Cardiogenic Shock Without Flow-Limiting Angiographic Coronary Artery Disease-(from the Should We Emergently Revascularize Occluded Coronary Arteries for Cardiogenic Shock Trial and Registry)

Myocardial infarction often develops when thrombosis occurs at lesions that have not previously been flow limiting. However, the development of cardiogenic shock complicating acute myocardial infarction in such circumstances has received little attention. The characteristics of 15 patients with cardiogenic shock who had no flow-limiting angiographic stenoses were compared with those of 767 patients with >= 1 stenosis who were enrolled in the Should We Emergently Revascularize Occluded Coronary Arteries for Cardiogenic Shock (SHOCK) trial and registry. Compared with patients with 1 flow-limiting stenosis, patients with no flow-limiting stenoses were less likely to have pulmonary edema on chest x-ray (29% vs 62%, p = 0.008) and to be white (53% vs 82%, p = 0.011), and they had lower median highest creatine kinase levels (702 vs 2,731 U/L, p = 0.018). For SHOCK trial patients, 1-year survival was 49% for patients with >= 1 flow-limiting stenosis and 71% for those with no flow-limiting stenoses (p = 0.268). In conclusion, patients with cardiogenic shock without flow-limiting stenosis have different characteristics, and potentially disease mechanisms, and they do not require revascularization. (c) 2009 Elsevier Inc. (Am J Cardiol 2009;104:24-28

Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction

Context Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. Objective To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. Design, Setting, and Patients The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock ( SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock ( mean [SD] age at randomization, 66 [ 11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years ( median for survivors, 6 years). Main Outcome Measures All-cause mortality during long-term follow-up. Results The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P=. 03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed ( HR, 0.59; 95% CI, 0.36-0.95; P=. 03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect. Conclusions In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure

QRST changes during and after percutaneous transluminal coronary angioplasty

This study reports preliminary results on 45 patients who underwent percutaneous transluminal coronary angioplasty (PTCA); 120-lead data (including the 12-lead standard electrocardiogram [ECG]) were recorded before, during, and after balloon inflation. Twenty-one patients underwent PTCA for left anterior descending coronary disease, 13 for right coronary artery disease, and 10 for left circumflex; 1 patient had combined left anterior descending and right coronary artery disease. In each patient, voltage data recorded during the various phases of the procedure were compared with the patient's own baseline data. In 18 patients, 120 leads were also recorded 24 hours after PTCA. In this study, the usefulness of the standard 12-lead ECG was investigated in locating the coronary artery being occluded, in elucidating the mechanisms of the QRS changes, and in identifying changes occurring 24 hours after completion of the procedure. Results indicate that the observation of ST elevation in the 12-lead ECG may lead to ambiguous interpretation. Also, limiting observation to ST-T patterns alone instead of including QRS changes further hampers correct identification of the involved vessel. QRS modifications during inflation are interpreted as conduction disturbances, although other mechanisms are evoked: study of surface maps may contribute to the understanding of these mechanisms. Changes present 24 hours later are visible in the standard leads, but again, in the absence of the thoracic potential distribution, these are difficult to interpret. These changes were different from those observed after cessation of inflation at the end of the procedure. It is hypothesized that next-day changes may reflect reperfusion injury and/or represent myocardial stunning. Presence of injury and reversibility of changes require further investigation. Also, biochemical markers such as creatine kinase-MB mass, creatine kinase-MB activity, myoglobin, and troponin-T may help elucidate the significance of these findings. © 1994 Churchill Livingstone.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

The prognostic significance of grade of ischemia in the ECG in patients with ST-elevation myocardial infarction : A substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial)

BACKGROUND: The importance of the grade of ischemia (GI) ECG classification in the risk assessment of patients with STEMI has been shown previously. Grade 3 ischemia (G3I) is defined as ST-elevation with distortion of the terminal portion of the QRS complex in two or more adjacent leads, while Grade 2 ischemia (G2I) is defined as ST-elevation without QRS distortion. Our aim was to evaluate the prognostic impact of the GI classification on the outcome in patients with STEMI. METHODS: 7,211 patients from the TOTAL trial were included in our study. The primary outcome was a composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year. RESULTS: The primary outcome occurred in 153 of 1,563 patients (9.8%) in the G3I group vs. 364 of 5,648 patients (6.4%) in the G2I group (adjusted HR 1.27; 95% CI, 1.04 - 1.55; p=0.022). The rate of cardiovascular death (4.8% vs. 2.5%; adjusted HR 1.48; 95% CI 1.09 - 2.00; p=0.013) was also higher in patients with G3I. CONCLUSIONS: G3I in the presenting ECG was associated with an increased rate of the composite of cardiovascular death, recurrent MI, cardiogenic shock, or NYHA class IV heart failure within one year compared to patients with G2I. Patients with G3I also had a higher cardiovascular death compared to patients with G2I.publishedVersionPeer reviewe