Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock.
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ABSTRACT: Background
Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI).Objective
We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI.Methods
We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation.Results
Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs.Conclusions
Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.
SUBMITTER: Pahuja M
PROVIDER: S-EPMC8344361 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Acute limb ischemia (ALI) is a rapid decrease in lower limb blood flow due to acute occlusion of peripheral artery or bypass graft, and in ALI not only limbs but also life prognosis will be poor unless quick and appropriate treatment is given. The etiology is broadly divided into embolism and thrombosis with various comorbidities. The symptoms of ALI are abrupt with pain, numbness, and coldness of lower limb, and paresthesia, contracture, and irreversible purpura will appear with the exacerbation of ischemia. Severity and treatment strategy should be determined based on physical findings and image findings. Considering life prognosis, limb amputation should be done without hesitation when the limb was diagnosed as irreversible. ALI can be treated by means of open surgical revascularization, endovascular, or hybrid approach with rapid systemic administration of heparin. In any cases, evaluating the lesions by intraoperative angiography and appropriate additional treatment are important. ALI is a serious disease requiring urgent treatment, and it is essential to promptly perform the best initial treatment that can be performed at each facility. (This is a translation of Jpn J Vasc Surg 2018; 27: 109-114.).
| S-EPMC6326052 | biostudies-other
Project description:Cardiogenic shock complicates about 5% to 8% of all admissions for acute myocardial infarction, and despite advancement in treatment over the past 50 years, mortality remains unacceptably high. Management with vasoactive agents after revascularization can have its limitations and thus mechanical circulatory support is often initiated. Intra-aortic balloon pumps (IABPs) are the devices most commonly used worldwide. IABPs appeared to improve mortality when used along with fibrinolytic therapy but may not when used along with percutaneous coronary interventions. Extracorporeal membrane oxygenation (ECMO) is utilized in the setting of worsening tissue perfusion despite inotropes and IABP utilization. Although retrospective studies show some mortality benefit, randomized prospective studies have not yet demonstrated ECMO to be advantageous either with or without IABP. Percutaneous left ventricular assist devices such as TandemHeart® and Impella are easier to institute than ECMO and are better for hemodynamics compared with the IABP but also have not yet shown a mortality benefit. More randomized studies are needed to define the most appropriate role of the various mechanical support devices in cardiogenic shock.
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Project description:BackgroundCardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD.ObjectivesTo assess whether mechanical assist devices improve survival in people with acute cardiogenic shock.Search methodsWe searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions.Selection criteriaRandomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support.Data collection and analysisWe performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs).Main resultsThe search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing.Authors' conclusionsThere is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.
| S-EPMC7271960 | biostudies-literature
Project description:AimsThe hospitalization of patients with MI has decreased during global lockdown due to the COVID-19 pandemic. Whether this decrease is associated with more severe MI, e.g. MI-CS, is unknown. We aimed to examine the association of Corona virus disease (COVID-19) pandemic and incidence of acute myocardial infarction with cardiogenic shock (MI-CS).MethodsOn March 11, 2020, the Danish government announced national lock-down. Using Danish nationwide registries, we identified patients hospitalized with MI-CS. Incidence rates (IR) and incidence rate ratios (IRR) were used to compare MI-CS before and after March 11 in 2015-2019 and in 2020.ResultsWe identified 11,769 patients with MI of whom 696 (5.9%) had cardiogenic shock in 2015-2019. In 2020, 2132 MI patients were identified of whom 119 had cardiogenic shock (5.6%). The IR per 100,000 person years before March 11 in 2015-2019 was 9.2 (95% CI: 8.3-10.2) and after 8.9 (95% CI: 8.0-9.9). In 2020, the IR was 7.5 (95% CI: 5.8-9.7) before March 11 and 7.7 (95% CI: 6.0-9.9) after. The IRRs comparing the 2020-period with the 2015-2019 period before and after March 11 (lockdown) were 0.81 (95% CI: 0.59-1.12) and 0.87 (95% CI: 0.57-1.32), respectively. The IRR comparing the 2020-period during and before lockdown was 1.02 (95% CI: 0.74-1.41). No difference in 7-day mortality or in-hospital management was observed between study periods.ConclusionWe could not identify a significant association of the national lockdown on the incidence of MI-CS, along with similar in-hospital management and mortality in patients with MI-CS.
