Shock in AMI: The Cape Horn for Trials?
Shock in AMI: The Cape Horn for Trials?
Despite therapeutic improvements, cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, fluids, adjunctive medication, intra-aortic balloon counterpulsation, and also assist devices are widely used for treatment. However, currently, there is only limited evidence for any of the above treatments. This review will therefore outline the underlying causes, pathophysiology, and treatment of CS complicating AMI with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical.
The incidence of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) differs depending on the definition of CS, but it has been estimated to range from 5 to 15% with some decline in the last years. Assuming a 5–8% incidence of CS of all hospitalized AMI, this translates in approximately 40 000–50 000 cases per year in the United States and approximately 60 000–70 000 cases in Europe. Numerous clinical complications are associated with the development of AMI, but none are more potentially devastating or carry a worse prognosis than CS.
Mortality of patients with AMI was reduced from 30% to <5% for non-CS patients during the last decades but in the subgroup of patients with CS, improvements were much less extensive. Despite advances in treatment during the last two decades leading to a steady reduction in mortality rates, CS remains to be the leading cause of death with hospital mortality rates still approaching 50%.
This review will outline the underlying causes, the pathophysiology, and treatment of CS complicating AMI—excluding mechanical complications and CS from right heart failure—with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical. Since studying the CS population in randomized trials remains very challenging, we will also focus on the challenges encountered in previous clinical trials and the implication for future research in CS.
Abstract and Introduction
Abstract
Despite therapeutic improvements, cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, fluids, adjunctive medication, intra-aortic balloon counterpulsation, and also assist devices are widely used for treatment. However, currently, there is only limited evidence for any of the above treatments. This review will therefore outline the underlying causes, pathophysiology, and treatment of CS complicating AMI with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical.
Introduction
The incidence of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) differs depending on the definition of CS, but it has been estimated to range from 5 to 15% with some decline in the last years. Assuming a 5–8% incidence of CS of all hospitalized AMI, this translates in approximately 40 000–50 000 cases per year in the United States and approximately 60 000–70 000 cases in Europe. Numerous clinical complications are associated with the development of AMI, but none are more potentially devastating or carry a worse prognosis than CS.
Mortality of patients with AMI was reduced from 30% to <5% for non-CS patients during the last decades but in the subgroup of patients with CS, improvements were much less extensive. Despite advances in treatment during the last two decades leading to a steady reduction in mortality rates, CS remains to be the leading cause of death with hospital mortality rates still approaching 50%.
This review will outline the underlying causes, the pathophysiology, and treatment of CS complicating AMI—excluding mechanical complications and CS from right heart failure—with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical. Since studying the CS population in randomized trials remains very challenging, we will also focus on the challenges encountered in previous clinical trials and the implication for future research in CS.
