Cardiogenic shock remains the leading cause of in hospital death in acute myocardial infarction (AMI) and is associated with a mortality rate of approximately 50%. Here we investigated the 17-year trends in incidence and prognosis of AMI-induced cardiogenic shock in Västra Götaland in western Sweden, an area with approximately 1.6 million inhabitants. The study period includes the transition from thrombolysis to primary percutaneous coronary intervention (PCI) as the region-wide therapy of choice for patients with ST-elevation myocardial infarction (STEMI).
Data on patients hospitalized in cardiac care units in Västra Götaland, Sweden between 1995 and 2013 were obtained from the Swedish Websystem for Enhancement of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). We determined the incidence of cardiogenic shock among patients diagnosed with AMI and the risk of death associated with developing cardiogenic shock. We fitted logistic regression models to study which factors predicted post-AMI cardiogenic shock. Analyses were performed on complete case data as well as after multiple imputation of missing data.
Incidence of cardiogenic shock as a complication of AMI declined in western Sweden in the past decade, from 14% in 1995 to 4% in 2012. The risk of dying once cardiogenic shock had developed increased during the study period (p
To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort.
Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization.
A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic regression.
ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09-0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002-1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04-11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73-39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1-6.2)) and peak lactate (P = 0.02).
The ability to achieve complete revascularization may be strongly associated with improved in-hospital survival in patients with cardiogenic shock.
Comment In: Catheter Cardiovasc Interv. 2011 Oct 1;78(4):549-5021953751
Myocardial infarction-related cardiogenic shock is frequently complicated by acute kidney injury. We examined the influence of acute kidney injury treated with renal replacement therapy (AKI-RRT) on risk of chronic dialysis and mortality, and assessed the role of comorbidity in patients with cardiogenic shock.
In this Danish cohort study conducted during 2005-2012, we used population-based medical registries to identify patients diagnosed with first-time myocardial infarction-related cardiogenic shock and assessed their AKI-RRT status. We computed the in-hospital mortality risk and adjusted relative risk. For hospital survivors, we computed 5-year cumulative risk of chronic dialysis accounting for competing risk of death. Mortality after discharge was computed with use of Kaplan-Meier methods. We computed 5-year hazard ratios for chronic dialysis and death after discharge, comparing AKI-RRT with non-AKI-RRT patients using a propensity score-adjusted Cox regression model.
We identified 5079 patients with cardiogenic shock, among whom 13% had AKI-RRT. The in-hospital mortality was 62% for AKI-RRT patients, and 36% for non-AKI-RRT patients. AKI-RRT remained associated with increased in-hospital mortality after adjustment for confounders (relative risk=1.70, 95% confidence interval (CI): 1.59-1.81). Among the 3059 hospital survivors, the 5-year risk of chronic dialysis was 11% (95% CI: 8-16%) for AKI-RRT patients, and 1% (95% CI: 0.5-1%) for non-AKI-RRT patients (adjusted hazard ratio: 15.9 (95% CI: 8.7-29.3). The 5-year mortality was 43% (95% CI: 37-53%) for AKI-RRT patients compared with 29% (95% CI: 29-31%) for non-AKI-RRT patients. The adjusted 5-year hazard ratio for death was 1.55 (95% CI: 1.22-1.96) for AKI-RRT patients compared with non-AKI-RRT patients. In patients with comorbidity, absolute mortality increased while relative impact of AKI-RRT on mortality decreased.
AKI-RRT following myocardial infarction-related cardiogenic shock predicted elevated short-term mortality and long-term risk of chronic dialysis and mortality. The impact of AKI-RRT declined with increasing comorbidity suggesting that intensive treatment of AKI-RRT should be accompanied with optimized treatment of comorbidity when possible.
Cites: Crit Care. 2013;17(4):R14523876346
Cites: Am J Cardiol. 2002 Jan 1;89(1):73-511779529
We investigated whether prior use of calcium antagonists in 80 (16.8%) out of 477 patients (64% males) admitted with acute myocardial infarction (MI) had any impact on in-hospital mortality. Patients using calcium antagonists were slightly older (74 years vs. 72 years, 2P = 0.039) than those not taking them and fewer were male patients. Previous MI, diabetes mellitus, and prior use of aspirin, beta-blockers, and long-acting nitrates were more frequent in patients on calcium antagonists. In contrast, fewer patients on calcium antagonists prior to symptoms received thrombolytic treatment (21.3% vs. 34.8%, 2P = 0.018). The study had an observational exposed/nonexposed design, and we looked for both crude and adjusted effects. Of the 83 patients (17.4%) who died during hospitalization, 18 patients were in the calcium antagonist group (22.5%). The odds ratio (OR) for these patients to die in the hospital was 1.48 and the 95% confidence interval (CI) 0.78-2.78; 2P = 0.19. When adjusting for confounders (gender, age, smoking habit, previous MI, and diabetes mellitus, as well as prior use of aspirin, beta-blockers, long-acting nitrates, and thrombolytic treatment at entry) OR was 1.08 and 95% CI 0.57-2.05; 2P = 0.85. Thus, we found no excess in-hospital mortality in patients with acute MI using calcium antagonists prior to the onset of symptoms.
