Jean-Christophe Stauffer

Ten-Year Trends in the Incidence and Treatment of Cardiogenic Shock

Context Are the incidence and management of cardiogenic shock changing? Contribution This analysis of hospital registry data from Switzerland showed that rates of cardiogenic shock in patients with acute coronary syndromes declined from 1997 to 2006. Declining rates were due to decreased rates of shock development during hospitalization rather than a change in rates of shock at admission. Use of percutaneous coronary intervention increased, and in-hospital mortality decreased. Implication The incidence and mortality of cardiogenic shock in hospitalized patients in Switzerland decreased during the past decade, possibly because of changes in management of patients with acute coronary syndromes. The Editors The incidence of cardiogenic shock complicating the acute coronary syndrome (ACS) differs depending on the exact definitions of cardiogenic shock, but it has been estimated to be between 5% and 10% (1). Recent findings of population-based studies show slightly lower incidence rates of 3.2% to 8.6%, but data on temporal trends are conflicting (24). Since the implementation of guideline-recommended early revascularization for cardiogenic shock (5, 6), mortality rates have steadily decreased below 50% (2, 3). This is important because survivors of cardiogenic shock have a long-term outcome similar to that of patients without cardiogenic shock (7, 8). Although decreased mortality rates have been ascribed to improved treatment with higher rates of percutaneous coronary intervention (PCI) and intra-aortic balloon counterpulsation, a strong relationship between improved therapeutic management and lower mortality rates has not been established in population-based studies (4). Also, we still do not know whether early invasive treatment of ACS may prevent hemodynamic deterioration in patients at risk and whether temporal trends in overall cardiogenic shock rates are similar among patients with cardiogenic shock on admission and those who develop cardiogenic shock during hospitalization. The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry is a nationwide survey collecting data on hospital admissions for ACS since 1997. Using this database, we analyzed temporal trends in incidence, therapeutic management, and mortality rates of patients with cardiogenic shock during the past decade and assessed predictors of mortality and shock development during hospitalization. Our a priori hypothesis was that in-hospital mortality decreased during the past decade. Methods The AMIS Plus Registry Since 1997, 70 of the 106 acute cardiac care hospitals in Switzerland have participated in the AMIS Plus Registry (911). All participating hospitals have either a catheterization laboratory (18 hospitals) or direct access to a tertiary care center guaranteeing PCI within 90 minutes for all patients (52 hospitals). The 70 participating hospitals are a representative sample of acute care hospitals in Switzerland in terms of size, available skills, and quality grading (10, 11). The Swiss Societies of Internal Medicine, Cardiology, and Intensive Care Medicine founded the AMIS Plus Registry project. A steering committee that includes members of the founding medical societies guides the project. The Swiss National Ethical Committee for Clinical Studies and the Board for Data Security approved the registry. Data Collection Investigators at participating centers collect data for the registry by using identical Web-based or written questionnaires. The questionnaire has 140 items that address medical history, cardiovascular risk factors, symptoms, out-of-hospital management, clinical presentation, early in-hospital management, reperfusion therapy, hospital course, diagnostic tests used or planned, length of stay, and discharge medication and destination. A data coordinating center checks data for plausibility and consistency. Investigators returned incomplete questionnaires to the participating centers for completion (19% in 2003). This approach helps ensure that few data are missing (<1% overall and 0% for therapeutic interventions) (11). Patient Enrollment Patients were enrolled in the registry if their final diagnosis met 1 of the 3 following definitions: acute myocardial infarction, defined as symptoms or electrocardiographic (ECG) changes compatible with ACS (or both) and cardiac markers at least twice the upper limit of normal; ACS with minimum necrosis, defined as symptoms or ECG changes compatible with ACS (or both) and cardiac markers lower than twice the upper limit of normal but still abnormal; or unstable angina, defined as symptoms or ECG changes compatible with ACS (or both) and normal cardiac markers. In this study, we included all patients with ACS entered in the AMIS Plus Registry between 1 January 1997 and 31 December 2006 from the participating hospitals. We excluded patients with unclear or noncardiac