Shock – ABC CARDIOL

ABCHF

Case Report

Cardiogenic Shock with High Pressure: A Case Report

Fiamma Ferreira Nogueira et al. Patricia Bezerra Rocha Montenegro Ana Carla Alves de Souza Lyra Taciana Queiroz Medeiros Gomes Carlos Eduardo Lucena Montenegro

Introduction

Shock is defined as a state of tissue hypoperfusion due to reduced supply, increased consumption, inadequate use of oxygen, or a combination of these processes. When it is of cardiogenic etiology, it occurs as a result of left or right ventricular or biventricular dysfunction with reduced cardiac output (CO) or increased filling pressures and normal intravascular volume. Although the most classic manifestation of shock is arterial hypotension, it is essential to recognize that a patient in shock may present with normal, elevated, or decreased blood pressure (BP). Therefore, early identification of clinical, laboratory, and hemodynamic signs of tissue hypoperfusion is crucial. Timely and appropriate treatment can prevent deterioration and signs of multiple organ dysfunction.

[…]

Read Full Article

ABC

Original Article

Revascularization Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock: Results from the Portuguese Registry on Acute Coronary Syndromes

Sofia Alegria et al. Ana Marques Ana Catarina Gomes Ana Rita F. Pereira … Daniel Sebaiti Gonçalo Morgado Rita Calé Cristina Martins Adriana Belo Inês Rangel Hélder Pereira

Abstract

Background:

In patients with acute myocardial infarction (MI), cardiogenic shock (CS), and multivessel disease (MVD) questions remain unanswered when it comes to intervention on non-culprit arteries.

Objective:

This article aims to 1) characterize patients with MI, CS and MVD included in the Portuguese Registry on Acute Coronary Syndromes (ProACS); 2) compare different revascularization strategies in the sample; 3) identify predictors of in-hospital mortality among these patients.

Methods:

Observational retrospective study of patients with MI, CS and MVD included in the ProACS between 2010 and 2018. Two revascularization strategies were compared: complete during the index procedure (group 1); and complete or incomplete during the index hospitalization (groups 2-3). The primary endpoint was a composite of in-hospital death or MI. Statistical significance was defined by a p-value <0.05.

Results:

We identified 127 patients with MI, CS, and MVD (18.1% in group 1, and 81.9% in groups 2-3), with a mean age of 7012 years, and 92.9% of the sample being diagnosed with ST-segment elevation MI (STEMI). The primary endpoint occurred in 47.8% of the patients in group 1 and 37.5% in group 2-3 (p = 0.359). The rates of in-hospital death, recurrent MI, stroke, and major bleeding were also similar. The predictors of in-hospital death in this sample were the presence of left ventricle systolic dysfunction on admission (OR 16.8), right bundle branch block (OR 7.6), and anemia (OR 5.2) (p ≤ 0.02 for both).

Conclusions:

Among patients with MI, CS, and MVD included in the ProACS, there was no significant difference between complete and incomplete revascularization during the index hospitalization regarding the occurrence of in-hospital death or MI. (Arq Bras Cardiol. 2021; 116(5):867-876)

Read Full Article

IJCS

Case Report

Tachycardiomyopathy and Extracorporeal Membrane Oxygenation: A Case Report

Joana Malheiro et al. João Almeida Daniel Caeiro Adelaide Dias … Marlene Fonseca Vasco Gama

Introduction

Tachycardiomyopathy (TCM) is a rare, but potentially reversible cause of cardiomyopathy and cardiogenic shock. It is defined by a global left ventricular systolic dysfunction secondary to persistent tachyarrhythmia, with partial (in patients with previous structural disease), or total recovery (in patients without previous structural disease) after cardiac rhythm normalization. The most commonly implicated arrhythmia is atrial fibrillation. The hemodynamic changes that characterize the patient with TCM include: increase in ventricular telediastolic and telesystolic volumes, global hypokinesis, increase in ventricular and pulmonary artery filling pressures, and, finally, decrease in ejection fraction (EF).^, It manifests clinically by congestive heart failure, and, in some cases, it may develop into cardiogenic shock. There are no specific methods to identify the presence of TCM. The diagnosis is usually attained retrospectively with normalization or improvement of left ventricular dysfunction, through tachyarrhythmia reversion or control. The most frequent complications of TCM are embolic events, complications due to the evolution of arrhythmia severity with degeneration to Ventricular Tachycardia (VT)/Ventricular Fibrillation (VF) and cardiogenic shock.

