Volume 4, Number 35; September 29, 2005
|
Volume 4, Number 35; September 29, 2005 |
|
|
|
|
|
|
|
|
Labs reveal hidden MI
Recommended reading:
|
Patient: 37 year old HIV+ female with shortness of breath, new onset cough, and fatigue. Patient reports retrosternal knife-like pain radiating to her back. Troponin analysis indicated recent MI.
|
|
Session Handout:
|
|
Clinical Question: 1) How effective is revascularization for cardiogenic shock?
|
|
Readings:
Link Directly to Fulltext Article at Science Direct <1> Unique Identifier [PMID]: 16022953 Authors: Sleeper LA. Ramanathan K. Picard MH. Lejemtel TH. White HD. Dzavik V. Tormey D. Avis NE. Hochman JS. SHOCK Investigators. Institution: New England Research Institutes, Watertown, Massachusetts 02472, USA. sleeper@neriscience.com Title: Functional status and quality of life after emergency revascularization for cardiogenic shock complicating acute myocardial infarction.[see comment]. Comments Comment in: J Am Coll Cardiol. 2005 Jul 19;46(2):274-6; PMID: 16022954
Source: Journal of the American College of Cardiology. 46(2):266-73, 2005 Jul 19. Abstract: OBJECTIVES: Our goal was to describe the functional status of cardiogenic shock survivors, identify the correlates of cardiogenic shock, and compare global quality of life and functional status of patients randomly assigned to treatment with emergency revascularization (ERV) versus initial medical stabilization (IMS). BACKGROUND: Historically, the hospital survival rate of patients with cardiogenic shock complicating acute myocardial infarction (MI) has been very low. Shock survivors are salvaged from a critically ill state, and their later functional status is not well documented. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial showed significantly improved one-year survival after ERV compared with IMS. METHODS: The SHOCK trial survivors completed interviews at 2 weeks after discharge and at 6 and 12 months after MI. Functional status assessment included the Multidimensional Index of Life Quality and New York Heart Association (NYHA) congestive heart failure functional class. RESULTS: Eighty-seven percent of one-year survivors of the SHOCK trial were in NYHA functional class I or II. Between two weeks after discharge and one year after MI, improvement was similar in the two treatment groups (18% overall), but fewer patients remained stable (44% vs. 71%), and more patients worsened or died (34% vs. 15%) in the IMS group compared with those assigned to ERV. Assignment to ERV was the only independent predictor of outcome at one year. CONCLUSIONS: Although one-year mortality after ERV is still high (54%), most survivors have good functional status. The ERV patients have a lower rate of deterioration than IMS patients. The level of recovery for shock patients undergoing ERV is similar to that of historical controls not in cardiogenic shock undergoing elective revascularization. Publication Type: Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled Trial.
Link Directly to Fulltext Article at Publisher <2> Unique Identifier [PMID]: 15917382 Authors: Hannan EL. Racz MJ. Walford G. Jones RH. Ryan TJ. Bennett E. Culliford AT. Isom OW. Gold JP. Rose EA. Institution: University at Albany, State University of New York, Albany, NY, USA. Title: Long-term outcomes of coronary-artery bypass grafting versus stent implantation.[see comment]. Comments Comment in: N Engl J Med. 2005 May 26;352(21):2235-7; PMID: 15917389
Source: New England Journal of Medicine. 352(21):2174-83, 2005 May 26. Abstract: BACKGROUND: Several studies have compared outcomes for coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), but most were done before the availability of stenting, which has revolutionized the latter approach. METHODS: We used New York's cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. We determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients' severity of illness before revascularization. RESULTS: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implantation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal left anterior descending coronary artery and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the nonproximal left anterior descending coronary artery. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6 percent for subsequent PCI). CONCLUSIONS: For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. Copyright 2005 Massachusetts Medical Society. Publication Type: Journal Article.
Link Directly to Fulltext Article at Publisher <4> Unique Identifier [PMID]: 15013709 Authors: Wernly JA. Institution: The University of New Mexico, Health Sciences Center, Thoracic and Cardiovascular Surgery, Division of Cardiothoracic Surgery, MSC 10-5610, 1 University of New Mexico, Albuquerque, New Mexico 87131, USA. jwernly@salud.unm.edu Title: Ischemia, reperfusion, and the role of surgery in the treatment of cardiogenic shock secondary to acute myocardial infarction: an interpretative review. [Review] [47 refs]
Source: Journal of Surgical Research. 117(1):6-21, 2004 Mar. Abstract: Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). Despite contemporary management of AMI, the incidence of shock due to left ventricular failure has not declined and its mortality continues to be in excess of 50%. Furthermore, the role and indications of the different means of acute revascularization remain unclear. Recent observational and randomized studies have shown improved survival in patients acutely revascularized by either percutaneous interventions or conventional surgery, particularly in patients younger than 75 years of age. Current guidelines recommend surgical revascularization in selected patients with multiple vessel disease who develop shock due to progressive ischemia of the remote myocardium up to 18 h from the onset of shock. However, patients with single-vessel disease who develop shock as a consequence of the initial infarction can only be helped if revascularization is achieved during the first 4 to 6 h after the occlusion of the infarct related artery, preferable by percutaneous techniques. Not all ischemic myocytes become irreversibly injured at the same time. Due to variability in the distribution of collateral flow, there is great variability in the severity of ischemia. Myocytes can exhibit different metabolic responses including hibernation, ischemic preconditioning, stunning, reperfusion injury, and necrosis. Precise knowledge of these biochemical and metabolic changes that take place in the myocardium after arterial occlusion and following reperfusion is paramount to the understanding of the indications for acute revascularization, the implementation of the different management strategies to enhance myocardial preservation and recovery, and the role of circulatory support in these exceedingly sick patients. [References: 47] Publication Type: Journal Article. Review. Review, Tutorial.
|
|
|
|
|
Resident Report / Department of Medicine & Grady Branch Library Emory University School of Medicine 2005 Edition Participating Faculty: Carlos Del Rio MD / Joyce Doyle MD / Lorenzo Difrancesco MD / Erich Folch MD / Alicia Hidron MD
Contact:
Karl Woodworth
|
