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Background: Scoring systems in critical care patients are essential for prediction of outcome and for evaluation of therapy. In this study we determined the value of the APACHE II, APACHE III, Elebute-Stoner, SOFA, and SAPS II scoring systems in the prediction of mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI)., Material and Methods: In this prospective, observational study, patients who were admitted to the ICU with CS complicating AMI were consecutively included. Data for the APACHE II, APACHE III, Elebute-Stoner, SOFA, and SAPS II scores were recorded on admission and during the following 96 h. Receiver operating characteristic curve analyses and the area under the curve (AUC) were used to estimate the predictive ability (mortality) of the scoring systems on admission and the maximum value., Results: Mortality among the 41 patients included in this study was 44 %. On admission, the mean APACHE II (p = 0.035), APACHE III (p = 0.003), SAPS II (p = 0.001), and SOFA (p = 0.042) scores were significantly higher in nonsurvivors than in survivors. At maximum score, APACHE II (p = 0.009), APACHE III (p < 0.001), and SAPS II (p < 0.001) appeared to have higher significance. On admission, the discrimination for APACHE III was 0.786, for SAPS II 0.790, and for APACHE II 0.691. The maximum-score AUC for APACHE II was 0.726, for APACHE III 0.827, and for SAPS II 0.832. Elebute-Stoner and SOFA did not yield valuable results at maximum score or, in the case of Elebute-Stoner, on admission., Conclusion: These results suggest that at the time of diagnosis and at maximum value, the SAPS II, APACHE III, and APACHE II scores may be useful in predicting a high probability of survival of patients with CS complicating AMI.

The European ST-elevated myocardial infarction (STEMI) guideline suggested the intra-aortic balloon pump (IABP) with a recommendation level I and a level of evidence C as an effective measure in combination with balloon angioplasty in patients with cardiogenic shock (CS), stent implantation, and inotropic and vasopressor support. Similarly, upon mechanical complication due to myocardial infarction (MI), the guideline suggests that in patients with a ventricular septal defect or in most patients with acute mitral regurgitation, preoperative IABP implantation is indicated for circulatory support. The American College of Cardiology/American Heart Association STEMI guideline recommends the use of the IABP with a recommendation level I and a level of evidence B if CS does not respond rapidly to pharmacological treatment. The guideline notes that the IABP is a stabilizing measure for angiography and early revascularization. Even in MI complications, the use of preoperative IABP is recommended before surgery. Within this overview, we summarize the current evidence on IABP use in patients with CS complicated by MI. From our Cochrane data analysis, we conclude that in CS due to acute MI (AMI) treated with adjuvant systemic fibrinolysis, the IABP should be implanted. In patients with CS following AMI, treated with primary percutaneous coronary intervention (PCI), the IABP can be implanted, although data are not distinctive (i.e., indicating positive and negative effects). In the future, randomized controlled trials are needed to determine the use of IABP in CS patients treated with PCI. When patients with CS are transferred to a PCI center with or without thrombolysis, patients should receive mechanical support with an IABP. To treat mechanical MI complications-in particular ventricular septal defect-patients should be treated with an IABP to stabilize their hemodynamic situation prior to cardiac surgery. Similar recommendations are given in the German Austrian guidelines on treatment of infarction-related CS patients (http://www.awmf.org/leitlinien/detail/ll/019-013.html)., (© 2012, Copyright the Authors. Artificial Organs © 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: The IABP-SHOCK-trial was a morbidity-based randomized controlled trial in patients with infarction-related cardiogenic shock (CS), which used the change of the quantified degree of multiorgan failure as determined by APACHE II score over a 4-day period as primary outcome measure. The prospective hypothesis was that adding IABP therapy to "standard care" would improve CS-triggered multi organ dysfunction syndrome (MODS). The primary endpoint showed no difference between conventionally managed cardiogenic shock patients and those with IABP support. In an inflammatory marker substudy, we analysed the prognostic value of interleukin (IL)-1β, -6, -7, -8, and -10 in patients with acute myocardial infarction complicated by cardiogenic shock., Design: Inflammatory marker substudy of the prospective, randomized, controlled, open label IABP-SHOCK-trial (ClinicalTrials.gov ID-NCT00469248)., Setting and Methods: A single-center study was performed in a 12-bed Intensive-Care-Unit in an university hospital in which 40 consecutive patients were enrolled with an observational period of 96 h., Results: The pro- and anti-inflammatory markers IL-6, -7, -8 and -10 showed a predictive power for mortality of infarct-related CS patients, while IL-1β did not discriminate. The maximal values during the observational period, in case of IL-7 the minimal value, showed the best power to predict mortality. Both, ROC and multivariate analyses confirmed these suggestions (area under the curve: IL-8, 0.80 ± 0.08; IL-6, 0.79 ± 0.08; IL-10, 0.76 ± 0.08; IL-7, 0.69 ± 0.08). Inflammatory markers were not affected by the presence of IABP support., Conclusion: The inflammatory response in patients with myocardial infarction complicated by cardiogenic shock, as reflected by the inflammatory markers IL-6, IL-7, IL-8 and IL-10, demonstrates a clinically relevant prognostic contribution to clinical outcome.