The treatment includes measures of hemodynamic support, frequency control, and reversion to sinus rhythm, when possible. Extracorporeal Membrane Oxygenation (ECMO) is a mechanical device that ensures blood oxygenation and perfusion of the main organs for prolonged periods of time in patients with lung and/or heart failure. The use of this device allows the patient to remain alive and hemodynamically stable, working as a bridge to eventual recovery, transplantation, decision-making or even as a “bridge to another bridge” (for instance, as a bridge to left ventricular assist device – LVAD – as target therapeutics).

[…]

Read Full Article

ABC

Anatomopathological Session

Case 1/2014 – Syncope Due to Cardiogenic Shock in a 25-year-old Male Patient

Tiago Rodrigues Politi et al. Paulo Gutierrez

Clinical aspects

This is a case of a male patient, 25 years of age with no previously described clinical history that sought medical attention complaining of malaise and feeling faint. The clinical picture had started 1 hour before he sought the local hospital emergency room. The patient clinical evolution was dramatic, presenting at the examination as shock, initially of undetermined etiology, going to aortic dissection and cardiac tamponade, and culminating in death within hours of symptom onset, before any surgical intervention. Acute dissection of the ascending aorta was then identified, with rapid and catastrophic clinical deterioration, a determining factor for the diagnosis to be attained as early as possible, as well as an early and accurate intervention.

Acute aortic dissection is a cardiovascular emergency with high mortality, ranging from 50 to 68% in 48 hours, 70% at 1 week and 85% in 1 month. The intimal tear is transversal, located in 70% of cases in the aorta ascending (just above the aortic valve), 20% in the descending aorta after the aortic arch, and 10% in the transverse aorta. Once started, the dissection progression can be distal, retrograde or occur in both directions and be of varying extension ^, . In the present case, the aortic dissection started in the ascending portion, retrograde, with bending of the anterior plan between the true and false lumen, generating a mechanical obstruction to the left ventricular outflow tract ().

[…]

Read Full Article

ABC

Artigo Original

Inappropriate shocks in patients with icds: single chamber versus dual chamber

Juliana Gonçalves et al. Telmo Pereira

BACKGROUND: Despite the technological evolution of the implantable defibrillator, one of the questions that remains is the possible benefit of the dual chamber versus single chamber implantable cardioverter defibrillator (ICD) in reducing inappropriate shocks. OBJECTIVE: To evaluate which type of device provides fewer inappropriate shocks (dual chamber versus single chamber) in patients with implantable cardioverter defibrillators (ICDs). METHODS: Meta-analysis of randomized studies published in the literature comparing dual-chamber implantable cardioverter defibrillators to single chamber devices which have been known to cause, as an evaluated endpoint, inappropriate shocks. RESULTS: The dual-chamber implantable cardioverter showed no benefit in reducing the number of inappropriate shocks. In fact, the opposite was shown. In the analysis of fixed effects, the association tended to favor single-chamber implantable cardioverter defibrillators (OR = 1.53, CI 95%: 0.91-2.57), despite the absence of statistical significance (p = 0.11). We highlight the heterogeneity observed in the results (I² = 53%), which motivated a replication of the analysis using a model of random effects. However, significant differences remained in the occurrence of inappropriate shocks in both groups (OR = 1.1, 95% CI: 0.37-3.31; p = 0.86). To complement the analysis, we proceeded to perform sensitivity analysis, which showed that the exclusion of a study resulted in the lowest heterogeneity observed (I²=24%) and the association with inappropriate shocks significantly favored the single chamber cardiodefibrillator (OR = 1.91; 95% CI: 1.09-3.37; p = 0.27). CONCLUSIONS: It was determined that there was no clear evidence of superiority of any of the devices evaluated.

