Which Patients Will Benefit?
The special topic of cardiogenic shock associated with ST-elevation myocardial infarction (STEMI) requires a more detailed explanation.
In spite of the results of the SCHOCK-I study, which showed a clear survival advantage at 6 months and 1 year after emergency revascularization (1), hospital mortality on the basis of multiorgan failure remains high in this group of patients, at 50%, in spite of the brief therapeutic window recommended by guidelines (door-to-balloon-time) of below 90 minutes (2). It remains unclear which patients actually benefit from early revascularization.
For this reason, and independently of the etiology of the cardiogenic shock, the focus should primarily be on restoring adequate hemodynamics and thus peripheral organ perfusion. Once all conservative measures have been exhausted, the timely use of temporary mechanical circulation support is crucial. Veno-arterial extracorporeal membrane oxygenation (ECMO) is used routinely as bridge-to-decision therapy these days. In order to increase the likelihood of myocardial recovery it is important to additionally relieve the left ventricle of volume. To this end, either an intra-aortic balloon pump is implanted contralaterally or, in transthoracically applied ECMO, an additional drain is placed in the left ventricle. The ECMO treatment is continued for seven days. The decision about further therapeutic procedures can then be made depending on the patient’s condition.
According to the insights gained from the SCHOCK-I study, the isolated use of an intra-aortic balloon pump does not affect patients’ survival and is no longer recommended (3).
Dr. med. Sotirios Spiliopoulos
Prof. Dr. med. Dr. h.c. Reiner Körfer
Prof. Dr. med. Gero Tenderich
Evangelisches Krankenhaus Duisburg
Klinik für Herz- und Gefäßchirurgie
Abteilung für die chirugische Therapie der terminalen Herzinsuffizienz und Kunstherzversorgung
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Hochman JS, Sleeper LA, White HD, et al.: One-year survival following early revascularization for cardiogenic schock. JAMA 2001; 285: 190–2 CrossRef MEDLINE|
|2.||Menees DS, Peterson ED, Wang Y, et al.: Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013; 369: 901–9 CrossRef MEDLINE|
|3.||Thiele H, Zeymer U, Neumann FJ, et al.: Intraaortic Balloon support for myocardial infarction with cardiogenic schock. N Engl J Med 2012; 367: 1287–96 CrossRef MEDLINE|
|4.||Hummel A, Empen K, Dörr M, Felix SB: De novo acute heart failure and acutely decompensated chronic heart failure. Dtsch Arztebl Int 2015; 112: 298–310 VOLLTEXT|