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|Year : 1986 | Volume
| Issue : 3 | Page : 146-9
Evaluation of parameters determining prognosis in cardiogenic shock in acute myocardial infarction.
Shah HG, Abraham PP, Dalvi CP
|How to cite this article:|
Shah H G, Abraham P P, Dalvi C P. Evaluation of parameters determining prognosis in cardiogenic shock in acute myocardial infarction. J Postgrad Med 1986;32:146
|How to cite this URL:|
Shah H G, Abraham P P, Dalvi C P. Evaluation of parameters determining prognosis in cardiogenic shock in acute myocardial infarction. J Postgrad Med [serial online] 1986 [cited 2020 Jan 23];32:146. Available from: http://www.jpgmonline.com/text.asp?1986/32/3/146/5339
Cardiogenic shock (CS) is characterised by low cardiac output with marked reduction in stroke volume and increase in venous pressure. In acute myocardial infarction (AMI), CS may be due to one or a combination of the following: acute diminution of coronary blood flow, rupture of papillary muscles, perforation of the interventricular septum, rupture of the free ventricular wall, arrhythmias and, rarely, acute cardiac tamponade. It has been estimated that 10-15% of patients of AMI who survive long enough to reach hospital develop CS. The mortality in CS varies from 80-95%, depending also on the criteria for diagnosis, and has not improved significantly despite advances in monitoring and therapeutic modalities. The cost effectiveness of these monitoring modalities in CS is, therefore, debatable and simple, easily available, yet reliable prognostic parameters would be desirable.
Attempts have been made in the past to evaluate simple clinical and investigative findings as possible prognostic indicators in CS, but the reports have been equivocal.,, The present study is a preliminary attempt to evaluate the prognostic importance of parameters which can be easily monitored where basic facilities are available.
Forty two (13.9%) consecutive cases of CS (34 males, 8 females), out of a total of 302 admissions (245 males, 57 females) of AMI in the ICCU over a nine month period, were studied during their stay in the ICCU (mean 8 days). CS was diagnosed in AMI when the following clinical picture was present: systolic pressure of 90 mm Hg or less at the time of admission, or the one which had decreased by 30 mm Hg or more below the previous level, if recorded; pulse rate of 100 per minute or faster (unless AV block present) ; poor peripheral circulation manifested by cold, clammy, pale, moist, mottled skin; cyanosis, collapse of the veins of the dorsum of the hands and feet; urine output of less than 20 ml/hour; mental changes such as depressed sensorium, apathy, lethargy, confusion, coma or agitation/restlessness: increased rate and depth of respiration.
Each patient had an ECG taken at the time of admission and at least one every day during the ICCU stay. The hematological and biochemical (serum cholesterol and triglycerides, fasting blood sugar) estimations were done after an overnight fast within 24 hours of admission. Transaminase estimation was done every day and the highest level obtained was used for correlation with prognosis.
Thirty two (76.2% ) of the 42 cases of CS expired in the study period. The age related mortality of these cases is given in [Table - 1]. All four cases who had previous history of myocardial infarction expired. The correlation of the mortality rate with sites of AMI and the types of arrhythmias observed are given in [Table - 2] and [Table - 3]. [Table - 4] shows the correlation of mortality with the haematological and biochemical parameters obtained in 30 patients (12 patients died before blood could be collected).
While all 3 patients with peel's index less than 10 survived, 7 of 14 (50%) with index 10-15 survived and all 25 cases with index more than 15 expired (p<0.001).
The prognosis in CS at various centres is not strictly comparable because of the variation in therapeutic approaches. Our survival rate of 24% compares well with the reported range.
Though the importance of simple clinical and hemodynamic monitoring and hematological and biochemical investigations has long been recognised, reports of their efficacy in determining prognosis have been equivocal.,, Afifi et al and Shubin et al could not find a significant correlation of prognosis to the history and clinical features, though they acknowledged that this could be due to their patient size, and discrete clinical variables may improve the reliability of prognostic indices., That advanced monitoring modalities may at best affect prognosis only marginally can be suspected from the fact that mortality in CS has remained dismally high over several decades. Their cost-effectiveness is, therefore, debatable and to some extent there may be an avoidable drain on scarce funds which could more profitably be used in therapy.
Our study suggests that the presence of simple individual abnormal parameters may indicate higher mortality. Though this may not Drove true in daily care, a combination of these parameters could be crucial. The overall prognosis, with or without these abnormal parameters is, however, still high.
The advantage of these parameters is that they can be easily monitored even in a moderately equipped centre, and yet provide a reliable complement to clinical features in determining prognosis. Valuable funds in such centres may be gainfully diverted to therapy, at least where resources are a concern, in an attempt to alter the grim prognostic outlook.
|1.||Afifi, A. A., Chang, P. C., Liu, V. Y., daLuz, P. L., Weil, M. H. and Shubin, H.: Prognostic indices in acute myocardial infarction complicated by shock. Amer. J. Cardiol., 33: 826-832, 1974. |
|2.||Peel, A. A. F., Semple, T., Wang, I., Lancaster, W. M. and Dall, J. L. G.: A coronary prognostic index for grading the severity of infarction. Brit. Heart J., 24: 745-760, 1962. |
|3.||Scheidt, S., Ascheim, R. and Killip, T.: Shock after acute myocardial infarction: a clinical and hemodynamic profile. Amer. J. Cordiol., 26: 556-564, 1970. |
|4.||Shubin, H., Afifi A. A. and Rand, W. M., et al: Objective index of hemodynamic status for quantitation of severity and prognosis of shock complicating myocardial infarction. Cardiovasc. Res., 2: 329-337, 1968. |
|5.||Sobel, B.E.: Cardiac and noncardiac forms of acute circulatory collapse (shock). In, "Heart Disease", Editor: E. Braunwald, W.B. Saunders Co., Philadelphia, 1980, pp. 590-629. |