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BACKGROUND
In a stark contrast to ∼5% in-hospital mortality in all comer ST Elevation Myocardial
Infarction (STEMI) patients, nearly 50% of STEMI patients complicated by cardiogenic
shock (STEMI-CS) die during their hospital admission. Despite advancements in pharmaco-mechanical
therapies treating STEMI-CS, mortality has remained unchanged. Failure to improve
mortality-rate is partly due to our inability to objectively define and identify CS
in a “pre-shock state”. As per the current guidelines/major studies, CS is defined
as either (1) systolic blood pressure (SBP) ≤ 90mmHg, (2) cardiac-index (CI) < 1.8
L/min/m2 or < 2.2 L/min/m2 in presence of inotropic/vasopressor therapy and/or (3)
lactate >2 mmol/L; these parameters are used interchangeably. Here, we wish to address
this problem by (1) evaluating consecutive STEMI patients to identify the incidence
of CS based on the above 3 parameters, (2) evaluating the concordance between the
above 3 parameters in CS patients, and (3) determining the impact of primary percutaneous
coronary intervention (PPCI) on these 3 parameters.
METHODS AND RESULTS
Consecutive patients with STEMI confirmed with electrocardiography were prospectively
recruited upon presentation to the cardiac catheterization lab. Hemodynamic parameters
were evaluated continuously pre- and post-PPCI using a whole-body impedance based
non-invasive technology. Systolic blood pressure (SBP) and lactate were measured before
and after PPCI. Sixty-eight STEMI patients were recruited; 22/68 (32%) were female
and the mean age was 65.8±1.5 years (34 – 90 years). At presentation pre-PPCI, mean
SBP was 126±4 mmHg; mean CI was 2.8±0.1 L/min/m2 and mean lactate was 3.0±0.5 mmol/L.
Based upon SBP, CI and lactate, 12.7%, 23.5% and 37.3% patients were in CS. Poor correlation
was observed between these parameters. Post-PPCI, CI (pre-PCI: 2.5±0.1 vs. post-PCI:
2.8±0.1 L/min/m2; p=0.00001) increased, whereas SBP (Pre-PCI: 125±4 vs. post-PCI:
112±3 mmHg; p=0.00006), and lactate (Pre-PCI: 3.2±0.53 vs. post-PCI: 2.4±0.5 mmol/L;
p=0.004) decreased.
CONCLUSION
Our study is the first to describe, (1) poor congruity between the current parameters
defining CS, (2) PPCI improves CI and reduces lactate, likely aborting impending CS
and associated mortality, and (3) that SBP is a suboptimal tool for assessing CI in
the setting of STEMI. With ongoing recruitment and 1-month follow-up, we wish to identify
outcome [death at 30-days, prolonged (>96 hours) in-hospital stay due to heart failure,
refractory arrhythmias, need for inotropic support and/or mechanical circulatory support,
including intra-aortic balloon pump insertion during the index hospital admission]
associated hemodynamic marker(s) that may help us identify high-risk STEMI patients
in a timely fashion.
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© 2021 Published by Elsevier Inc.
