07 Sep 08
Posted in Coronary artery disease, Heart failure/Cardiogenic shock, Inotropic support at 19:27 by Laci
By JT Fuhrmann, A Schmeisser, MR Schulze, C Wunderlich, SP Schoen, T Rauwolf, C Weinbrenner, RH Strasser
Critical Care Medicine 2008:36:2257-2266
Cardiogenic shock is the leading cause of death in patients hospitalized for acute myocardial infarction. The objectives were to investigate the effects of levosimendan, a novel inodilator, compared with the phosphodiesterase-III inhibitor enoximone in refractory cardiogenic shock complicating acute myocardial infarction, on top of current therapy.
Design
Prospective, randomized, controlled single-center clinical trial.
Setting
Medical and coronary intensive care unit in a university hospital.
Patients
Thirty-two patients with refractory cardiogenic shock for at least 2 hrs requiring additional therapy.
Interventions
Infusion of either levosimendan (12 ug/kg over 10 min, followed by 0.1 ug/kg/min over 50 min, and of 0.2 ug/kg/min for the next 23 hrs) or enoximone (fractional loading dose of 0.5 mg/kg, followed by 2-10 ug/kg/min continuously) after initiation of current therapy, always including revascularization, intra-aortic balloon pump counterpulsation, and inotropes.
Measurements and main results
Survival rate at 30 days was significantly higher in the levosimendan-treated group (69%, 11 of 16) compared with the enoximone group (37%, 6 of 16, p = 0.023). Invasive hemodynamic parameters during the first 48 hrs were comparable in both groups. Levosimendan induced a trend toward higher cardiac index, cardiac power index, left ventricular stroke work index, and mixed venous oxygen saturation. In addition, lower cumulative values for catecholamines at 72 hrs and for clinical signs of inflammation were seen in the levosimendan-treated patients. Multiple organ failure leading to death occurred exclusively in the enoximone group (4 of 16 patients).
Conclusions
In severe and refractory cardiogenic shock complicating acute myocardial infarction, levosimendan, added to current therapy, may contribute to improved survival compared with enoximone.
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16 Aug 08
Posted in Coronary artery disease, Heart failure/Cardiogenic shock at 20:57 by Laci
By M Hamon, D Agostini, O Le Page, J Riddell, M Hamon
Crit Care Med 2008;36:2023-2033
The objective of this study was to examine the relationship between right ventricular involvement (RVI) in acute myocardial infarction (AMI) and the increase in mortality and morbidity frequently suggested in the last two decades.
Design
The authors conducted a systematic review and meta-analysis.
Setting
This study was conducted at an academic medical center.
Data Source
The authors reviewed PubMed, BioMedCentral, and the Cochrane database and conducted a manual review of article bibliographies.
Study Selection and Data Extraction
Using a prespecified search strategy, 22 relevant studies involving a total of 7,136 patients with AMI at baseline, of whom 1,963 had RVI (27.5%), were included in a meta-analysis using a random effects model. Pooled relative risks of the impact of RVI on patient mortality and morbidity were calculated.
Main Results
An overall pooled relative risk mortality increase of 2.59 (95% confidence interval, 2.02-3.31) was found (Z = 7.57; p < .00001). RVI in AMI was also associated with a statistically significant increase in all secondary end points assessed, including cardiogenic shock, ventricular arrhythmias, advanced atrioventricular block, and mechanical complications.
Conclusions
Our results support the view that early recognition of RVI, namely by means of right electrocardiographic leads in acute myocardial infarction, may have prognostic value. Whether or not this recognition will permit improvement of outcomes through more aggressive percutaneous coronary intervention would need to be tested in future studies.
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25 Jul 08
Posted in Echocardiography, Heart failure/Cardiogenic shock, Sepsis at 16:47 by Laci
By A Vieillard-Baron, V Caille, C Charron, G Belliard, B Page, F Jardin
Crit Care Med 2008;36:1701-1706
To evaluate the actual incidence of global left ventricular hypokinesia in septic shock.
Method
All mechanically ventilated patients treated for an episode of septic shock in our unit were studied by transesophageal echocardiography, at least once a day, during the first 3 days of hemodynamic support. In patients who recovered, echocardiography was repeated after weaning from vasoactive agents. Main measurements were obtained from the software of the apparatus. Global left ventricular hypokinesia was defined as a left ventricular ejection fraction of <45%.
Measurements and Main Results
During a 3-yr period (January 2004 through December 2006), 67 patients free from previous cardiac disease, and who survived for >48 hrs, were repeatedly studied. Global left ventricular hypokinesia was observed in 26 of these 67 patients at admission (primary hypokinesia) and in 14 after 24 or 48 hrs of hemodynamic support by norepinephrine (secondary hypokinesia), leading to an overall hypokinesia rate of 60%. Left ventricular hypokinesia was partially corrected by dobutamine, added to a reduced dosage of norepinephrine, or by epinephrine. This reversible acute left ventricular dysfunction was not associated with a worse prognosis.
Conclusion
Global left ventricular hypokinesia is very frequent in adult septic shock and could be unmasked, in some patients, by norepinephrine treatment. Left ventricular hypokinesia is usually corrected by addition of an inotropic agent to the hemodynamic support.
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19 Jul 08
Posted in Arrhythmia, Heart failure/Cardiogenic shock at 18:43 by Laci
By D Roy, M Talajic, S Nattel, D G Wyse, P Dorian, et al for the Atrial Fibrillation and Congestive Heart Failure Investigators
NEJM 2008;358:2667-2677
It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome. However, the benefits and risks of this approach have not been adequately studied.
Methods
We conducted a multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes.
Results
A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup.
Conclusions
In patients with atrial fibrillation and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy.
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