Cardiogenic shock is characterized by inadequate tissue perfusion due to cardiac dysfunction, and it is often caused by acute myocardial infarction. The mortality rate in patients with cardiogenic shock is still very high (i.e., 50-60%). The pathophysiology of cardiogenic shock involves a vicious spiral circle: ischemia causes myocardial dysfunction, which in turn aggravates myocardial ischemia. Myocardial stunning and/or hibernating myocardium can enhance myocardial dysfunction, thus, worsening the cardiogenic shock. Low perfusion pressures with global ischemia leads to multiorgan dysfunction. Ischemia and reperfusion can result in systemic inflammation or within the first few days sepsis due to the translocation of bacteria or bacterial toxins from the intestines, which can result in increased mortality. The key to an optimal treatment of cardiogenic shock patients is a structured approach: (1) rapid diagnosis and prompt initiation of therapy to increase blood pressure and augment cardiac output with subsequently improved perfusion. (2) Rapid coronary revascularization is of critical importance. Using this approach, mortality can be reduced. In many hospitals, initial stabilization is achieved by intraaortic balloon counterpulsation (IABP). However, evidence for improved survival from randomized studies on the use of IABP in combination with PCI is lacking. (3) In order to achieve adequate perfusion, dobutamine and sometimes in combination with norepinephrine might be necessary. Recent studies have shown that the calcium sensitizer levosimendan in cardiogenic shock can be a useful addition to medical therapy. In this overview, epidemiology, pathophysiology, and guideline-oriented treatment strategies for cardiogenic shock are presented.

We developed a scoring system to predict the artery responsible for an acute myocardial infarction (AMI) using ST-segment and T-wave changes on the initial electrocardiogram (ECG) using data from 228 patients (development set) with symptoms compatible with AMI and tested in a similar group of 223 patients (test set) from the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI-5) Trial. Using stepwise logistic regression we were able to accurately predict the left anterior descending (LAD), right, or left circumflex (LC) coronary artery as the infarct-related artery using 2 variables: (1) the summation of the ST-segment elevation in leads V1 to V4; and (2) the summation of the T-wave negativity in leads I, aVL, and V5. In the development set, these 2 variables demonstrated respective sensitivity and specificity of 98% and 90% for LAD lesions, 82% and 85% for right narrowings, and 82% and 84% for LC narrowings. In the test set, the sensitivity and specificity were 97% and 95% for LAD lesions, 85% and 86% for right lesions, and 73% and 60% for LC coronary artery lesions. Information easily obtained on the ECG can accurately predict the likelihood of the LAD, right, or LC artery as the infarct-related artery. This may be useful in the decision to administer thrombolytic treatment.

Kawasaki disease (KD) is a pediatric vasculitis. Its main complication is the development of coronary artery aneurysms (CAA), with giant CAA at the end of the spectrum. We evaluated regression and event-free rates in a non-Asian cohort of patients with giant CAA using the current z-scores adjusted for body surface area instead of absolute diameters. KD patients with giant CAA ( z-score ≥10) visiting our outpatient clinic between January 1999 and September 2015 were included. Patient characteristics and clinical details were extracted from medical records. Regression was defined as all coronary arteries having a z-score of ≤3. A major adverse event was defined as cardiac death, myocardial infarction, cardiogenic shock, or any coronary intervention. Regression-free and event-free rates were calculated using the Kaplan-Meier method. We included 52 patients with giant CAA of which 45 had been monitored since the acute phase. The 1-, 2-, and 5-year regression-free rates were 0.86, 0.78, and 0.65, respectively. The 5-year, 10-year, and 15-year event-free rates were 0.79, 0.75, and 0.65, respectively. Four children, whose CAA would not have been classified as 'giant' based on absolute diameters instead of z-scores, had experienced an event during follow-up. Conclusion: We found a high percentage of children in whom the lumen of giant CAA completely normalized. Four children not classified as 'giant' based on absolute diameters with z-scores of ≥10 experienced a cardiac event. Hence, the use of z-scores seems to be justified. [ABSTRACT FROM AUTHOR]

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