What’s new in cardiogenic shock?
Society for Cardiovascular Angiography and Intervention (SCAI) 最近提出了新的心因性休克的分類，根據心因性休克的clinical、biological 和hemodynamic signs，分為嚴重程度逐漸增加的五個階段 (A-E)：
▲A new classification for cardiogenic shock. 2023
▲ 2024更新 A, B, Diagrams showing SCAI shock classification pyramid (A) and the dynamic evolution of cardiogenic shock and progression or recovery through SCAI shock stages (B). AMI = acute myocardial infarction; CA = cardiac arrest; CS = cardiogenic shock; HF = heart failure; MCS = mechanical circulatory support; SCAI = Society for Cardiovascular Angiography and Interventions; Tx = treatment. (Reproduced with permission from Naidu et al.12)
Culprit‑lesion‑only or multivessel percutaneous coronary intervention (PCI)?
歐洲心臟學會 (European Society of Cardiology, ESC) 指引建議不要在心因性休克情況下立即進行immediate multivessel PCI
CULPRIT-SHOCK 研究將 706 名發生心因性休克的complicating AMI病人隨機分為culprit-lesion-only PCI或immediate multivessel PCI 。Composite primary endpoint為（death or renal replacement therapy within 30 days after randomization）在multivessel group 的比例較高(55.4% vs. 45.9%, p = 0.001)，並且死亡率有增加趨勢 (43.3% vs. 51.5%; p = 0.03)。 然而，一年後，culprit-lesion-only group的repeat revascularization發生率 (32.3% vs. 9.4%) 和心臟衰竭再住院率(5.2% vs. 1.2%)比multivessel group更高。因此，歐洲心臟學會 (European Society of Cardiology, ESC) 指引建議不要在心因性休克情況下立即進行immediate multivessel PCI ，可再之後在對其他lesions 進行revascularization。
Norepinephrine or epinephrine?Norepinephrine but not epinephrine should be considered as the first-line vasopressor in patients with cardiogenic shock
Non‑pharmalogical interventionsCULPRIT-SHOCK 研究將 706 名發生心因性休克的complicating AMI病人隨機分為culprit-lesion-only PCI或immediate multivessel PCI 。Composite primary endpoint為（death or renal replacement therapy within 30 days after randomization）在multivessel group 的比例較高(55.4% vs. 45.9%, p = 0.001)，並且死亡率有增加趨勢 (43.3% vs. 51.5%; p = 0.03)。 然而，一年後，culprit-lesion-only group的repeat revascularization發生率 (32.3% vs. 9.4%) 和心臟衰竭再住院率(5.2% vs. 1.2%)比multivessel group更高。因此，歐洲心臟學會 (European Society of Cardiology, ESC) 指引建議不要在心因性休克情況下立即進行immediate multivessel PCI ，可再之後在對其他lesions 進行revascularization。
- 一個prospective multicenter study 比較epinephrine和norepinephrine 治療AMI 併發心因性休克的療效和安全性的前瞻性多中心研究提前終止，因為epinephrine組的refractory心因性休克的發生率(main safety endpoint)更高(37% vs. 7%, p = 0.008)。 然而，primary efficacy outcome (cardiac index evolution from baseline to 72小時)在各組之間沒有差異 (p = 0.4)。(Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction, link)
- 一個meta-analysis，收納了16 個研究包含2583 名心因性休克病人的分析中，與其他藥物相比，epinephrine會增加 adjusted short-term mortality(OR [95%CI] = 4.4 [3.4–6.4])。 此結果在 338 名propensity-matched病人的subset 中得到了證實(OR [95%CI] = 4.3 [3.0–6.0])。(Intensive Care Med, 2018: Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients)
Temporary circulatory support (TCS): ESC 指引中對IABP的使用為class IIIB
- IABP-SHOCK II 試驗將600 名有心因性休克的的AMI 病人隨機分組，結果顯示主動脈內氣球幫浦(IABP) 在30 天、1 年和6 年死亡率或任何其他 secondary outcomes方面，沒有有任何益處。(Intraaortic balloon pump in cardiogenic shock complicating acute myocardial infarction: long-term 6-year outcome of the randomized IABP-shock II trial)
- Temporary circulatory support (TCS )設備包括Impella®（ABIOMED Inc., Danvers, MA, USA）、TandemHeart®（LivaNova, London, UK）和venoarterial extracorporeal membrane oxygenation (VA-ECMO)，後者提供循環支持和氣體交換。 然而，ESC 指引（Class IIb, Level of Evidence C）建議僅在特定的心因性休克的病人中考慮使用TCS。(2018 ESC/EACTS Guidelines on myocardial revascularization, link)
▲ （2024更新）Flowchart showing medical management of cardiogenic shock. This management algorithm represents the expert opinions of the authors and is informed by trial data and society guidelines
參考資料：
Latest update: 25. June. 2024
沒有留言:
張貼留言