Unlocking the mystery of cardiogenic shock in STEMI patients: why concordance matters and how PPCI can help
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Date
2023-05-26
Authors
Islam, Mohammad Zahurul
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Abstract
Background: ST Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock
(CS) is associated with significant morbidity and mortality which remains unchanged over the last decade. One potential reason is lack of concordance among CS defining parameters: (1) systolic blood pressure (SBP) <90 mmHg for ≥30 min or requiring vasopressors and/or mechanical support, (2) cardiac index (CI) ≤1.8 L/min/m2 or ≤ 2.2 L/min/m2 in the presence of inotropic agents/vasopressors, (3) lactate ≥ 2 mmol/L. Limited knowledge exists regarding the concordance among these three parameters in STEMI patients.
Objectives: We aim to evaluate (1) incidence and concordance among these CS defining parameters in STEMI patients; (2) impact of primary percutaneous coronary intervention (PPCI) on these parameters, and (3) identify their association with outcomes.
Material & methods: 204 STEMI patients were taken to cardiac catheter laboratory for primary PCI at the St. Boniface hospital were recruited by non-invasive cardiac system derived hemodynamic parameters, invasive blood pressure and lactate level on arterial blood gas analysis, pre-PPCI, post-PPCI, and POD-1.
Results: The incidence of CS defining parameters pre-PPCI [SBP: 17 (8.5%); CI: 31 (15.5%); lactate 58 (29%)], post-PPCI [SBP: 17 (8.5%); CI: 18 (9%); lactate 35 (17.5%)] demonstrated a low-degree of concordance of three CS defining parameters. PPCI improved CI and lactate parameters, but not SBP. Adverse outcomes (death at 30 days and in-hospital stay >4 days) were observed in 21.6% patients and these patients were marked by low stroke index, pre-PPCI (28.99.5 vs 38.29.9) ml/m2, p<0.001; post-PPCI (29.410.5 vs 39.59.5) ml/m2, p<0.001 and POD-1 (28.79.5 vs 35.38.1) ml/m2, p<0.001, low CI at rest, [(2.40.9 vs 2.90.9) L/min/m2, p<0.05], low CPI at rest [(0.50.3 vs 0.60.2) Watt/m2, p<0.05], low CPO at rest [(0.90.6 vs 1.20.5) Watt, p<0.05], and low Granov-Goor Index, pre-PPCI (9.53.6) vs (12.43.6), p<0.001; post-PPCI (9.53.8) vs (12.83.8), p<0.001 and POD-1 (8.72.6) vs (10.72.8), p<0.001.
Conclusion: Incidence of a CS defining parameter is significantly different in STEMI patients compared to non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), and cannot be used interchangeably. PPCI improves these parameters, with the exception of SBP. Low SI, GGI were observed in patients experiencing adverse outcomes.
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Keywords
Cardiogenic shock, STEMI, Heart attack, Non-invasive cardiac system