Faculty Bibliography

BACKGROUND: Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states. METHODS: We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states. RESULTS: New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non-New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non-New York patients (P < .001) taken for CABG within 3 days of shock onset. CONCLUSIONS: In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients

BACKGROUND: In cardiogenic shock (CS), conclusive data on serial hemodynamic measurements for treatment guidance and prognosis are lacking. METHODS: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock?) Trial tested early revascularization (ERV) vs initial medical stabilization (IMS) in CS complicating acute myocardial infarction and serially assessed hemodynamics by pulmonary artery catheter. RESULTS: Data were available in 278 patients (95%) surviving to the first measurement with predominant left ventricular failure at baseline and in 174 patients (70%) at follow-up. Baseline and follow-up hemodynamic data were similar in the treatment groups. The median time from CS to baseline measurements was 3.3 h in both treatment groups, whereas follow-up measurements were obtained earlier in the IMS group (median time, 10.6 h) than in the ERV group (median time, 12.5 h; p = 0.043). At baseline, stroke volume index (SVI) was an independent predictor of 30-day mortality after adjustment for age (odds ratio, 0.69 per 5 mL/m2 increase; 95% confidence interval, 0.55 to 0.87; p = 0.002). At follow-up, both stroke work index (SWI) [odds ratio, 0.54 per 5 g/m/m2 increase; 95% confidence interval, 0.39 to 0.76; p < 0.001] and SVI (odds ratio, 0.59 per 5 mL/m2 increase; 95% confidence interval, 0.45 to 0.77; p < 0.001) were similarly powerful predictors of 30-day mortality after adjustment for age. CONCLUSIONS: SVI and SWI are the most powerful hemodynamic predictors of 30-day mortality in CS patients. Hemodynamic parameters are similar for surviving patients following ERV and IMS. Thus, early hemodynamic stability after IMS should not delay revascularization since long-term outcomes are superior with ERV

BACKGROUND: It is unclear whether abnormalities of arginine and nitric oxide metabolism are related to hemodynamic dysfunction and mortality in patients with cardiogenic shock (CS) after acute myocardial infarction. METHODS AND RESULTS: Plasma metabolites reflecting arginine bioavailability, nitric oxide metabolism, and protein oxidation were analyzed by mass spectrometry in patients with CS (n=79) and age- and gender-matched patients with coronary artery disease and normal left ventricular function (n=79). CS patients had higher levels of asymmetric dimethylarginine (ADMA; P<0.0001), symmetric dimethylarginine (P<0.0001), monomethylarginine (P=0.0003), nitrotyrosine (P<0.0001), and bromotyrosine (P<0.0001) and lower levels of arginine (P<0.0001), ratio of arginine to ornithine (P=0.03), and ratio of arginine to ornithine plus citrulline) (P=0.0003). CS patients with elevated ADMA levels were 3.5-fold (95% confidence interval, 1.4 to 11.3; P=0.02) more likely to die in 30 days than patients with low ADMA levels. ADMA remained the only independent predictor of mortality on multiple logistic regression analysis. In patients with normal renal function, symmetric dimethylarginine levels inversely correlated with mean arterial pressure and systemic vascular resistance, whereas levels of ADMA correlated with pulmonary capillary wedge pressure and both systolic and diastolic pulmonary artery pressures. Despite dramatic elevations, levels of protein oxidation products did not predict hemodynamic dysfunction or mortality in CS patients. CONCLUSIONS: CS is characterized by an arginine-deficient and highly specific pro-oxidant state, with elevated levels of methylated arginine derivatives, including endogenous nitric oxide synthase inhibitors. Levels of methylated arginine derivatives strongly correlate with hemodynamic dysfunction. Among all clinical and laboratory parameters monitored, ADMA levels were the strongest independent predictor of 30-day mortality

As of April 2007 the early open artery hypothesis is alive and well, but the late open artery hypothesis is adrift. For the foreseeable future, stable patients with persistent occlusion of the infarct artery late after myocardial infarction, and without severe ischaemia or uncontrollable angina, should be managed initially with optimal medical treatment alone, and not with percutaneous coronary intervention. Efforts should focus on establishing reperfusion earlier, including reducing the time to patient presentation