Grollier G, Saloux E, Lecluse E, Agostini D, Hamon M, Potier J C
Service de cardiologie, CHU, Côte de Nacre, Caen.
Arch Mal Coeur Vaiss. 1998 Sep;91(9):1145-9.
Despite improved management of myocardial infarction, the incidence of cardiogenic shock remains constant at about 7.5% of cases. Patients who develop cardiogenic shock are older and much more often women. The site of infarction is usually anterior, transmural with greater left ventricular systolic dysfunction and a higher increase in cardiac enzymes. Diastolic intra-aortic balloon pumping is the usual treatment but survival only seems to be increased in patients undergoing revascularisation. Surgical revascularisation and circulatory assist devices have been proposed but patient selection in these studies was biased and optimised the results. The effect of thrombolysis was analysed in a subgroup of patients in the GISSI study. The 30 day mortality was 69.9% in 146 patients treated by streptokinase and 70.1% in patients given placebo. Thrombolysis only benefitted patients with an anterior myocardial infarction aged less than 65 and treated within 6 hours of the onset of pain. Although there are no randomised studies of the value of angioplasty in patients in cardiogenic shock. Several uncontrolled series suggest that this type of procedure reduces short and long-term mortality. However, the prognosis is not as good when unselected consecutive groups of patients are studied in whom infarction is complicated by cardiogenic shock immediately and who undergo "aggressive" revascularisation: 72% of patients die in hospital and there are few long-term survivors. The prognosis appears to be particularly poor in patients over 70 years of age with a previous history of myocardial infarction or who undergo prolonged pre-hospital cardiopulmonary resuscitation. However, the implantation of coronary stents associated with circulatory assist devices seems to improve the prognosis of infarction complicated by cardiogenic shock by ensuring adequate coronary flow and reducing the risk of reocclusion.
尽管心肌梗死的治疗有所改善，但心源性休克的发生率仍保持在约7.5%的病例中。发生心源性休克的患者年龄较大，女性更为常见。梗死部位通常在前壁，为透壁性，左心室收缩功能障碍更严重，心肌酶升高幅度更大。主动脉内球囊反搏是常用的治疗方法，但似乎只有接受血运重建的患者生存率会提高。有人提出了外科血运重建和循环辅助装置，但这些研究中的患者选择存在偏差，结果得到了优化。在GISSI研究的一个亚组患者中分析了溶栓的效果。146例接受链激酶治疗的患者30天死亡率为69.9%，接受安慰剂治疗的患者为70.1%。溶栓仅使年龄小于65岁、在疼痛发作后6小时内接受治疗的前壁心肌梗死患者受益。虽然没有关于心源性休克患者血管成形术价值的随机研究。几个非对照系列研究表明，这种手术可降低短期和长期死亡率。然而，当对未经选择的连续患者组进行研究时，预后并不理想，这些患者立即发生梗死并伴有心源性休克，且接受了“积极”的血运重建：72%的患者在医院死亡，长期存活者很少。70岁以上有心肌梗死病史或在院前接受长时间心肺复苏的患者预后似乎特别差。然而，与循环辅助装置相关的冠状动脉支架植入似乎可以通过确保足够的冠状动脉血流并降低再闭塞风险来改善伴有心源性休克的梗死的预后。