causes of ACS. We analyzed and compared patients who had ACS and cardiogenic shock with patients who had ACS without cardiogenic shock. Definitions We classified patients who had ST-segment elevation or new left bundle-branch block on their initial ECG as having ST-segment elevation ACS. We classified patients who had ST-segment depression or T-wave abnormalities in the absence of ST-segment elevation on the initial ECG as having nonST-segment elevation ACS. Patients with cardiogenic shock were those with cardiogenic shock on admission and those who developed cardiogenic shock during hospitalization as a complication of ACS. We defined cardiogenic shock at admission and during hospitalization similarly at participating centers by using the Killip definition of hypotension (systolic blood pressure <90 mm Hg) and evidence of peripheral vasoconstriction (oliguria, cyanosis, or sweating) (12). When they became available, we advised investigators at PCI sites to follow current guidelines recommending the performance of revascularization within 36 hours after shock onset (5, 6), but we did not record the exact timing of PCI. Statistical Analysis We present descriptive statistics as means (SDs), medians with interquartile ranges, or percentages. We compared categorical variables and temporal trends by using the chi-square test and continuous variables by using the t test. Our primary outcome of interest was in-hospital death, although we also examined major adverse cardiac events during hospitalization (reinfarction, cerebrovascular events, and shock). We used multivariable logistic regression models to examine predictors of in-hospital death and predictors of cardiogenic shock development during hospitalization. We included in these models all of the following available covariates evaluated at admission: age; sex; history of coronary artery disease, hypertension, diabetes, and dyslipidemia; current smoking status; Killip class if applicable; ST-segment elevation ACS; symptom-to-admission delay greater than 6 hours; cardiopulmonary resuscitation before admission; cardioversion or defibrillation before admission; atrial fibrillation; heart rate; systolic and diastolic blood pressures; obesity (body mass index >30 kg/m2); Charlson Comorbidity Index score (13); the use of various medications, such as acetylsalicylic acid, clopidogrel, glycoprotein IIb/IIIa inhibitors, -blockers, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and thrombolytics; primary PCI; intra-aortic balloon counterpulsation; and coronary artery bypass graft surgery. We forced all candidate variables into the final models. We simultaneously adjusted odds ratios for all other predictors. We conducted analyses by using commercially available statistical software (SPSS version 14.0, SPSS, Chicago, Illinois). All P values were 2-sided and were considered statistically significant if 0.050 or less. Role of the Funding Source The AMIS Plus Registry project was supported by the following sources (all in Switzerland; then were grouped by city, rather than by grant size or any other preferential factor): Swiss Heart Foundation and Novartis Pharma Schweiz, Bern; A. Menarini, Bayer (Schweiz), Pfizer, SPSS (Schweiz), and St. Jude Medical, Zurich; AstraZeneca, Zug; Biotronik Schweiz, Bristol-Myers Squibb, and Schering, Baar; Boehringer Ingelheim (Schweiz), Basel; Boston Scientific, Solothurn; Cordis, Johnson & Johnson, Spreitenbach; GlaxoSmithKline, Mnchenbuchsee; Invatec, Schaffhausen; Medtronic Schweiz, Tolochenaz; MCM medsys, Kirchberg; Merck Sharp & Dohme Chibret, Opfikon-Glattbrugg; Nycomed Pharma, Dbendorf; Sanofi-Aventis (Suisse) and Servier (Suisse), Meyrin; and Takeda Pharma, Lachen. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Results Patients From January 1997 to December 2006, 23696 patients with ACS were enrolled in the AMIS Plus Registry (Figure 1 and Table 1). Overall, 1977 patients (8.3%) had cardiogenic shock. Of these, 564 patients (2.3% of those with ACS and 28.5% of those with cardiogenic shock) had cardiogenic shock on admission and 1413 patients (6.0% of those with ACS and 71.5% of those with cardiogenic shock) developed cardiogenic shock during hospitalization. Baseline risk for cardiovascular disease was higher among patients with cardiogenic shock than among those without (Table 1); this difference was mainly driven by patients who developed cardiogenic shock during hospitalization. Patients with cardiogenic shock on admission were similar to patients without cardiogenic shock in terms of sex and age. Figure 1. Study flow diagram. Table 1. Baseline Characteristics, Treatment, and In-Hospital Outcome Multivariable Analysis In the ACS group, variables indicative of higher baseline risk, such as older age, history of diabetes, higher Killip classes, ST-segment elevation ACS, cardiopulmonary resuscitation on admission, faster heart rate, lower systolic blood pressure, higher Charlson Comorbid

