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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the epidemiology of ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock, and its association with the increasing use of reperfusion therapy, especially primary percutaneous coronary intervention (PCI). Specific topics include reperfusion therapy, cardiac assist devices, shock after resuscitated cardiac arrest, and the use of PCI in refractory in- or out-of-hospital cardiac arrest.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EChristian Spaulding, MD, European Hospital Georges Pompidou and INSERM U 970, Paris, France, discussed the epidemiology of ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS), and its association with the increasing use of reperfusion therapy, especially primary percutaneous coronary intervention (PCI).\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIMPROVED USE OF REPERFUSION THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EEvaluation of French survey data showed an improved use of reperfusion therapy from 1995 to 2010, associated with an increased use of primary PCI and decreased use of thrombolysis from 2000 to 2010 (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). During the decade, the mortality rate 30 days after STEMI declined by \u223c9% absolute [Puymirat E et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Changes in Use of Reperfusion Therapy, PCI, and Thrombolysis Over Time\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-109793463\u0022 data-figure-caption=\u0022Changes in Use of Reperfusion Therapy, PCI, and Thrombolysis Over Time\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13474\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EChanges in Use of Reperfusion Therapy, PCI, and Thrombolysis Over Time\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from C Spaulding, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EProf. Spaulding discussed key data from three French nationwide registries [Aissaoui N et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012] conducted between 1995 and 2005, comparing mortality in patients with acute myocardial infarction (AMI) with versus without CS. The key findings were 1) the incidence of CS decreased over time (6.9% in 1995; 5.7% in 2005; p=0.07); 2) 30-day mortality was more than 10-fold higher in CS patients (60.9% vs 5.2%); and 3) mortality decreased both among patients with (70% to 51%; p=0.003) and without CS (8.7% to 3.6%; p\u0026lt;0.001). Correspondingly, the use of PCI increased from 20% to 50% (p\u0026lt;0.001), and was associated with decreased mortality (OR, 0.38; 95% CI, 0.24 to 0.58; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EOf patients enrolled in the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock trial [SHOCK], 302 had AMI complicated by CS. Compared with initial medical stabilization, early revascularization resulted in a 13.2% absolute and 67% relative improvement in 6-year survival, reinforcing the need to rapidly identify patients who are candidates for early revascularization [Hochman JS et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2006].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECARDIAC ASSIST DEVICES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EDespite the lack of clear guidelines for the timing and choice of cardiac assist devices (CADs), numerous options are available:\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003E\n            \u003Cem\u003EIntraaortic Balloon Pump (IABP)\u003C\/em\u003E: Although it was considered a Class I treatment for CS complicating AMI, clinical data are lacking to confirm this. In one recent trial, intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in such patients [Thiele H et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012] although this lack of benefit may, in part, be explained by the use of IABP in 10% of the patients in the control arm.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\n            \u003Cem\u003EExtracorporeal membrane oxygenator\/extracorporeal life support (ECMO\/ECLS)\u003C\/em\u003E: ECLS has shown encouraging outcomes in cardiac arrest (CA), and early ECMO-assisted primary PCI improves 30-day outcomes in STEMI complicated with CS.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EBetween 2002 and 2009, 1650 patients with acute STEMI underwent primary PCI. Of these, 13.3% had CS and 46 patients were treated with ECMO. The outcomes of the patients treated in an era in which ECMO was available was compared with historical controls of patients who presented between 1993 and 2002 with STEMI complicated by CS who underwent primary PCI prior to the availability of ECMO. The incidence of profound shock was similar in both groups (21.7% vs 21.0%; p\u0026gt;0.5); however, in patients treated in the ECMO era, the mortality of patients with profound shock and total 30-day mortality were lower (all p\u0026lt;0.04), and hospital survival time was increased (p=0.0005) [Sheu JJ et al. \u003Cem\u003ECrit Care Med\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EECMO for temporary circulatory support is sometimes the only option for patients with refractory CS (RCS), but is typically only available in tertiary-care centers. However, a pilot study suggested this as a feasible option even in remote hospitals. Mortality was compared between tertiary and nontertiary care centers in the greater Paris area, and results demonstrated successful transfer of 75 of 87 RCS patients to tertiary care following local ECMO support, and 32 survived to hospital discharge (overall survival rate, 36.8%; 95% CI, 27.4 to 46.2). There was no significant difference in mortality between patients who received ECMO locally or at a tertiary care institution (OR, 1.48; 95% CI, 0.72 to 3.00, p=0.29) [Beurtheret S et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003E\n            \u003Cem\u003EImpella 2.5\u003C\/em\u003E: Advantages of the Impella 2.5 system include the ease of percutaneous insertion, its user-friendly console, and trends toward improved outcomes compared with IABP-support.