Anuradha Lala1, Yu Guo2, Jinfeng Xu3, Michele Esposito4, Kevin Morine4, Richard Karas4, Stuart D Katz2, Judith S Hochman2, Daniel Burkhoff5, Navin K Kapur6. 1. Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai Hospital, New York, New York. 2. New York University School of Medicine, New York, New York. 3. Department of Statistics and Actuarial Science, University of Hong Kong, Hong Kong. 4. Cardiovascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts. 5. Columbia University, New York, New York. 6. Cardiovascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts. Electronic address: nkapur@tuftsmedicalcenter.org.
Abstract
BACKGROUND: The prevalence and significance of right ventricular dysfunction (RVD) in patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) have not been well characterized. We hypothesized that RVD is common in AMI-CS and associated with worse clinical outcomes. METHODS AND RESULTS: We retrospectively analyzed patients with available hemodynamics enrolled in the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial (n = 139) and registry (n = 258) to identify RVD in AMI-CS. RVD was defined by an elevated central venous pressure (CVP), elevated CVP-pulmonary capillary wedge pressure (PCWP) ratio, decreased pulmonary artery pulsatility index, and decreased right ventricular stroke work index. A P value of <.01 was used to infer significance. In the SHOCK trial and registry, respectively, 38% and 37% of patients had RVD, but RVD was not associated with 30-day or 6-month survival (hazard ratio [HR] 1.51, (99% CI 0.92-2.49; P = .10). RV failure with the use of inclusion criteria from the Recover Right Trial for RV Failure (RR-RVF) requiring percutaneous mechanical circulatory support included elevated CVP and CVP/PCWP and a low cardiac index despite ≥1 inotrope or vasopressor. In the SHOCK trial and registry, respectively, 45% (n = 63/139) and 38% (n = 98/258) of patients met RR-RVF criteria. The RR-RVF criteria were not significantly associated with 30-day mortality in the registry cohort (HR 1.44, 99% CI 1.01-2.04; P = .04), or in the trial cohort (HR 1.51, 99% CI 0.92-2.49; P = .10). CONCLUSIONS: Hemodynamically defined RVD is common in AMI-CS. Routine assessment with pulmonary artery catherization allows detection of RVD; however, further work is needed to identify interventions that will result in improved outcomes for these patients.
RCT Entities:
BACKGROUND: The prevalence and significance of right ventricular dysfunction (RVD) in patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) have not been well characterized. We hypothesized that RVD is common in AMI-CS and associated with worse clinical outcomes. METHODS AND RESULTS: We retrospectively analyzed patients with available hemodynamics enrolled in the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial (n = 139) and registry (n = 258) to identify RVD in AMI-CS. RVD was defined by an elevated central venous pressure (CVP), elevated CVP-pulmonary capillary wedge pressure (PCWP) ratio, decreased pulmonary artery pulsatility index, and decreased right ventricular stroke work index. A P value of <.01 was used to infer significance. In the SHOCK trial and registry, respectively, 38% and 37% of patients had RVD, but RVD was not associated with 30-day or 6-month survival (hazard ratio [HR] 1.51, (99% CI 0.92-2.49; P = .10). RV failure with the use of inclusion criteria from the Recover Right Trial for RV Failure (RR-RVF) requiring percutaneous mechanical circulatory support included elevated CVP and CVP/PCWP and a low cardiac index despite ≥1 inotrope or vasopressor. In the SHOCK trial and registry, respectively, 45% (n = 63/139) and 38% (n = 98/258) of patients met RR-RVF criteria. The RR-RVF criteria were not significantly associated with 30-day mortality in the registry cohort (HR 1.44, 99% CI 1.01-2.04; P = .04), or in the trial cohort (HR 1.51, 99% CI 0.92-2.49; P = .10). CONCLUSIONS: Hemodynamically defined RVD is common in AMI-CS. Routine assessment with pulmonary artery catherization allows detection of RVD; however, further work is needed to identify interventions that will result in improved outcomes for these patients.
Authors: Carlos D Davila; Michele Esposito; Colin S Hirst; Kevin Morine; Lena Jorde; Sarah Newman; Vikram Paruchuri; Evan Whitehead; Katherine L Thayer; Navin K Kapur Journal: Front Cardiovasc Med Date: 2021-02-11