Racial Differences in the RAAS and its Relationship to Electrolyte Losses in Collegiate Athletes

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Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock.

OBJECTIVES: This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). BACKGROUND: In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). METHODS: From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. RESULTS: Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). CONCLUSIONS: In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Cardiogenic Shock.

OBJECTIVES: This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). BACKGROUND: In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). METHODS: From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. RESULTS: Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). CONCLUSIONS: In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support

Impact of early mechanical support in patients with acute myocardial infarction complicated by cardiogenic shock with culprit left main coronary artery disease: Insights from national cardiogenic shock initiative

Background: Previous retrospective studies have demonstrated unacceptably high hospital mortality (60-65%) in patients presenting with acute myocardial infarction complicated by cardiogenic shock (AMICS) undergoing primary percutaneous coronary intervention (PCI) of a culprit left main coronary artery (LMCA). We sought to assess the impact of early mechanical support (MCS) specifically in this cohort using data from the National Cardiogenic Shock Initiative, a single-arm, prospective, multicenter study. Methods: Between July 2016 and August 2018, 23 sites participated in the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the \u27SHOCK\u27 trial with an additional exclusion criterion being use of intra-aortic balloon pump counter-pulsation prior to MCS. Results: Out of a total of 104 patients enrolled, 16 patients had a culprit LMCA. In the culprit LMCA cohort, the mean age was 64 ± 11 years and 75% were males. Prior to MCS, 25% had witnessed out of hospital cardiac arrest, 25% had in-hospital cardiac arrest and 32% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 87% of patients had an MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 84% of patients. Cardiac power output improved from 0.68 W pre-procedure to 0.98 W 24-hours post-procedure (p = 0.04). TIMI III flow was achieved in 88% of patients post-reperfusion. Mean length of stay was 16 days. Left ventricle ejection fraction improved from 12.5 ± 3.8 % baseline to 25.6 ± 9.6 % at the time of discharge (p = 0.002). Survival to explant was 94% and survival to discharge was 75%. Conclusions: Early MCS in patients with AMICS with a culprit LMCA was associated with rapid improvement in hemodynamics and improved survival to discharge

Culprit-Vessel Versus Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: Insights From the National Cardiogenic Shock Initiative

Background: The National Cardiogenic Shock Initiative (NCSI) is a single-arm, prospective, multicenter study to assess clinical outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). We aim to determine if patients with AMICS with MCS benefit from culprit versus multivessel PCI. Methods: From July 2016 to February 2019, patients who presented with AMICS to the 35 participating hospitals were included in the study and were treated using a standard protocol with invasive hemodynamic monitoring, early MCS, and PCI. Patients with multivessel coronary artery disease (MVCAD) were analyzed on the basis of culprit-only PCI (CV-PCI) versus multivessel PCI (MV-PCI). Results: Among 171 patients included in the NCSI, 108 had MVCAD, of whom 69 underwent MV-PCI (64%) and 39 CV-PCI (36%). The mean ages were 64.8 years for the MV-PCI group and 63.2 years for the CV-PCI group; in both groups, the majority were men (81.2% and 79.5%). Patients who underwent MV-PCI had higher frequencies of diabetes (44.6% vs. 40.5%), heart failure (34.4% vs. 22.2%), prior myocardial infarction (24.2% vs. 15.8%), and prior stroke (14.1% vs. 5.4%) and a lower frequency of chronic kidney disease (12.3% vs. 18.4%) compared with those who underwent CV-PCI. In-hospital mortality was not significantly different between groups (29% for MV-PCI vs. 25.6% for CV-PCI; p = 0.824), as well as the rate of acute kidney injury (AKI) (65.1% vs. 61.1%; p = 0.828). Conclusion: Among patients with AMICS supported with MCS, the in-hospital mortality and incidence of AKI were not significantly different if they underwent multivessel or culprit vessel PCI. Further randomized controlled trials are needed to evaluate multivessel versus culprit vessel PCI in cardiogenic shock with the use of MCS