Schwarz B, Abdel-Wahab M, Robinson D R, Richardt G
Heart Center, Herzzentrum, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel and Hamburg), Am Kurpark 1, 23795, Bad Segeberg, Germany.
Mathematics Department, University of Sussex, Brighton, UK.
Med Klin Intensivmed Notfmed. 2016 Nov;111(8):715-722. doi: 10.1007/s00063-015-0118-8. Epub 2015 Nov 23.
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.
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.
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.
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.
心源性休克仍然是急性心肌梗死（AMI）住院患者最严重的并发症。早期血运重建是侵入性治疗的基石，而主动脉内球囊反搏（IABP）的机械支持存在争议。我们从机构休克登记处试图确定院内死亡率的预测因素，包括IABP使用时机方面，并为AMI休克患者制定临床风险评分。
对2005年1月至2010年12月期间因AMI接受直接经皮冠状动脉介入治疗（PCI）和IABP治疗的102例心源性休克患者进行分析。采用单因素和多因素逻辑回归分析确定院内死亡的独立预测因素。使用逻辑回归分析和受试者工作曲线生成死亡风险评分。
该队列患者的平均年龄为70.1±11.0岁，70%为男性。三分之一的患者为非ST段抬高型心肌梗死，30%的患者在冠状动脉介入治疗前需要进行心肺复苏。平均左心室射血分数为25%。入院后，23%的患者发生急性肾衰竭，10%的患者在住院期间需要进行肾透析。52%的患者在直接PCI后开始IABP治疗，其余患者接受IABP辅助的直接PCI。全因院内死亡率为40.2%。通过多因素分析，年龄（比值比[OR]1.08，p = 0.006）、PCI前心肺复苏（OR 3.46，p = 0.045）、血管升压药使用（OR 7.88，p = 0.003）、急性肾衰竭（OR 11.18，p = 0.001）和PCI后IABP植入（OR 4.36，p = 0.011）与院内死亡率独立相关。基于这些预测因素，计算出死亡风险评分为：1.5×PCI前IABP使用时机+0.1×年龄+PCI前心肺复苏+2×血管升压药使用+2.5×急性肾衰竭。使用截断值10.4时，该评分预测院内死亡的特异性为83%，敏感性为82%。
我们确定年龄、血管升压药使用、PCI前心肺复苏、急性肾衰竭和PCI后IABP植入是AMI所致心源性休克患者院内死亡的独立预测因素。IABP置入时机是我们队列中预测院内死亡率唯一可改变的因素。因此，应在PCI前开始球囊反搏以改善心源性休克患者的预后。
