Related Experiment Videos
[Treatment of cardiogenic shock with thrombolysis and coronary angioplasty]
1Servicio de Cardiología y Unidad Coronaria, Hospital Clínic i Provincial, Universidad de Barcelona.
Insights
Cardiogenic shock following acute myocardial infarction has high mortality. Coronary angioplasty shows promising results for reperfusion and survival, outperforming conventional fibrinolytic therapy.
Area of Science:
- Cardiology
- Interventional Cardiology
Context:
- Cardiogenic shock complicates acute myocardial infarction (AMI) in 2-12% of patients.
- High mortality (approx. 75%) associated with cardiogenic shock in AMI.
- Extensive myocardial necrosis (>40% LV mass) and severe coronary disease (3-vessel disease in ~70%) are common.
Purpose:
- Evaluate the efficacy of different treatments for cardiogenic shock in AMI.
- Compare fibrinolytic therapy, intracoronary streptokinase, coronary angioplasty, and surgery.
Summary:
- Fibrinolytic therapy shows limited benefit in reducing mortality for AMI patients with shock.
- Intracoronary streptokinase achieved lower recanalization rates and had high mortality.
- Coronary angioplasty demonstrates superior outcomes, with promising survival rates (56-61%) and high recanalization (75%).
- Surgery is indicated for cardiac rupture, with survival around 50%.
Impact:
- Coronary angioplasty emerges as a potentially superior reperfusion strategy for cardiogenic shock in AMI.
- Findings may guide treatment decisions, favoring angioplasty over traditional fibrinolysis.
- Further research needed to define the role of surgery in non-rupture scenarios.
Abstract:
The incidence of cardiogenic shock in patients with acute myocardial infarction can be estimated between 2 and 12%, with a mortality close to 75%. Most pathologic studies demonstrate that myocardial necrosis involves more than 40% of left ventricular mass in these patients. Severe coronary disease is the rule, with three vessel disease in nearly 70% of cases. The efficacity of fibrinolytic treatment in reducing mortality is less evident in patient with shock. In the GISSI-1 study, Killip class IV patients had 69% mortality with streptokinase and 70% without; In the GISSI-2 trial, mortality was 65% with streptokinase and 78% with tPA. The thrombolytic drug used does not seem, thus, to influence the results. In a small series of 44 patients, intracoronary streptokinase achieved recanalization in 43% of cases, less than the average for the general population of patients with acute myocardial infarction receiving conventional treatment. Mortality was 42% in successfully treated patients, less than in those not reperfused. Coronary angioplasty seems superior to conventional fibrinolytic treatment. Results are promising, with survival between 56% and 61% in successfully reperfused patients. Recanalization rate may reach 75%. Surgery offers the only alternative when shock is due to any types of cardiac rupture; in the absence of this complication, its role is not well defined yet. Survival may be estimated in 50%.