A delicate duty for ambulance personnel is to care for patients who suffer from chest pain, caused by acute myocardial infarction (AMI-patient). In Sweden pain-relieving drugs may be administered, such as: oxygen, entonox, or morphine according to the skill of the ambulance personnel. The aim of this study was to find out if AMI-patients' expressions of pain were monitored and evaluated, in which way the AMI-patients received pain-relief, and to which degree they were relieved of pain. Examinations of the records of the ambulance personnel's observations during transport of AMI-patients revealed that nine tenths of those who complained about chest pain received pain-relieving drugs. The results of the treatments varied, however, from a good rate of response to morphine to less responses to oxygen and entonox. In order to treat AMI-patients who are in need of pain-relief during their transit to hospital the ambulance personnel must possess thorough knowledge of both pain theory and communication theory. Furthermore, they need tools for assessment of pain and for administering adequate pain-relieving drugs in clinical practice. In the future it may be necessary to differentiate between ambulance personnel in routine service and those in emergency service according to their levels of education.
To examine the prevalence of acute stress disorder (ASD) after a myocardial infarction (MI) and the factors associated with its development.
Of 1344 MI patients admitted to three Canadian hospitals, 474 patients did not meet the inclusion criteria and 393 declined participation in the study; 477 patients consented to participate in the study. A structured interview and questionnaires were administered to patients 48 hours to 14 days post MI (mean +/- standard deviation = 4 +/- 2.73 days).
Four percent were classified as having ASD using the Structured Clinical Interview for DSM-IV, ASD module. The presence of symptoms of depression (Beck Depression Inventory; odds ratio (OR) = 29.92) and the presence of perceived distress during the MI (measured using the question "How difficult/upsetting was the experience of your MI?"; OR = 3.42, R(2) = .35) were associated with the presence of symptoms of ASD on the Modified PTSD Symptom Scale. The intensity of the symptoms of depression was associated with the intensity of ASD symptoms (R = .65). The models for the detection and estimation of ASD symptoms were validated by applying the regression equations to 72 participants not included in the initial regressions. The results obtained in the validation sample did not differ from those obtained in the initial sample.
The symptoms of depression and the subjective distress during the MI could be used to improve the detection of ASD.
OBJECTIVES: The objectives were to compare quality of life (QoL) after first myocardial infarction with an age- and sex-adjusted normative population and to test whether the 1-month QoL had predictive properties. DESIGN: QoL was assessed by self-administered questionnaires (SF-36 and Cardiac Health Profile) 1, 3 and 6 months after index-event. Participants were 60 consecutive patients (20% women) with a mean age of 58 +/- 7.4 years. RESULTS: Patients > or =59 years improved in Physical (PCS) and Mental Component Summary (MCS), scoring comparable to community norms at 6 months. However, patients
AIMS: To evaluate the prognosis of patients > or = 80 years old, we analysed a large, community-based population with acute myocardial infarction who received intensive observation and similar pharmacotherapy regardless of age. METHODS AND RESULTS: In a 12-year period, before the introduction of thrombolysis, 4259 consecutive patients hospitalized with acute myocardial infarction from the same hospital in Denmark were prospectively registered. Their complications and mortality in hospital, and 1 and 5 years after discharge were analysed retrospectively. Overall, in-hospital mortality was 11% for patients less than or = 80 years old. Two thirds of patients > or = 80 years old had heart failure, and cardiogenic shock was twice as common in this age group than in patients 60-69 years. Heart failure was a strong independent risk, factor for post-discharge mortality, particularly in the oldest age groups. Four out of eight patients > or = 80 years survived one year if discharged alive after experiencing in-hospital ventricular fibrillation. CONCLUSION: The life-saving potential of preventing or treating heart failure seems considerable even in the oldest patient groups. Patients > or = 80 years old who survive in-hospital ventricular fibrillation have an acceptable prognosis 1 year post-discharge.
OBJECTIVE: To explore the choice of transportation mode to hospital in patients experiencing acute myocardial infarction. METHOD: A descriptive survey study at the Coronary Care Unit of one Swedish University Hospital. The study was carried out between July 2000 and March 2001. RESULTS: The study population consisted of 114 consecutive patients with acute myocardial infarction. Thirty-two percent stated that they did not know the importance of a short delay when experiencing an acute myocardial infarction. Only 60% called the emergency service number, 112. Patients calling for an ambulance differed from those who did not in several aspects. Medical characteristics associated with ambulance use in a univariate analysis were ST-elevation myocardial infarction and prior history of myocardial infarction. There were no differences regarding gender or age. When looking at the patients' symptom-experience, patients with vertigo or nausea and severe pain chose an ambulance for transport to the hospital. The only significant reasons for not choosing an ambulance were cramping pain and the patient perceiving the symptoms not to be serious. In a multivariate analysis, ST-elevation (OR = 0.30, P = .04), unbearable symptoms (OR = 0.20, P = .03), and nausea (OR = .33, P = .04) appeared as independent predictors of ambulance use and cramping pain (OR = 5.17, P = .01) for not using an ambulance. CONCLUSIONS: Patients with acute myocardial infarction view the ambulance as an option for transportation to hospital only if they feel really sick. For that reason, it needs to be made well known to the public that ambulances are not only a mode of transport, but also provide diagnostics and treatment.