Editorial comment
Cardiogenic shock in acute myocardial infarction: Stratify to prevent
Choque cardiogénico no enfarte agudo do miocárdio: estratificar para prevenir
António José Fiarresga
Serviço de Cardiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal
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[ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918302034?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301993?idApp=UINPBA00004E" "url" => "/08702551/0000003700000006/v2_201806270452/S0870255117301993/v2_201806270452/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Cardiogenic shock in acute myocardial infarction: Stratify to prevent" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "489" "paginaFinal" => "490" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "António José Fiarresga" "autores" => array:1 [ 0 => array:3 [ "nombre" => "António José" "apellidos" => "Fiarresga" "email" => array:1 [ 0 => "a.fiarresga@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Choque cardiogénico no enfarte agudo do miocárdio: estratificar para prevenir" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiogenic shock (CS) is defined as persistent hypotension (systolic blood pressure <90 mmHg) secondary to myocardial dysfunction, associated with signs of organ hypoperfusion. CS may be present in 10% of patients with ST-segment elevation myocardial infarction (STEMI) and is associated with 30-day mortality of about 50%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In the majority of STEMI patients, hemodynamic deterioration occurs after hospital admission, which means that there may be room for preventive measures and highlights the importance of early recognition of those most likely to evolve to CS.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Scores such as Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Thrombolysis in Myocardial Infarction (TIMI), the Global Registry of Acute Coronary Events (GRACE) and the Zwolle risk score are used to stratify patients and enable the adoption of different levels of clinical monitoring, therapeutic care and post-discharge strategies.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> However, the search for simpler and more accurate scores has continued.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The shock index (SI) is defined as the ratio of heart rate to systolic blood pressure, and was introduced in 1967 by Allgower and Burri to assess the degree of hypovolemia in hemorrhagic or infectious shock states.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The SI, which is easy to calculate, is an objective measure of cardiovascular performance and a marker for predicting the onset of hypotension. Assessment of SI in the context of acute myocardial infarction was only used more recently, and a first meta-analysis, of eight studies enrolling 20<span class="elsevierStyleHsp" style=""></span>404 patients, was published last year.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> A high SI was associated with increased in-hospital mortality and higher risk of short- and long-term adverse outcomes compared to low SI.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An important limitation of SI is the lack of information about systemic vascular resistance status. Mean arterial pressure (incorporating both systolic and diastolic blood pressure) best represents tissue perfusion status. The modified shock index (MSI), which is the ratio of heart rate to mean arterial pressure, has been shown to be a better predictor of mortality than heart rate, systolic blood pressure, diastolic blood pressure and SI alone in trauma patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Shangguan et al. were the first to assess the predictive value of MSI in the context of STEMI.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In a retrospective study of 160 consecutive patients, they found that MSI ≥1.4, assessed in the emergency department, was an independent factor for major adverse cardiac events and seven-day all-cause mortality, with a stronger association than SI. Yu et al. retrospectively studied 1864 STEMI patients undergoing primary coronary angioplasty to assess whether admission age SI (age multiplied by SI) and MSI were useful clinical parameters to predict long-term prognosis, with both showing good prognostic performance.