Age-Related Differences in the Use of Guideline-Recommended Medical and Interventional Therapies for Acute Coronary Syndromes: A Cohort Study

OBJECTIVES: To compare the use of guideline‐recommended medical and interventional therapies in older and younger patients with acute coronary syndromes (ACSs).

Acute coronary syndromes in young patients: Presentation, treatment and outcome

BACKGROUND Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. METHODS In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). RESULTS 195 patients (0.7%) were 35 years old or younger. Compared to patients>35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; P<0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; P<0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. CONCLUSIONS Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Recognition and treatment of left ventricular diastolic dysfunction

B ASED ON EXTENSIVE research, it has become possible to focus on individual factors that cause or contribute to the clinical syndrome of congestive heart failure. These factors include the effects of ischemia and hypertrophy, changes in the peripheral circulation, alterations in reflex and neurohumoral function, the interdependent function of the right and left ventricles, and of signal importance to the clinician, the difference between systolic and diastolic dysfunction of the left ventricle.‘-” This article will discuss the distinction between systolic and diastolic dysfunction (Fig 1) and will answer three clinically relevant questions. What is diastolic dysfunction? How is it diagnosed? How is it treated? Diastolic dysfunction of the left ventricle (LV) is defined as an impaired capacity to accept blood or fill without a compensatory increase in left atria1 pressure. In its mildest form, diastolic dysfunction may appear as a slow or delayed pattern of relaxation and filling, with little or no elevation of LV diastolic pressure (there is generally little or no systolic dysfunction); thus, in patients with LV hypertrophy or coronary disease, an alteration in diastolic filling can serve as a sensitive and early indicator of disease.‘re2’ Diastolic dysfunction may also appear as overt congestive heart failure, even in the presence of normal or near-normal systolic function.22*23 In some ways diastolic dysfunction is similar to mitral stenosis; in this case, however, impaired filling is due to a reduced effective mitral orifice area. Thus, the concept of diastolic dysfunction as a mechanism underlying heart failure is similar to the description of “backward failure” as originally proposed by Hope.24 In recent years, clinicians and physiologists alike have reexamined their concepts about the pathophysiology of heart failure. The major focus has been to clarify the distinction between diastolic dysfunction (or failure) and systolic dysfunction. Simply stated, systolic dysfunction is the inability of the myofibrils to shorten against a load; thus, the left ventricle loses its ability to eject blood into a high-pressure aorta. Diastolic dysfunction implies that the ventricle can not accept blood at low pressures; ventricular filling is slow, delayed, or incomplete unless atria1 pressure increases. Consequently, pulmonary and/or systemic venous congestion develops. Thus, the signs and symptoms of pulmonary and/or systemic venous congestion are not necessarily the result of systolic dysfunction, instead they are related to alterations in diastolic properties of the LV chamber. These properties may consist of changes in the passive (or “static”) diastolic properties of the LV and/or changes in the “active” processes of relaxation and filling.

Temporal trends in treatment of ST-elevation myocardial infarction among men and women in Switzerland between 1997 and 2011

Background: Few data are available concerning the impact of gender on temporal trends in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: All STEMI patients consecutively enrolled in the AMIS (Acute Myocardial Infarction in Switzerland) Plus project from 1997–2011 were included. Temporal trends in presentation, treatment and outcomes were analyzed using multiple logistic regressions with generalized estimations. Results: Of 21,620 STEMI patients, 5786 were women and 15,834 men from 78 Swiss hospitals. Women were 8.6 years older, presented 48 minutes later with less pain, but more dyspnea, and more frequently had atrial fibrillation (5.5 vs. 3.9%, p<0.001), heart failure (Killip class >2) (9.7 vs. 7.3%, p<0.001), and moderate or severe comorbidities (24.8 vs. 18.2%, p<0.001). Women were less likely to undergo primary reperfusion treatment after adjustment for baseline characteristics and admission year (OR 0.80, 95% CI 0.71–0.90, p<0.001) or receive early and discharge drugs, such as thienopyridines, angiotensin-converting-enzyme inhibitors, angiotensin II receptor antagonists, and statins. In 1997, thrombolysis was performed in 51% of male and 39% of female patients; its use rapidly decreased during the 1990s and has now become negligible. Primary percutaneous coronary intervention increased from under 10% in both genders in 1997 to over 70% in females and over 80% in males since 2006. Patients admitted in cardiogenic shock increased by 8% per year in both genders. The incidence of both reinfarction and cardiogenic shock developing during hospitalization decreased significantly over 15 years while in-hospital mortality decreased from 10 to 5% in men and from 18 to 7% in women. This corresponds to a relative reduction of 5% per year for males (OR 0.95, 95% CI 0.92–0.99, p=0.006) and 6% per year for female STEMI patients (OR 0.94, 95% CI 0.91–0.97, p<0.001). Despite higher crude in-hospital mortality, female gender per se was not an independent predictor of in-hospital mortality (OR 1.07, 95% CI 0.84–1.35, p=0.59). Conclusion: Substantial changes have occurred in presentation, treatment, and outcome of men and women with STEMI in Switzerland over the past 15 years. Although parallel trends were seen in both groups, ongoing disparities in certain treatments remain. However, these did not translate into worse risk-adjusted in-hospital mortality, suggesting that the gender gap in STEMI care may be closing.

