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25 years of acute coronary syndrome and cardiogenic shock: how have we changed?

Session HFA Discoveries - ePosters

Speaker Ana Elvira Laffond

Event : HFA Discoveries 2020

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Coronary Artery Disease: Treatment, Revascularization
  • Session type : ePoster

Authors : D Gonzalez-Calle (Salamanca,ES), A Elvira Laffond (Salamanca,ES), F Martin-Herrero (Salamanca,ES), M Antunez-Ballesteros (Salamanca,ES), VE Vallejo-Garcia (Salamanca,ES), PL Sanchez-Fernandez (Salamanca,ES)

Authors:
D Gonzalez-Calle1 , A Elvira Laffond1 , F Martin-Herrero1 , M Antunez-Ballesteros1 , VE Vallejo-Garcia1 , PL Sanchez-Fernandez1 , 1Clinical Universitary Hospital of Salamanca - Salamanca - Spain ,

Citation:

Introduction

Acute coronary syndrome (ACS) presenting with cardiogenic shock (Killip IV) is still a frequent condition with a sombre prognosis in the short-term. The original article in which the Killip classification was proposed, published in the late 1960s, described a mortality over 80% in this group of patients. Today we can offer these patients other therapeutic approaches and procedures which have significantly reduced this percentage, but which imply new treatment-related complications.

Methods

This is a retrospective analysis of patients admitted to a cardiac intensive care unit (CICU) in the past 25 years (1993-2018, n = 7669 patients). Patients presenting with ACS complicated with cardiogenic shock (Killip IV) were included (n = 539). 170 variables were analysed. In order to enable adequate comparison between different treatment strategies, only patients from three specific time periods were analysed:
Phase A (1993-1996): thrombolysis, a less invasive management of the patient.
Phase B (2003-2006): beginning of primary percutaneous coronary intervention (PCI), 24-hour and 7-days a week.
Phase C (2015-2018): current management, advanced mechanical circulatory support.

ResultsĀ 

The number of patients admitted in the CICU with the diagnosis of acute coronary syndrome has progressively increased in the past decades. On the contrary, incidence of cardiogenic shock in this context shows a tendency to decrease: from 7 % in phase A to a 6.45 % in phase B and a 5.4 % in phase C. Importantly, mortality has been significantly reduced in these patients (88% in phase A and 41.9 % in phase C, p < 0.001). This is in great part due to universal early revascularization (88.8 % of emergent PCI in phase C) compared to the more conservative approach in the previous phases (35 % of emergent thrombolysis in phases A and B). The use of circulatory support devices has also increased throughout the period of study. Intra-aortic balloon pump was the preferred device in phase B (22.8 % of patients, compared with a 7.4 % in phase A and 15.6 % in phase C), while extracorporeal membrane oxygenation has emerged as a new option for these patients (13.1 % of patients in phase C). Another significant change in the management of these patients is inotropic support: while dobutamine and dopamine were first-line therapies in phases A and B, noradrenaline is currently the inotropic drug of choice (p < 0.0001).

Conclusions

Incidence of acute coronary syndrome presenting with cardiogenic shock (Killip IV) has decreased in the past decades. Furthermore, the paradigmatic change of emergent primary coronary intervention as the mainstay of treatment has contributed to significantly decrease the mortality of this otherwise fatal condition. New circulatory devices have been implemented in the last years, and although not routinely used, will offer further assistance in the management of these patients.

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