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Project description:BackgroundH syndrome (HS) is a rare autoinflammatory disease caused by a mutation in the solute carrier family 29, member 3 (SCL29A3) gene. It has a variable clinical presentation and little phenotype-genotype correlation. The pathognomonic sign of HS is cutaneous hyperpigmentation located mainly in the inner thighs and often accompanied by other systemic manifestations. Improvement after tocilizumab treatment has been reported in a few patients with HS. We report the first patient with HS who presented cardiogenic shock, multiorgan infiltration, and digital ischemia.Case presentation8-year-old boy born to consanguineous parents of Moroccan origin who was admitted to the intensive care unit during the Coronavirus Disease-2019 (COVID-19) pandemic with tachypnoea, tachycardia, and oliguria. Echocardiography showed dilated cardiomyopathy and severe systolic dysfunction compatible with cardiogenic shock. Additionally, he presented with multiple organ dysfunction syndrome. SARS-CoV-2 polymerase chain reaction (PCR) and antibody detection by chromatographic immunoassay were negative. A previously ordered gene panel for pre-existing sensorineural hearing loss showed a pathological mutation in the SCL29A3 gene compatible with H syndrome. Computed tomography scan revealed extensive alveolar infiltrates in the lungs and multiple poor defined hypodense lesions in liver, spleen, and kidneys; adenopathy; and cardiomegaly with left ventricle subendocardial nodules. Invasive mechanical ventilation, broad antibiotic and antifungal coverage showed no significant response. Therefore, Tocilizumab as compassionate use together with pulsed intravenous methylprednisolone was initiated. Improvement was impressive leading to normalization of inflammation markers, liver and kidney function, and stabilising heart function. Two weeks later, he was discharged and has been clinically well since then on two weekly administration of Tocilizumab.ConclusionsWe report the most severe disease course produced by HS described so far in the literature. Our patient's manifestations included uncommon, new complications such as acute heart failure with severe systolic dysfunction, multi-organ cell infiltrate, and digital ischemia. Most of the clinical symptoms of our patient could have been explained by SARS-CoV-2, demonstrating the importance of a detailed differential diagnosis to ensure optimal treatment. Although the mechanism of autoinflammation of HS remains uncertain, the good response of our patient to Tocilizumab makes a case for the important role of IL-6 in this syndrome and for considering Tocilizumab as a first-line treatment, at least in severely affected patients.
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Project description:BackgroundThere are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS).ObjectiveTo assess the trends, rates and predictors of complications.MethodsUsing a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied.ResultsOf 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all p<0.001 except for amputation). Non-White race, higher comorbidity, organ failure, and extracorporeal membrane oxygen use were predictors of complications for both cohorts. The pLVAD cohort with complications had higher in-hospital mortality (45.5% vs. 33.1%; adjusted odds ratio 1.65 [95% confidence interval 1.55-1.75]), shorter duration of hospital stay, and higher hospitalization costs compared to the IABP cohort with complications (all p<0.001). These results were consistent in propensity-matched pairs.ConclusionsAMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.
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Project description:The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.
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Project description:Despite all well-known benefits of transradial access, patients presenting with cardiogenic shock are usually submitted to coronary angiography and percutaneous coronary intervention via traditional transfemoral access, mainly due to challenge puncture of radial artery in the setting of hemodynamic instability. We report a challenging case of STEMI-related cardiogenic shock requiring primary PCI of an occluded and unprotected left main, safety, and successfully performed via right distal trans radial access in the anatomical snuffbox.
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Project description:Cardiogenic shock (CS) carries high mortality and morbidity. Early revascularization is an important strategy in management of these patients. We sought to determine the outcomes and predictors of revascularization among patients with CS. Patients with CS and acute myocardial infarction were identified using the National Inpatient Sample (NIS) data from January 2002 to December 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Subsequently, patients who underwent revascularization were then selected. A total of 118,618 patients with CS were identified. Out of these, about 55,735 (47%) patients underwent revascularization. Mean age of patients who underwent revascularization was lower when compared with patients not who underwent revascularization (66.40 vs 72.24 years, p < 0.01). Patients who underwent revascularization had lower mortality when compared with patients not who underwent revascularization (25.1% vs 52.2%, p < 0.01). Extracorporeal membrane oxygenation and mechanical circulatory support devices were often utilized more in patients who underwent revascularization. Overall, we found modest increased trend of revascularization over our study years with decline in mortality. Female gender, weekend admission, drug abuse, pulmonary hypertension, anemia, renal failure, neurological disorders, malignancy were associated with lower odds of revascularization. In conclusion, in this large nationally represented US population sample of CS patients, we found revascularization rate of about 47% with improvement in overall mortality over our study years.
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