Tol Maneesha M, Shekar Kiran, Barnett Adrian G, McGree James, McWhinney Brett C, Ziegenfuss Marc, Ungerer Jacobus P, Fraser John F
Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia.
Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia.
J Crit Care. 2014 Jun;29(3):470.e1-6. doi: 10.1016/j.jcrc.2014.01.020. Epub 2014 Jan 31.
This study investigated the significance of baseline cortisol levels and adrenal response to corticotropin in shocked patients after acute myocardial infarction (AMI).
A short corticotropin stimulation test was performed in 35 patients with cardiogenic shock after AMI by intravenously injecting of 250 μg of tetracosactrin (Synacthen). Blood samples were obtained at baseline (T0) before and at 30 (T30) and 60 (T60) minutes after the test to determine plasma total cortisol (TC) and free cortisol concentrations. The main outcome measure was in-hospital mortality and its association with T0 TC and maximum response to corticotropin (maximum difference [Δ max] in cortisol levels between T0 and the highest value between T30 and T60).
The in-hospital mortality was 37%, and the median time to death was 4 days (interquartile range, 3-9 days). There was some evidence of an increased mortality in patients with T0 TC concentrations greater than 34 μg/dL (P=.07). Maximum difference by itself was not an independent predictor of death. Patients with a T0 TC 34 μg/dL or less and Δ max greater than 9 μg/dL appeared to have the most favorable survival (91%) when compared with the other 2 groups: T0 34 μg/dL or less and Δ max 9 μg/dL or less or T0 34 μg/dL or higher and Δ max greater than 9 μg/dL (75%; P=.8) and T0 greater than 34 μg/dL and Δ max 9 μg/dL or less (60%; P=.02). Corticosteroid therapy was associated with an increased mortality (P=.03). There was a strong correlation between plasma TC and free cortisol (r=0.85).
A high baseline plasma TC was associated with a trend toward increased mortality in patients with cardiogenic shock post-AMI. Patients with lower baseline TC, but with an inducible adrenal response, appeared to have a survival benefit. A prognostic system based on basal TC and Δ max similar to that described in septic shock appears feasible in this cohort. Corticosteroid therapy was associated with adverse outcomes. These findings require further validation in larger studies.
本研究调查了急性心肌梗死（AMI）后休克患者基线皮质醇水平及肾上腺对促肾上腺皮质激素反应的意义。
对35例AMI后心源性休克患者进行短程促肾上腺皮质激素刺激试验，静脉注射250μg二十四肽促皮质素（辛纳科辛）。在试验前的基线（T0）以及试验后30分钟（T30）和60分钟（T60）采集血样，以测定血浆总皮质醇（TC）和游离皮质醇浓度。主要观察指标为住院死亡率及其与T0时的TC以及对促肾上腺皮质激素的最大反应（T0与T30至T60之间皮质醇水平的最大差值[Δmax]）的关联。
住院死亡率为37%，死亡中位时间为4天（四分位间距，3 - 9天）。有一些证据表明，T0时TC浓度大于34μg/dL的患者死亡率增加（P = 0.07）。最大差值本身并非死亡的独立预测因素。与其他两组相比，T0时TC为34μg/dL或更低且Δmax大于9μg/dL的患者似乎具有最有利的生存率（91%）：T0为34μg/dL或更低且Δmax为9μg/dL或更低，或T0为34μg/dL或更高且Δmax大于9μg/dL（75%；P = 0.8），以及T0大于34μg/dL且Δmax为9μg/dL或更低（60%；P = 0.02）。皮质类固醇治疗与死亡率增加相关（P = 0.03）。血浆TC与游离皮质醇之间存在强相关性（r = 0.85）。
高基线血浆TC与AMI后心源性休克患者死亡率增加的趋势相关。基线TC较低但肾上腺反应可诱导的患者似乎具有生存获益。基于基础TC和Δmax的预后系统，类似于脓毒性休克中所描述的系统，在该队列中似乎可行。皮质类固醇治疗与不良结局相关。这些发现需要在更大规模的研究中进一步验证。
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