Pulmonary artery catheterization in acute coronary syndromes: Insights from the GUSTO IIb and GUSTO III trials

Cohen, Mauricio G.; Kelly, Robert V.; Kong, David F.; Menon, Venu; Shah, Monica; Ferreira, Jorge; Pieper, Karen S.; Criger, Douglas A.; Poggio, Rosana; Ohman, E. Magnus; Gore, Joel M.; Califf, Robert M.; Granger, Christopher B.

doi:10.1016/j.amjmed.2004.12.018

Cited by 72 publications

(29 citation statements)

References 36 publications

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“…One of these was thwarted, however, by lack of equipoise when physicians refused to enroll the majority of eligible patients (13). Since then, several multinational trials have found little evidence to support routine use of PACs in the management of patients with acute coronary syndromes (14), highrisk noncardiac surgery (15), refractory congestive heart failure (16), shock (17), acute respiratory distress syndrome (18), and critical illness (19,20).…”

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confidence: 99%

Pulmonary artery catheters: Evolving rates and reasons for use*

Koo

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Zhou

et al. 2011

Critical Care Medicine

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Pulmonary artery catheters: Evolving rates and reasons for use*

Koo

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Zhou

et al. 2011

Critical Care Medicine

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“…46 No such association has been shown in CS. 47 Individualized PA catheter use is recommended for severely hypotensive MI patients 44 ; however, many centers now choose to manage CS without PA catheterization. Clinical assessment with echocardiography is a reasonable alternative: Both PA systolic pressure and wedge pressure can be accurately estimated with Doppler echocardiography, and in particular, the finding of a short mitral deceleration time (Յ140 ms) is highly predictive of pulmonary capillary wedge pressure Ն20 mm Hg in CS.…”

Section: Hemodynamic Managementmentioning

confidence: 99%

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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“…The post hoc analysis of the data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) IIb and GUSTO III trials reported that the hazard ratio for the risk of 30-day mortality with pulmonary artery catheterization in patients without cardiogenic shock was increased almost 5-fold. 19 Although proper randomized trials are lacking in acute coronary syndromes, routine pulmonary artery catheterization is not indicated in patients with acute myocardial infarction. It should be emphasized, however, that in patients with cardiogenic shock due to left ventricular or right ventricular myocardial infarction after reperfusion therapy, the use of balloon flotation catheters to determine the hemodynamic response to supportive therapy is still necessary and strongly recommended.…”

Section: Acute Myocardial Infarctionmentioning

confidence: 99%

The Swan-Ganz Catheters: Past, Present, and Future

2009

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Abstract-The Swan-Ganz balloon flotation catheter was introduced in 1970. It can be placed at the bedside within a few minutes even in critically ill patients. Although placement of these catheters is not difficult, some training and experience are required to avoid complications and for proper interpretation of the hemodynamic data that can be obtained by pulmonary artery catheterization. Because of the many advantages of balloon flotation catheters compared with conventional catheters, they have been used without a proper indication and frequently overused in critical care units, resulting in many complications, including mortality. The prospective randomized trials have reported that in the majority of clinical circumstances, the routine use of balloon flotation catheters is not indicated. These results are not surprising because balloon flotation catheters are diagnostic and not therapeutic tools. That we have learned a great deal about hemodynamics in critically ill patients with the use of balloon flotation catheters should not be ignored or forgotten. Furthermore, our clinical knowledge of hemodynamics has been made possible because of extensive experience gained from directly determined hemodynamics with the use of balloon flotation catheters. It should also be realized that despite the introduction and refinement of newer noninvasive imaging modalities, a number of clinical circumstances exist in which determination of hemodynamics with the use of a balloon flotation catheter is necessary and should be considered, but only by experienced physicians. With the proper use of Swan-Ganz catheters, our knowledge of hemodynamics has been enhanced considerably.

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Pulmonary artery catheterization in acute coronary syndromes: Insights from the GUSTO IIb and GUSTO III trials

Cited by 72 publications

References 36 publications

Pulmonary artery catheters: Evolving rates and reasons for use*

Pulmonary artery catheters: Evolving rates and reasons for use*

Cardiogenic Shock

The Swan-Ganz Catheters: Past, Present, and Future

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