09 Jan 10

Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock

Posted in Heart failure/Cardiogenic shock, IABP at 0:44 by Laci

By R Prondzinsky, H Lemm, M Swyter, N Wegener, S Unverzagt et al

Crit Care Med 2010;38:152-160

Patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction with cardiogenic shock (CS) are often treated with intra-aortic balloon pump counterpulsation (IABP), even though the evidence to support this is limited. We determined whether IABP as an addition to PCI-centered therapy ameliorates multiorgan dysfunction syndrome (MODS) in patients with acute myocardial infarction complicated by CS.

Design
A prospective, randomized, controlled, open-label clinical trial recruiting patients between March 2003 and June 2004

Setting
Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: The prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndromeTertiary care university hospital.

Patients and interventions
Forty-five consecutive patients with AMI and CS undergoing PCI were randomized to treatment with or without IABP.

Measurements and main results
Acute Physiology and Chronic Health Evaluation (APACHE) II scores (primary outcome measure), hemodynamic values, inflammatory markers, and plasma brain natriuretic peptide (BNP) levels (secondary outcomes) were collected over 4 days from randomization. The prospective hypothesis was that adding IABP therapy to “standard care” would improve CS-triggered MODS. The addition of IABP to standard therapy did not result in a significant improvement in MODS (measured by serial APACHE II scoring over 4 days). IABP use had no significant effect on cardiac index or systemic inflammatory activation, although BNP levels were significantly lower in IABP-treated patients. Initial and serial APACHE II scoring correlated with mortality better than cardiac index, systemic inflammatory state, and BNP levels in this group of patients. Nonsurvivors had significantly higher initial APACHE II scores (29.9 ± 2.88) than survivors (18.1 ± 1.66, p < .05). Nevertheless, discrepancies among patients within the groups cannot be ruled out and might interfere with our results.

Conclusions
In this randomized trial addressing addition of IABP in CS patients, mechanical support was associated only with modest effects on reduction of APACHE II score as a marker of severity of disease, improvement of cardiac index, reduction of inflammatory state, or reduction of BNP biomarker status compared with medical therapy alone. However, the limitations of our present trial preclude any definitive conclusion, but request for a larger prospective, randomized, multicentered trial with mortality as primary end point.

27 Oct 09

Hemodynamic variables and mortality in cardiogenic shock

Posted in Heart failure/Cardiogenic shock, Monitoring at 0:01 by Laci

By C Torgersen, C Schmittinger, S Wagne, H Ulmer, J Takala, S Jakob and M Dunser

Critical Care 2009,13:R157

Despite the key role of hemodynamic goals, there are few data addressing the question as to which hemodynamic variables are associated with outcome or should be targeted in cardiogenic shock patients. The aim of this study was to investigate the association between hemodynamic variables and cardiogenic shock mortality.

Methods
Medical records and the patient data management system of a multidisciplinary intensive care unit (ICU) were reviewed for patients admitted because of cardiogenic shock. In all patients, the hourly variable time integral of hemodynamic variables during the first 24 hours after ICU admission was calculated. If hemodynamic variables were associated with 28-day mortality, the hourly variable time integral of drops below clinically relevant threshold levels was computed. Regression models and receiver operator characteristic analyses were calculated. All statistical models were adjusted for age, admission year, mean catecholamine doses and the Simplified Acute Physiology Score II (excluding hemodynamic counts) in order to account for the influence of age, changes in therapies during the observation period, the severity of cardiovascular failure and the severity of the underlying disease on 28-day mortality.

Results
One-hundred-nineteen patients were included. Cardiac index (CI) (P=0.01) and cardiac power index (CPI) (P=0.03) were the only hemodynamic variables separately associated with mortality. The hourly time integral of CI drops <3, 2.75 (both P=0.02) and 2.5 (P=0.03) L/min/m2 was associated with death but not that of CI drops <2 L/min/m2 or lower thresholds (all P>0.05). The hourly time integral of CPI drops <0.5-0.8 W/m2 (all P=0.04) was associated with 28-day mortality but not that of CPI drops <0.4 W/m2 or lower thresholds (all P>0.05).

Conclusions
During the first 24 hours after intensive care unit admission, CI and CPI are the most important hemodynamic variables separately associated with 28-day mortality in patients with cardiogenic shock. A CI of 3 L/min/m^2 and a CPI of 0.8 W/m2 were most predictive of 28-day mortality. Since our results must be considered hypothesis-generating, randomized controlled trials are required to evaluate whether targeting these levels as early resuscitation endpoints can improve mortality in cardiogenic shock.

