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Predictors of mortality in patients with cardiogenic shock treated with primary percutaneous coronary intervention and intra-aortic balloon counterpulsation

Unabhängige Prädiktoren für Mortalität bei IABP-unterstützter primärer Koronarintervention im akuten Myokardinfarkt mit kardiogenem Schock

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Abstract

Background

Cardiogenic shock remains the most serious complication of patients hospitalized with acute myocardial infarction (AMI). Early revascularization is the cornerstone of invasive therapy, while mechanical support with intra-aortic balloon pump (IABP) is debatable. From our institutional shock registry we sought to determine predictors of in-hospital mortality—including the aspect of IABP timing—and to develop a clinical risk score for shock patients with AMI.

Methods

From January 2005 till December 2010, 102 patients with cardiogenic shock due to AMI treated with primary percutaneous coronary intervention (PCI) and IABP were analyzed. Univariate and multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality. Logistic regression analysis and receiver-operating curves were used to generate a mortality risk score.

Results

The mean age of the cohort was 70.1 ± 11.0 years and 70 % were men. One third of patients had a non-ST segment elevation myocardial infarction and 30 % had to be resuscitated before coronary intervention. Mean left ventricular ejection fraction was 25 %. After admission, 23 % of patients developed an acute renal failure and 10 % needed renal dialysis during hospital stay. In 52 % of patients IABP therapy was initiated after primary PCI, while the remaining patients had an IABP-assisted primary PCI. All-cause in-hospital mortality was 40.2 %.

Using multivariate analysis, age (odds ratio [OR] 1.08, p = 0.006), resuscitation before PCI (OR 3.46, p = 0.045), vasopressor use (OR 7.88, p = 0.003), acute renal failure (OR 11.18, p = 0.001), and IABP implantation after PCI (OR 4.36, p = 0.011) were independently associated with in-hospital mortality. Based on these predictors, a mortality-risk score was calculated as follows: 1.5 × IABP timing before PCI + 0.1 × age + resuscitation before PCI + 2 × vasopressor use + 2.5 × acute renal failure. Using a cut-off value of 10.4, this score had a specificity of 83 % and a sensitivity of 82 % for prediction of in-hospital death.

Conclusions

We identified age, vasopressor use, resuscitation before PCI, acute renal failure and IABP implantation after PCI as independent predictors of in-hospital mortality in patients with cardiogenic shock due to AMI. The timing of IABP insertion was the only modifiable factor predicting in-hospital mortality in our cohort. Consequently, balloon pumping should be started before PCI to improve outcome of cardiogenic shock patients.

Zusammenfassung

Hintergrund

Der kardiogene Schock ist weiterhin eine gefürchtete Komplikation des akuten Myokardinfarkts mit hoher Mortalität, die trotz moderner medikamentöser und mechanischer Unterstützung nicht signifikant reduziert werden konnte. In unserem Segeberger Schock-Register suchten wir nach Prädiktoren für diese hohe Mortalität. Durch die Entwicklung eines Risiko-Scores wollten wir die gefährdeten Patienten aufdecken.

Methode

Diese retrospektive Untersuchung führten wir an 102 Patienten im kardiogenen Schock bei akutem Myokardinfarkt durch, die in einem Zeitraum von Januar 2005 bis Dezember 2010 in unserem Herzzentrum aufgenommen wurden. Multivariable, logistische Regressionsanalysen nutzten wir zur Identifizierung der Prädiktoren für Mortalität. Multivariate Regressionsanalysen und Receiver-Operating-Kurven halfen uns bei der Entwicklung des Mortalitäts-Risiko-Score.

Ergebnisse

In unserem Kollektiv lag das durchschnittliche Alter bei 70,1 ± 11,0 Jahren und 70 % der Patienten waren männlich. Ein Drittel der Patienten hatten einen NSTEMI und 30 % aller Patienten mussten vor PCI reanimiert werden. Die mittlere Ejektionsfraktion war bei 25 %. 23 % der Patienten entwickelten ein akutes Nierenversagen und 10 % mussten während des stationären Aufenthaltes dialysiert werden. In 52 % der Fälle wurde die IABP nach der primären PCI implantiert, während die übrigen Patienten die IABP vor der PCI erhalten haben. Die inhospitale Gesamtmortalität lag bei 40,2 %.

Wir konnten Alter (Odds Ratio [OR] 1,08, p = 0,006), Reanimation vor PCI (OR 3,46, p = 0,045), Einsatz von Vasopressoren (OR 7,88, p = 0,003), akutes Nierenversagen (OR 11,18, p = 0,001) und die Implantation der IABP nach Koronarintervention (OR 4,36, p = 0,011) als unabhängige Prädiktoren für die inhospitale Mortalität ermitteln. Um gefährdete Patienten in dieser Gruppe zu ermitteln, konnten wir den folgenden Mortalitäts-Risiko-Score erarbeiten:

1,5 × IABP-Timing + 0,1 × Alter + Reanimation vor PCI + 2 × Vasopressoreinsatz + 2,5 × akutes Nierenversagen

Liegt der Wert über 10,4, ergibt sich mit einer Spezifität von 83 % und einer Sensitivität von 82 % eine prognostisch erhöhte Wahrscheinlichkeit im kardiogenen Schock zu versterben.

Schlussfolgerung

In unserem großen Segeberger Schockregister konnten wir Alter, Vasopressoreinsatz, kardiopulmonale Reanimation vor PCI, akute Niereninsuffizienz und die Implantation einer IABP nach Koronarintervention als unabhängige Prädiktoren für die inhospitale Mortalität definieren. In unserem Kollektiv ist die Implantation der IABP der einzige veränderbare Prädiktor für die inhospitale Mortalität. Schlussfolgernd sollte die Implantation der IABP vor der primären PCI erfolgen, um das Outcome der Patienten mit kardiogenem Schock zu verbessern.

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Correspondence to B. Schwarz MD.

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B. Schwarz, M. Abdel-Wahab, D.R. Robinson, and G. Richardt state that there are no conflicts of interest.

The study complied with the Declaration of Helsinki and data collection was approved by the local ethics committee.

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Schwarz, B., Abdel-Wahab, M., Robinson, D. et al. Predictors of mortality in patients with cardiogenic shock treated with primary percutaneous coronary intervention and intra-aortic balloon counterpulsation. Med Klin Intensivmed Notfmed 111, 715–722 (2016). https://doi.org/10.1007/s00063-015-0118-8

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