Top Things to Know: Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published: March 04, 2021
Prepared by Anne Leonard, Sr. SMA, MPH, BSN, RN, FAHA
- Cardiogenic shock (CS) is the most common cause of mortality in patients with acute myocardial infarction (AMI), is the inability of the heart to maintain effective cardiac output to meet metabolic demands of the body as a result of underlying cardiac pathology.
- Overall, the incidence of ST-segment elevation myocardial infarction is decreasing, but the incidence of CS complicating AMI (AMICS) remains stable (7-10%), if not increasing, and especially in the elderly.
- Mortality associated with AMICS is high, with a 30-day mortality of about 40-45% in contemporary randomized trials.
- Several centers have developed specific institutional protocols for triage and management of AMICS. These protocols include triage, diagnosis, and management, with considerations for early use of mechanical circulatory support (MCS).
- When AMICS is recognized, viable patients with spontaneous circulation should be triaged to invasive management and brought to the cardiac catheterization laboratory of a percutaneous coronary intervention (PCI)-capable hospital as quickly as possible.
- Initial stabilization of blood pressure in AMICS patients includes the use of vasopressors to maintain mean arterial blood pressure of >65mmHg and favors norepinephrine as first-line intervention. AMICS predisposes to hypoxemia (due to cardiogenic pulmonary edema) and metabolic acidosis (due to lactic acidosis and acute kidney injury), placing patients at risk for acute respiratory failure. Early intubation and ventilatory support may facilitate revascularization with improved oxygenation, better sedation, and an enhanced metabolic profile.
- For coronary revascularization, PCI of the infarct-related artery is the priority method of reperfusion for patients with AMICS irrespective of time delay. Management of multivessel disease is also addressed in this statement.
- Comprehensive critical care following acute invasive management includes:
- Prevention of an event
- Diagnosis and management of multiorgan system failure complicating AMICS
- Continuous reassessment of hemodynamics and perfusion status using clinical and invasive measures.
- Ongoing and relentless titration of therapies based on evolving data, anticipation, and management of complications of acute invasive management.
- Collaboration and shared decision making by a multidisciplinary shock team, including consideration of timing and approach to escalation or de-escalation of MCS.
- Close communication with family to provide regular updates and reassessment of prognosis and goals of care.
- Cardiac arrest is common among patients with AMICS and confers an increased risk of mortality independent of stage of shock.
- AMICS is a complex clinical entity that remains prevalent and is a major cause of death following AMI that must be recognized and treated immediately to prevent morbidity and mortality.
Citation
Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Pina IL, Kapur NK, Dangas GD; on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing. Invasive management of acute myocardial infarction complicated by cardiogenic shock: a scientific statement from the American Heart Association [published online ahead of print Thursday, March 4, 2021]. Circulation. 2021;143:e•••–e•••. doi: 10.1161/CIR.0000000000000959