Read Full Article

ABC

Correlação Clínico-Radiográfica

Case 05/12: a 67 year-old hypertensive woman with atrial fibrillation who presented shock followed by cardiac arrest with pulseless electric activity two months after surgical repair of ascending aorta aneurysm

Fernanda Marinho Mangione et al. Thiago Nunes Pereira Leite Paulo Sampaio Gutierrez

ANATOMOPATHOLOGICAL SESSION

Case 05/12 – a 67 year-old hypertensive woman with atrial fibrillation who presented shock followed by cardiac arrest with pulseless electric activity two months after surgical repair of ascending aorta aneurysm

[…]

Read Full Article

ABC

Anatomopathological Session

Case 5: 50-year-old woman with restrictive cardiomyopathy, renal failure and proteinuria

Odilson Marcos Silvestre et al. Henrique Barbosa Ribeiro Leonardo Jorge C. de Paula Sérgio Ricardo V. Macêdo Jussara Bianchi Castelli

ANATOMOPATHOLOGICAL SESSION

Case 5 50-year-old woman with restrictive cardiomyopathy, renal failure and proteinuria

[…]

Read Full Article

ABC

Artigo Original

Positive end-expiratory pressure and renal function influence B-type natriuretic peptide in patients with severe sepsis and septic shock

Victor Sarli Issa et al. Leandro Utino Taniguchi Marcelo Park Luiz Monteiro Cruz … Edimar Alcides Bocchi Irineu Tadeu Velasco Francisco Soriano

BACKGROUND: Myocardial dysfunction is a complication associated with a poor prognosis in septic patients. A biomarker of cardiac function providing prognostic information is of paramount interest. OBJECTIVE: We sought to determine the value of B-type natriuretic peptide in patients with severe sepsis/septic shock. METHODS: We performed a prospective study in patients with severe sepsis/septic shock in a medical intensive care unit. B-type natriuretic peptide level was determined within 24 hours after the diagnosis of severe sepsis/septic shock. We also analyzed mortality, and presence of association between B-type natriuretic peptide and clinical, hemodynamic and respiratory variables. RESULTS: 23 (9 women; 14 men) patients with ages ranging from 20-79 (mean 51.3±18.6) years old and APACHE score of 22.6±11.8 were included; 15 (65.2%) patients received pulmonary artery catheters, and 20 (87%) were mechanically ventilated. Multivariate analysis disclosed inverse association between B-type natriuretic peptide values with positive end-expiratory pressure values, and direct association with creatinine (beta 0.548 and 0.377, p 0.02 and 0.002, respectively), but not with mortality, clinical and hemodynamic parameters. CONCLUSION: This is the first report on an inverse association between positive end-expiratory pressure and BNP levels in patients with severe sepsis and septic shock. BNP and creatinine levels should be taken into consideration when analyzing B-type natriuretic peptide levels in this setting.

Read Full Article

ABC

Artigo Original

Major clinical characteristics of patients surviving 24 months or more after hospitalization due to decompensated heart failure

Mucio Tavares de Oliveira Jr et al. Manoel Fernandes Canesin Robson Tadeu Munhoz Carlos Henrique Del Carlo … Airton Scipioni José Antonio Franchini Ramires Antonio Carlos Pereira Barretto

OBJECTIVE: To study the major clinical characteristics of patients with heart failure who survived more than 24 months after hospitalization for compensation. METHODS: The study comprised 126 patients with heart failure in functional class III or IV, with a mean age of 51.7 years. Most patients were men (73%), had a mean ejection fraction (EF) of 0.36 and left ventricular diastolic diameter (DD) of 7.13 cm. The major clinical and laboratory characteristics were assessed, and, on follow-up, 25 (19.8%) patients, who survived more than 24 months after hospital discharge, were identified. Data of survivors (G1) were compared with those of patients who died (G2) before 24 months. RESULTS: In G1, the following levels were greater: serum sodium (138.3±3.4 vs 134.5±5.8 mEq/L; P=0.001); blood pressure levels (120.0 vs 96.7 mm Hg; P=0.003); and LVEF levels (0.40±0.08 vs 0.34±0.09; P=0.004); and the following levels were lower: urea (59.8 vs 76.3 mg/dL; P=0.007); prothrombin time (12.9 vs 14.8 seconds; P=0.001); LVDD (6.78±0.55 vs 7.22±0.91; P=0.003); and LA diameter (4.77 vs 4.99cm; P=0.0003). More survivors were found among patients with idiopathic cardiomyopathy and arterial hypertension than among patients with Chagas’ disease and coronary artery disease. In multivariate analysis, the following variables remained as independent predictors of mortality: LVDD > 7.8 cm (HR 1.95); Na 14 seconds (HR 1.69). CONCLUSION: The study allowed predicting which patients with heart failure will have a good survival after hospital discharge and those with a greater chance of a long survival after discharge.

Read Full Article