Complications and follow-up after intracoronary stenting: Critical analysis of a 6-year single-center experience

From April 1986 through April 1992, 123 patients received 153 intracoronary stents (131 Medinvent, 13 Palmaz-Schatz, 9 Wiktor) during 131 procedures. The indication was bail-out treatment in 39, restenosis in 59 native coronary arteries, and stenosis or restenosis in 33 vein grafts. Stent-related events were studied during the in-hospital stay and on follow-up and included closure, stent restenosis, myocardial infarction, death, and the need for coronary bypass surgery. A Kaplan-Meier estimate extended to 6 years showed different short- and long-term outcomes for the distinct treatment groups (p < 0.05): right coronary artery stenting (more particularly, stenting for restenosis after angioplasty) had the lowest and vein graft stenting had the highest stent-related complication rate. The complication rate was similar (p > 0.25) (1) in the case of multiple nontandem stent implantation during the same procedure; (2) for the different endoprosthesis sizes; and (3) during the different procedural years. In native coronary arteries, restenosis after angioplasty of the right coronary artery could be a preferential indication for coronary artery stenting. Despite a favorable short-term outcome, vein graft stenting has a high incidence of events on long-term follow-up, mainly because of late restenosis. Multiple nontandem stenting during the same procedure is not associated with a higher incidence of complications, in particular, the restenosis rate is not appreciably higher. Finally, only a minor benefit for the learning curve is apparent from this single-center experience with continual unchanged postprocedural management.

Effectiveness of percutaneous transluminal coronary angioplasty in cardiogenic shock during acute myocardial infarction

Abstract The prognosis of cardiogenic shock during acute myocardial infarction (AMI) is poor; the mortality rate varies from 80 to 100%.1,2 Recently, interventional therapy including intracoronary thrombolysis and mechanical recanalization have been proposed and seem to improve prognosis.3–5

Comparison of in-hospital mortality for acute myocardial infarction in Switzerland with admission during routine duty hours versus admission during out of hours (insight into the AMIS plus registry)

To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p <0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killips class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.

Long-term follow-up of the first 56 patients treated with intracoronary self-expanding stents (the Lausanne experience)

Fifty-six patients treated with the self-expanding intracoronary stent for acute occlusion during percutaneous transluminal coronary angioplasty (PTCA) or restenosis were followed for 24 to 43 months (mean 34). Successful deployment and positioning were achieved in 55 of 56 patients. Occlusion of the stent was documented in 8 patients, the earliest occurring 30 minutes and the latest 8 months after implantation. Three of the occluded stents were recanalized by PTCA. Coronary artery bypass grafts (CABG) were required in 4 patients: 1 for symptomatic restenosis, 1 for left main stenosis adjacent to the stent and 2 for acute ischemia during the in-hospital stay (less than 7 days). Myocardial infarction occurred in the territory of the stented vessel in 8 patients. Seven patients died between 1 day and 19 months after implantation. Local bleeding complications occurred in 10 patients, with 5 requiring blood transfusion. Restenosis within the stent was angiographically documented in 5 patients (9%). A new lesion in the treated vessel was found in 10 patients, followed by implantation of a second stent in 5 and a third stent in 1 patient. Medical treatment was instituted in the remaining 4 patients. Forty-nine patients (88%) are alive. Twenty-nine patients (51%) remained asymptomatic, and 44 (78%) are in a better functional class than before the implantation. Eleven of 15 (79%) major complications (acute occlusions or deaths) occurred in patients who received a stent in the left anterior descending coronary artery. In conclusion, implantation of the self-expanding intracoronary stent appears to be a new therapeutic option for treating acute occlusion or restenosis after PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term clinical and angiographic follow-up of patients treated with the self-expanding coronary stent for acute occlusion during balloon angioplasty of the right coronary artery

A self-expanding coronary stent was implanted in 17 patients to treat acute occlusion of the right coronary artery after percutaneous transluminal angioplasty. There were 2 women and 15 men, with a mean age of 59 +/- 8 years. All patients underwent at least one follow-up angiographic examination 4 to 6 months after implantation and six patients had additional follow-up angiography. During a mean follow-up interval of 32 +/- 10 months no patient died or had a myocardial infarction. Restenosis within the stent did not occur. Two patients had a new stenosis adjacent to the stent. Stent occlusion was found on follow-up angiography in one patient who had not been treated with an antiplatelet agent. The mean intraluminal diameter was 2.77 +/- 0.5 mm after implantation and 2.67 +/- 0.5 mm on follow-up angiography. It is concluded that coronary stenting is effective in treating right coronary artery occlusion after balloon angioplasty. Immediate and long-term outcome suggest that the right coronary artery may be a particularly favorable site for stent implantation.