCardiogenic shock complicates approximately 5-10 % of all MI events and remains the most common cause of death among MI cases. Over the past few decades, the mortality rate associated with cardiogenic shock has decreased with the introduction of early revascularisation, although there are limited data for patients with triple-vessel disease and left main stem disease. In more recent years, there have been a number of advances in the mechanical circulatory support devices that can help improv...

Steps To Prevent Mortality in a Patient with Coinciding Severe Sepsis and Cardiogenic Shock Post-Non-ST-Elevation Myocardial Infarction (NSTEMI): A Case Report

“…The patient’s global registry of acute coronary events (GRACE) score was 204 points, and the thrombolysis in myocardial infarction (TIMI) score was 7 points. The patient met four of the criteria for severe sepsis [ 7 ], requiring transfer to the intensive care unit (ICU), placement on intravenous (IV) fluids, and cefepime. The infectious disease team was consulted, and plans for a peripherally inserted central catheter (PICC) were made for high-volume antibiotic administration once WBC levels decreased.…”

“…Decreased heart function secondary to cardiac muscle death results in decreased blood flow and oxygen delivery to other organ systems, leading to complications such as acute kidney injury (AKI), a risk factor for inpatient mortality [ 6 ]. In addition, a fatal complication that follows 5% to 10% of MIs is the occurrence of cardiogenic shock, which is the most common cause of death post-MI [ 7 ].…”