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The cutoff value of MSI for the prediction of all-cause mortality was 0.71.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the Journal, Abreu et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> assess the prognostic value of MSI to predict six-month mortality in a large retrospective observational study of 1158 STEMI patients without cardiogenic shock on admission. They found that MSI ≥0.93 was present in about a quarter of the patients and was associated with worse in-hospital clinical course. Adverse events, acute heart failure and cardiogenic shock were significantly more frequent in this subgroup. MSI was also an independent predictor of overall six-month mortality. The cutoff of 0.93 identified by the authors is between those in the above studies, which presumably reflects methodological differences, such as population selection and the timing and method for assessing hemodynamic parameters. However, their approach of using MSI in patients with no shock at admission, and assessing heart rate and blood pressure in the hemodynamic laboratory, seems to be the most appropriate and practical way to apply this index in clinical practice.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Their study has limitations, some of which are acknowledged by the authors, including its single-center and retrospective design, the lack of a control group to effectively test their hypothesis, and the lack of comparison with other hemodynamic indices or risk scores. Nevertheless, the authors should be congratulated for their important contribution to an issue that is still poorly defined and that needs further investigation, since a simple risk stratification of these patients remains an unmet clinical need. They have paved the way for future studies that may validate this strategy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)" "etal" => true "autores" => array:3 [ 0 => "B. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 8 | 15 |
| 2024 Outubro | 27 | 30 | 57 |
| 2024 Setembro | 47 | 19 | 66 |
| 2024 Agosto | 34 | 22 | 56 |
| 2024 Julho | 41 | 29 | 70 |
| 2024 Junho | 28 | 16 | 44 |
| 2024 Maio | 29 | 22 | 51 |
| 2024 Abril | 27 | 28 | 55 |
| 2024 Maro | 26 | 18 | 44 |
| 2024 Fevereiro | 28 | 20 | 48 |
| 2024 Janeiro | 24 | 28 | 52 |
| 2023 Dezembro | 22 | 24 | 46 |
| 2023 Novembro | 42 | 22 | 64 |
| 2023 Outubro | 18 | 16 | 34 |
| 2023 Setembro | 17 | 23 | 40 |
| 2023 Agosto | 23 | 17 | 40 |
| 2023 Julho | 26 | 11 | 37 |
| 2023 Junho | 40 | 6 | 46 |
| 2023 Maio | 39 | 30 | 69 |
| 2023 Abril | 14 | 9 | 23 |
| 2023 Maro | 31 | 22 | 53 |
| 2023 Fevereiro | 21 | 16 | 37 |
| 2023 Janeiro | 15 | 12 | 27 |
| 2022 Dezembro | 28 | 23 | 51 |
| 2022 Novembro | 28 | 21 | 49 |
| 2022 Outubro | 26 | 23 | 49 |
| 2022 Setembro | 29 | 38 | 67 |
| 2022 Agosto | 30 | 38 | 68 |
| 2022 Julho | 30 | 37 | 67 |
| 2022 Junho | 26 | 25 | 51 |
| 2022 Maio | 24 | 30 | 54 |
| 2022 Abril | 38 | 33 | 71 |
| 2022 Maro | 37 | 44 | 81 |
| 2022 Fevereiro | 34 | 29 | 63 |
| 2022 Janeiro | 20 | 31 | 51 |
| 2021 Dezembro | 24 | 33 | 57 |
| 2021 Novembro | 32 | 39 | 71 |
| 2021 Outubro | 31 | 52 | 83 |
| 2021 Setembro | 25 | 18 | 43 |
| 2021 Agosto | 46 | 34 | 80 |
| 2021 Julho | 19 | 27 | 46 |
| 2021 Junho | 19 | 20 | 39 |
| 2021 Maio | 23 | 33 | 56 |
| 2021 Abril | 41 | 46 | 87 |
| 2021 Maro | 58 | 21 | 79 |
| 2021 Fevereiro | 55 | 23 | 78 |
| 2021 Janeiro | 26 | 11 | 37 |
| 2020 Dezembro | 36 | 24 | 60 |
| 2020 Novembro | 29 | 15 | 44 |
| 2020 Outubro | 12 | 14 | 26 |
| 2020 Setembro | 52 | 10 | 62 |
| 2020 Agosto | 15 | 12 | 27 |
| 2020 Julho | 29 | 17 | 46 |
| 2020 Junho | 32 | 15 | 47 |
| 2020 Maio | 23 | 12 | 35 |
| 2020 Abril | 23 | 25 | 48 |
| 2020 Maro | 41 | 12 | 53 |
| 2020 Fevereiro | 53 | 44 | 97 |
| 2020 Janeiro | 22 | 7 | 29 |
| 2019 Dezembro | 24 | 7 | 31 |
| 2019 Novembro | 26 | 4 | 30 |
| 2019 Outubro | 34 | 9 | 43 |
| 2019 Setembro | 19 | 7 | 26 |
| 2019 Agosto | 21 | 13 | 34 |
| 2019 Julho | 46 | 9 | 55 |
| 2019 Junho | 25 | 21 | 46 |
| 2019 Maio | 54 | 20 | 74 |
| 2019 Abril | 9 | 16 | 25 |
| 2019 Maro | 41 | 8 | 49 |
| 2019 Fevereiro | 42 | 7 | 49 |
| 2019 Janeiro | 45 | 9 | 54 |
| 2018 Dezembro | 43 | 18 | 61 |
| 2018 Novembro | 29 | 11 | 40 |
| 2018 Outubro | 50 | 25 | 75 |
| 2018 Setembro | 27 | 15 | 42 |
| 2018 Agosto | 27 | 23 | 50 |
| 2018 Julho | 65 | 28 | 93 |
| 2018 Junho | 42 | 36 | 78 |
| 2018 Maio | 1 | 4 | 5 |
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