Kumar Anirudh, Huded Chetan P, Zhou Leon, Krittanawong Chayakrit, Young Laura D, Krishnaswamy Amar, Menon Venu, Lincoff A Michael, Ellis Stephen G, Reed Grant W, Kapadia Samir R, Khot Umesh N
Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Am J Cardiol. 2020 Nov 1;134:1-7. doi: 10.1016/j.amjcard.2020.08.012. Epub 2020 Aug 15.
Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 ± 1.8 vs 2.8 ± 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 ± 156.0 vs 151.5 ± 98.5 ng/ml, p = 0.005), ejection fraction (40.8 ± 14.5% vs 46.7 ± 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.
ST段抬高型心肌梗死（STEMI）相关心源性休克（CS）患者的死亡率正在上升。目前尚不清楚全面的ST段抬高型心肌梗死（STEMI）方案（CSP）是否能改善对这些患者的治疗并降低死亡率。我们评估了CSP对STEMI相关CS患者的发病率和预后的影响。我们实施了一个包含4个步骤的CSP，包括：（1）急诊科导管室激活；（2）STEMI安全交接检查表；（3）立即转运至导管室；（4）优先采用桡动脉途径的经皮冠状动脉介入治疗（PCI）。我们研究了1272例连续接受PCI的STEMI患者，并根据美国国家心血管数据注册中心的定义评估了PCI后24小时内的CS发病率、治疗情况以及在CSP实施前（2011年1月1日至2014年7月14日；n = 723）和实施后（2014年7月15日至2016年12月31日；n = 549）的死亡率。CSP实施后，CS发病率降低（13.0%对7.8%，p = 0.003）。在137例CS患者中，43例（31.4%）在CSP组。CSP组患者的IABP - Shock II风险评分更高（1.9±1.8对2.8±2.2，p = 0.014），但在血流动力学和基线特征、心脏骤停发生率以及机械循环支持使用方面相似。指南指导的药物治疗的应用情况相似（89.4%对97.7%，p = 0.172），CSP组在经桡动脉PCI（9.6%对44.2%，p < 0.001）和门球时间（129.0[89:160]对95.0[81:116]分钟，p = 0.001）方面有显著改善，这转化为梗死面积（肌酸激酶同工酶220.9±156.0对151.5±98.5 ng/ml，p = 0.005）、射血分数（40.8±14.5%对46.7±14.6%，p = 0.037）和住院死亡率（30.9%对14.0%，p = 0.037）的改善。总之，CSP的实施与STEMI相关CS患者的CS发病率、梗死面积、射血分数和住院死亡率的改善相关。这一策略为弥合其治疗中历史上难以捉摸的差距提供了一个潜在的解决方案。