07 Aug 09

Early assessment of outcome in cardiogenic shock: Relevance of plasma N-terminal pro-B-type natriuretic peptide and interleukin-6 levels

Posted in BNP, Heart failure/Cardiogenic shock at 11:59 by Laci

By R Jarai, B Fellner, D Haoula, N Jordanova, G Heinz, G Karth, K Huber, A Geppert

Crit Care Med 2009;37:1837-1844

Plasma N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) levels are frequently elevated in critically ill patients and are associated with an increased mortality. In this study, we determined Nt-pro-BNP levels in patients with cardiogenic shock (CS) and evaluated its association with clinical and hemodynamic parameters and 30-day mortality.

Design
Retrospective study.

Setting
Two, eight-bed intensive care units at a university and a community hospital.

Patients
Retrospective study on stored plasma samples of 58 patients with CS, obtained at admission to the intensive care unit.

Interventions
None.

Measurements and main results
Massively elevated Nt-pro-BNP concentrations showed no significant association with duration of shock, total Sequential Organ Failure Assessment score, or invasive hemodynamic parameters at the time of blood sampling but a significant association with estimated glomerular filtration rate (p < 0.001), C-reactive protein (p = 0.03), age (p = 0.005), and body weight (p = 0.03). Both in univariate and multivariate survival analyses, Nt-pro-BNP levels above the median (>12,782 pg/mL) were significant predictors of 30-day mortality (p < 0.001) and showed a complementary role with interleukin (IL)-6 in predicting outcome. Patients with IL-6 >195 pg/mL and Nt-pro-BNP above the median value had the highest 30-day mortality (93.7%), whereas patients with lower IL-6 levels together with lower Nt-pro-BNP levels had significantly better survival (mortality rate 26.3%). Among patients who had acute myocardial infarction, those with Nt-pro-BNP concentrations above the median level showed a highly impaired clinical course even if coronary revascularization was successful (30-day mortality 90.9% vs. 29.4%, p = 0.001), whereas survival of patients with unsuccessful revascularization did not differ significantly with respect to the median of Nt-pro-BNP (30-day survival rate 81.8% vs. 75.0%, p = 0.71).

Conclusion
The massive elevations of Nt-pro-BNP observed in the early phase of CS seem to be independent of ventricular performance. Nt-pro-BNP levels are nevertheless predictive of 30-day survival in patients with CS especially in those with successful revascularization and might be used in combination with IL-6 for estimation of outcome early on.

16 Feb 09

Left ventricular function and exercise capacity

Posted in Echocardiography, Heart failure/Cardiogenic shock at 0:43 by Laci

By J Grewal, R B McCully, G C Kane, C Lam, P A Pellikka

JAMA. 2009;301:286-294

Limited information exists regarding the role of left ventricular function in predicting exercise capacity and impact on age- and sex-related differences.

Objectives
To determine the impact of measures of cardiac function assessed by echocardiography on exercise capacity and to determine if these associations are modified by sex or advancing age.

Design
Cross-sectional study of patients undergoing exercise echocardiography with routine measurements of left ventricular systolic and diastolic function by 2-dimensional and Doppler techniques. Analyses were conducted to determine the strongest correlates of exercise capacity and the age and sex interactions of these variables with exercise capacity.

Setting
Large tertiary referral center in Rochester, Minnesota, in 2006.

Participants
Patients undergoing exercise echocardiography using the Bruce protocol (N = 2867). Patients with echocardiographic evidence of exercise-induced ischemia, ejection fractions lower than 50%, or significant valvular heart disease were excluded.

Main outcome measure
Exercise capacity in metabolic equivalents (METs).

Results
Diastolic dysfunction was strongly and inversely associated with exercise capacity. Compared with normal function, after multivariate adjustment, those with moderate/severe resting diastolic dysfunction (–1.30 METs; 95% confidence interval [CI], –1.52 to –0.99; P < .001) and mild resting diastolic dysfunction (–0.70 METs; 95% CI, –0.88 to –0.46; P < .001) had substantially lower exercise capacity. Variation of left ventricular systolic function within the normal range was not associated with exercise capacity. Left ventricular filling pressures measured by resting E/e’ of 15 or greater (–0.41 METs; 95% CI, –0.70 to –0.11; P = .007) or postexercise E/e’ of 15 or greater (–0.41 METs; 95% CI, –0.71 to –0.11; P = .007) were similarly associated with a reduction in exercise capacity, each in separate multivariate analyses. Individuals with impaired relaxation (mild dysfunction) or resting E/e’ of 15 or greater had a progressive increase in the magnitude of reduction in exercise capacity with advancing age (P < .001 and P = .02, respectively). Other independent correlates of exercise capacity were age (unstandardized β coefficient, –0.85 METs; 95% CI, –0.92 to –0.77, per 10-year increment; P < .001), female sex (–1.98 METs; 95% CI, –2.15 to –1.84; P < .001), and body mass index greater than 30 (–1.24 METs; 95% CI, –1.41 to –1.10; P < .001).

Conclusion
In this large cross-sectional study of those referred for exercise echocardiography and not limited by ischemia, abnormalities of left ventricular diastolic function were independently associated with exercise capacity.

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