Cardiogenic shock secondary prevention: Difference between revisions
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==Overview== | ==Overview== | ||
Once patients at high risk for shock are identified, a subset of patients most likely to benefit from aggressive intervention must be selected , the question remains as to which interventions are most efficacious? There is an emerging body of literature suggesting that high-risk patients with acute MI may fare best with primary angioplasty. For example, in the PAM1 study,a which was the largest of the early randomized trials comparing thrombolysis with PTCA, there was a strong trend toward lower mortality in the primary PTCA group compared with patients treated with TPA (6.5 vs. 2.6%, p = 0.06). A posthoc analysis demonstrated little difference in outcome between the two strategies in low-risk patients, but in a high-risk subset (defined as anterior MI, age >70, or HR > 100 beatdmin) there was a significant mortality benefit of primary angioplasty compared with thrombolysis (2 vs. 10.4% mortality, p = 0.01). This finding has subsequently been observed in additional studies of primary angioplasty. Because of the probable benefit of primary PTCA in high-risk patients, one recent studf6 randomized a consecutive series of low-risk patients to thrombolysis versus primary FTCA, and performed primary PTCA on all high-risk patients (using the PAM1 criteria). The interesting finding was that not only did low-risk patients have a lower incidence of the combined end point of death, cerebrovascular accident, and reinfarction with primary PTCA, but also that high-risk patients undergoing primary PTCA had a lower incidence of the combined end point than did low-risk patients undergoing thrombolysis. This suggest that primary PTCA, if performed in a timely fashion in high-risk patients, offers a significant benefit over thrombolytic therapy. | |||
==Secondary prevention== | ==Secondary prevention== | ||
Revision as of 17:08, 31 December 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Syed Musadiq Ali M.B.B.S.[3]
Overview
Once patients at high risk for shock are identified, a subset of patients most likely to benefit from aggressive intervention must be selected , the question remains as to which interventions are most efficacious? There is an emerging body of literature suggesting that high-risk patients with acute MI may fare best with primary angioplasty. For example, in the PAM1 study,a which was the largest of the early randomized trials comparing thrombolysis with PTCA, there was a strong trend toward lower mortality in the primary PTCA group compared with patients treated with TPA (6.5 vs. 2.6%, p = 0.06). A posthoc analysis demonstrated little difference in outcome between the two strategies in low-risk patients, but in a high-risk subset (defined as anterior MI, age >70, or HR > 100 beatdmin) there was a significant mortality benefit of primary angioplasty compared with thrombolysis (2 vs. 10.4% mortality, p = 0.01). This finding has subsequently been observed in additional studies of primary angioplasty. Because of the probable benefit of primary PTCA in high-risk patients, one recent studf6 randomized a consecutive series of low-risk patients to thrombolysis versus primary FTCA, and performed primary PTCA on all high-risk patients (using the PAM1 criteria). The interesting finding was that not only did low-risk patients have a lower incidence of the combined end point of death, cerebrovascular accident, and reinfarction with primary PTCA, but also that high-risk patients undergoing primary PTCA had a lower incidence of the combined end point than did low-risk patients undergoing thrombolysis. This suggest that primary PTCA, if performed in a timely fashion in high-risk patients, offers a significant benefit over thrombolytic therapy.
Secondary prevention
Attending to the definition of secondary prevention, namely the methods or techniques used in order to avoid the development of symptoms of an already existent disease, and considering the fact that left ventricular failure following MI is the most common cause of cardiogenic shock, these patients should undergo secondary prevention of myocardial infarction. This is a crucial part of the management of STEMI patients, regardless of their gender.[1][2][3][4] Since atherosclerotic disease is commonly found in multiple vessels in STEMI patients, these should be evaluated for possible signs or symptoms of peripheral vascular or cerebrovascular disease.[1] As secondary prevention, these patients have the following indications:[1]
- Education of patient and family members before discharge - particularly about the importance of lifestyle changes and adherence to the selected treatment.
- Exercise/physical activity - with an optimal target of daily physical activity and a minimum of 30 minutes/day, 3 to 4 times per week.
- Lipid management - if TG <200 mg/dL, then goal of LDL-C <<100 mg/dL; if TG ≥200 mg/dL, then goal of non-HDL-C << 130 mg/dL
- Weight management - goal BMI of 18.5-24.9 kg/m2 and Waist Perimeter: women - <35 inches, men - <40 inches.
- Blood pressure control - goal <140/90 mm Hg or <130/80 mm Hg if concomitant diabetes or kidney disease.
- Control of diabetes - goal of HbA1c < 7%.
- Smoking cessation - goal of complete cessation.
- Antiplatelet therapy
- RAAS inhibition
- Beta-blockage
- Hormone therapy in women
- Warfarin therapy
- Antioxidant intake
References
- ↑ 1.0 1.1 1.2 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
- ↑ Smith, S. C.; Blair, S. N.; Bonow, R. O.; Brass, L. M.; Cerqueira, M. D.; Dracup, K.; Fuster, V.; Gotto, A.; Grundy, S. M.; Miller, N. H.; Jacobs, A.; Jones, D.; Krauss, R. M.; Mosca, L.; Ockene, I.; Pasternak, R. C.; Pearson, T.; Pfeffer, M. A.; Starke, R. D.; Taubert, K. A. (2001). "AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update: A Statement for Healthcare Professionals From the American Heart Association and the American College of Cardiology". Circulation. 104 (13): 1577–1579. doi:10.1161/hc3801.097475. ISSN 0009-7322.
- ↑ Mosca, L. (2004). "Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women". Circulation. 109 (5): 672–693. doi:10.1161/01.CIR.0000114834.85476.81. ISSN 0009-7322.
- ↑ Dalal H, Evans PH, Campbell JL (2004). "Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction". BMJ. 328 (7441): 693–7. doi:10.1136/bmj.328.7441.693. PMC 381231. PMID 15031243.