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe PROTECT II trial was performed in stable patients undergoing high-risk PCI and compared the Impella system with an IABP. The with a primary endpoint of 30-day incidence of major adverse events (MAEs), which were defined as all-cause death, Q-wave or non-Q-wave MI, stroke or transient ischemic attack, any repeat revascularization procedure (PCI or coronary artery bypass graft), need for a cardiac or a vascular operation (including a vascular operation for limb ischemia), acute renal insufficiency, severe intraprocedural hypotension requiring therapy, cardiopulmonary resuscitation or ventricular tachycardia requiring cardioversion, aortic insufficiency and angiographic failure of PCI. MAEs at 30 days were not significantly different, but at 90-day follow-up there was a strong trend toward reduced MAEs in the Impella group in the intent-to-treat and per-protocol populations (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [O\u0027Neill WW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012]. There is limited data on the use of the Impella device in CS. Registries have shown improvement in hemodynamic parameters.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Outcomes of the PROTECT II Trial\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-109793463\u0022 data-figure-caption=\u0022Outcomes of the PROTECT II Trial\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/6\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13475\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EOutcomes of the PROTECT II Trial\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from O\u0027Neill WW et al. A Prospective, Randomized Clinical Trial of Hemodynamic Support With Impella 2.5 Versus Intra-Aortic Balloon Pump in Patients Undergoing High-Risk Percutaneous Coronary Intervention: The PROTECT II Study. \u003Cem\u003ECirculation\u003C\/em\u003E 2012;126(14):1717\u20131727. With permission from Lippincott, Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESHOCK AFTER RESUSCITATED CARDIAC ARREST\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EIn patients with resuscitated CA in whom electrocardiography shows ST-segment elevation, the strategy of choice is immediate angiography with a view to primary PCI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EAnd due to the high potential for coronary occlusions and difficulties in interpreting the electrocardiogram in patients following CA, immediate angiography should be considered when ongoing infarction is suspected.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThere is also evidence that survivors of out-of-hospital CA who are comatose have improved neurological outcomes if cooling occurs soon after resuscitation. These patients should considered for prompt initiation of therapeutic hypothermia [Steg PG et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPCI IN REFRACTORY IN- OR OUT-OF-HOSPITAL CARDIAC ARREST\u003C\/h2\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EStudies have shown that survival rate decreases rapidly after 10 minutes of cardiopulmonary resuscitation (CPR), and even more rapidly after 30 minutes.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EA 3-year prospective study investigated the use of ECLS as compared with conventional CPR for patients with in-hospital CA of cardiac origin undergoing CPR of \u0026gt;10 minutes. The primary endpoint was survival to hospital discharge. Patients randomized to extracorporeal CPR had a higher survival rate to discharge (p\u0026lt;0.0001), 30-day survival (p=0.003), and 1-year survival as compared with the conventional CPR group (p=0.007) [Chen YS et al. \u003Cem\u003ELancet\u003C\/em\u003E 2008].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPCI IN REFRACTORY OUT-OF-HOSPITAL CARDIAC ARREST\u003C\/h2\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EECLS has recently been introduced in the treatment of refractory CA. Time from CA to implementation of ECLS is a major prognostic factor for survival. Data from a pilot study has suggested that prehospital ECLS is a safe and feasible option even if the provider is not surgeon. Prehospital ECLS for refractory CA was implemented in seven patients by a team of providers that did not include surgeons. ECLS was started 22 minutes after incision and 57 minutes after onset of advanced cardiovascular life support. One patient survived without sequelae, and brain death resulted in three patients [Lamhaut L et al. \u003Cem\u003EResuscitation\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EProf. Spaulding highlighted that, although CS remains a concern in patients with STEMI, it is rare and usually occurs after admission. He stressed the importance of always considering shock in the management of patients with AMI, and noted that beyond PCI, other factors (such as age, diabetes, past history, coronary artery bypass graft, and AMI) also contribute to the reduced mortality of patients with STEMI.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/7\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznsv2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznsv2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}