Medizinische Klinik B, Klinikum Ludwigshafen , Ludwigshafen, Germany.
Stiftung, Institut Für Herzinfarktforschung Ludwigshafen , Germany.
Expert Rev Cardiovasc Ther. 2021 Jan;19(1):41-46. doi: 10.1080/14779072.2021.1854733. Epub 2021 Jan 19.
Cardiogenic shock (CS) remains the leading cause of death among patients admitted with acute myocardial infarction (AMI). Early restoration of blood flow of the infarct-related artery is of paramount importance, either with percutaneous coronary intervention (PCI) or with coronary artery bypass grafting (CABG). In addition, early risk stratification is a critical task and required to guide complex decisions on management and therapy of CS after AMI. The use of short-term mechanical circulatory support (MCS) is increasing, although evidence for their effectiveness is limited.
We review the evidence for early revascularization of the culprit-lesion and risk stratification in patients with AMI complicated by cardiogenic shock. The current data for the use of MCS will be discussed and put into clinical perspective.
The SHOCK trial has introduced an early invasive strategy with subsequent revascularization as standard of care in patients with AMI complicated by CS. In clinical practice PCI is the by far the most often used revascularization therapy in CS. Most important is restoration of normal flow (so called TIMI 3 patency) of the infarct artery to reduce mortality. Therefore, all efforts including intense antithrombotic therapy should be made to achieve TIMI 3 patency. Around three quarters of patients with CS have multivessel coronary artery disease. According to the results of the CULPRIT-SHOCK trial PCI of the culprit lesion only is recommended as the preferred revascularization strategy in these patients, while additional lesions can be revascularized during a staged procedure. Immediate multivessel PCI could be performed in some specific angiographic scenarios, such as subtotal non-culprit lesions with reduced Thrombolysis In Myocardial Infarction (TIMI)-flow, or multiple possible culprit lesions. However, this should be considered on an individual basis. CABG should be performed only in case of failed PCI and coronary anatomies not suitable for PCI. However, small case series report good outcomes in selected patients with CS undergoing CABG. Therefore, a randomized trial comparing PCI and CABG in patients with CS and multivessel disease seems warranted. Hopefully such a trial will take place to determine the optimal revascularization therapy in CS. One problem might be to find a sufficient number of cardiac surgeons who are willing to operate such high-risk surgical patients.
心源性休克（CS）仍然是急性心肌梗死（AMI）患者死亡的主要原因。恢复梗死相关动脉的血流至关重要，可以通过经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）来实现。此外，早期风险分层是一项关键任务，需要指导 AMI 后 CS 的管理和治疗的复杂决策。尽管短期机械循环支持（MCS）的有效性有限，但它的使用正在增加。
我们回顾了 AMI 并发 CS 患者早期罪犯病变血运重建和风险分层的证据。将讨论当前关于 MCS 使用的数据，并将其置于临床视角下。
SHOCK 试验提出了一种早期侵入性策略，随后将血运重建作为 AMI 并发 CS 患者的标准治疗方法。在临床实践中，PCI 是 CS 中最常用的血运重建治疗方法。最重要的是恢复梗死动脉的正常血流（所谓的 TIMI 3 通畅）以降低死亡率。因此，应尽一切努力包括强化抗血栓治疗来实现 TIMI 3 通畅。大约四分之三的 CS 患者有多支冠状动脉疾病。根据 CULPRIT-SHOCK 试验的结果，建议在这些患者中仅对罪犯病变进行 PCI 作为首选血运重建策略，而在分期手术中可以对其他病变进行血运重建。在某些特定的血管造影情况下，如部分罪犯病变伴 TIMI 血流减少，或多个可能的罪犯病变，可能会进行即刻多支 PCI。然而，这应根据具体情况考虑。只有在 PCI 失败且冠状动脉解剖不适合 PCI 时才应进行 CABG。然而，一些小型病例系列报告了选择性接受 CABG 的 CS 患者的良好结果。因此，在 CS 合并多支血管疾病的患者中比较 PCI 和 CABG 的随机试验似乎是合理的。希望这样的试验将进行，以确定 CS 的最佳血运重建治疗方法。一个问题可能是找到足够数量愿意为这些高危手术患者进行手术的心脏外科医生。
