Abstract
Introduction: Cardiogenic shock (CS) is the most extreme complication of myocardial infarction and it is the initial presentation of at least 1 in 15 patients admitted to ICCU. Despite heroic efforts, the in-hospital mortality due to CS is still very high.
Aims
- To determine the prognosis of patients admitted with cardiogenic shock as a complication of acute MI
- To stratify the risk in the above patients with respect to the levels of admission day random blood glucose, thyroid hormone levels- T3,T4,TSH, Lipid profile- Total cholesterol, triglycerides, HDL,LDL, serum uric acid, blood urea and serum creatinine.
Methodology: We conducted a prospective, observational, descriptive, intention to treat study of patients presenting with cardiogenic shock as a result of acute MI presenting to the ICCU of Government Medical College, Coimbatore. The outcome and the multiple variables (hematological and biochemical parameters) were studied so as to stratify the risk of poor prognosis.
Results & Discussion: Out of the 200 cases of cardiogenic shock included in the study, 170 cases survived and 30 patients died attributing to 15%. The mean age in the death group was 53.13 years and in the survival group was 59.7 years. Most patients presented within a window period of 6-12 hrs. Admission blood pressure <40 mmhg was associated with early mortality despite use of vasopressor agents. EF <40% was associated with early death. Thrombolytic therapy didn’t show to improve the outcome of cardiogenic shock. Age, smoking, past history of hypertension, window period, admission blood pressure < 60 mmHg , anterior wall STEMI were found to be statistically significant determinants of death. An RBS >200 mg/dl, urea >40 mg/dl, creatinine >2 mg/dl, TC >200 mg/dl, TG >150 mg/dl, HDL <40 mg/dl predicts MACE in acute MI patients. The admission time blood pressure, uric acid and urea were independently associated with bad outcomes in cardiogenic shock.
Conclusion: The prognosis of cardiogenic shock is poor despite effective early intervention methods. Early identification of risk factors can prompt prevention of MACE and hence help early treatment initiation to avoid bad prognosis in CS.
Keywords: Myocardial Infarction, ST elevation Myocardial Infarction, Shock, Coronary artery disease.
References
- Bermudez C, Rocha R, Toyoda Y, et al. Extracorporeal membrane oxygenation for advanced refractory shock in acute and chronic cardiomyopathy. Ann Thorac Surg 2011;92:2125-31. Vincent, J.L. and De Backer, D, . Circulatory Shock. N Engl J Med 18369, 1726–34 (2013).
- Reynolds, H. R. & Hochman, J. S. Cardiogenic Shock: Current Concepts and Improving Outcomes. Circulation 117, 686–697 (2008).
- Aissaoui, N., Puymirat, E., Tabone, X., Charbonnier, B., Schiele, F. Lefèvre, T., Durand, E. Blanchard, D., Simon, T., Cambou, J.P. and Danchin, N. Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: A report from the USIK 1995, USIC 2000, and FAST-MI French Nationwide Registries. Heart J. 33, 2535–2543 (2012).
- McMurray, J. J. V. et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart. Heart J. 33, 1787–1847 (2012).
- Holmes DR Jr, Bates ER, Kleiman NS, Sadowski Z, Horgan JH, MorrisDC, et al. Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol. 1995;26:668-74.
- Thiele H, Allam B, Chatellier G, Schuler G, Lafont A: Shock in acute myocardial infarction: the Cape Horn for trials? Eur Heart J 2010, 31:1828–1835.
- Valente S, Lazzeri C, Vecchio S, Giglioli C, Margheri M, Bernardo P, Comeglio M, Chiocchini S, Gensini GF: Predictors of in-hospital mortality after percutaneous coronary intervention for cardiogenic shock. Int J Cardiol 2007, 114:176–182.
- Iwakura K, Ito H, Ikushima M, Kawano S, Okamura A, Asano K, Kuroda T, Tanaka K, Masuyama T, Hori M, Fujii K: Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction. J Am Coll Cardiol 2003, 41:1–7.
- Goldberg RJ, Kramer DG, Lessard D, Yarzebski J, Gore JM: Serum glucose levels and hospital outcomes in patients with acute myocardial infarction without prior diabetes: a community-wide perspective. Coron Artery Dis 2007, 18:125–131.
- Capes SE, Hunt D, Malmberg K, Gerstein HC: Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000, 355:773–778.
- Krinsley JS, Egi M, Kiss A, Devendra AN, Schuetz P, Maurer PM, Schultz MJ,van Hooijdonk RT, Kiyoshi M, Mackenzie IM, Annane D, Stow P, Nasraway SA, Holewinski S, Holzinger U, Preiser JC, Vincent JL, Bellomo R: Diabetic status and the relation of the three domains of glycemic control tomortality in critically ill patients: an international multicenter cohortstudy. Crit Care 2013, 17:R37.
- Walsh CR, O’Donnell CJ, Camargo Jr CA, Giugliano RP, Lloyd-Jones, DM. Elevated serum creatinine is associated with 1-year mortality after acute myocardial infarction. Am Heart J 2002; 144: 1003-11.
- Brand FN, McGee DL, Kannel WB, Stokes J 3rd, Castelli WP. Hyperuricemia as a risk factor of coronary heart disease: The Framingham study. Am J Epidemiol 1985;121:11‑8.
- Balci B. The modification of serum lipids after acute coronary syndrome and importance in clinical practice. Curr Cardiol Rev. 2011;7:272-6.
- Klemperer JD, Klein I, Gomez M, et al. Thyroid hormone treatment after coronary-artery bypass surgery. N Engl J Med. 1995;333:1522–1527.
- Iervasi G, Pingitore A, Landi P, et al. Low-T3 syndrome: a strong prognostic predictor of death in patients with heart disease. Circulation. 2003;107:708–713.
Corresponding Author
Dr Poornima Nair
The Tamilnadu Dr MGR Medical University, Kerala University of Health Science
DOI: https://dx.doi.org/10.18535/jmscr/v11i9.13
