Cardiogenic Shock - Diagnosis and Treatment

68 Part III / Contemporary Treatment
In a placebo-controlled trial of 47 patients with acute myocardial infarction, N-
acetylcysteine was used adjunctively with reperfusion therapy, resulting in smaller
infarct sizes as determined by the electrocardiographic QRS score and better echocar-
diographic left ventricular function at d 7 (61). Larger trials are ongoing.
GLUCOSE – INSULIN – POTASSIUM INFUSION
In patients with acute myocardial infarction, infusion of glucose, insulin, and potas-
sium (GIK) reduces blood levels—and, consequently, myocardial uptake—of free fatty
acids, which cause membrane damage, arrhythmogenesis, and impaired contractility
(62). (See further discussion of GIK in Chapter 2.) In addition to increasing glycolytic
flux in myocardial cells, GIK helps to minimize cellular changes resulting from ongo-
ing ischemia (63).
A meta-analysis of studies performed in the prethrombolytic era, totaling 1932
patients, showed that GIK infusions reduced in-hospital mortality by 28% (64). A
recent prospective study, in which patients received either a high- or low-dose GIK
infusion, found that GIK was beneficial, particularly in the subgroup receiving reperfu-
sion therapy (relative risk of in-hospital mortality 0.34, p = 0.008) and the frequency of
cardiogenic shock was 4.6% in those who received GIK compared with 7.6% in those
who did not (relative risk 0.60, 95% CI 0.21-1.69, p = NS) (65). There have been no
published studies of GIK use in patients with cardiogenic shock.
CONCLUSIONS
Since the late 1980s, the mortality rates from cardiogenic shock complicating acute
myocardial infarction have fallen from 70–80% to 50–60% (1,3,20,48). The reasons
for this include the use of thrombolytic therapy to achieve expeditious reperfusion,
support measures such as intra-aortic balloon counterpulsation, right-heart catheteriza-
tion-guided therapies, and urgent revascularization. New myocardial protection agents
currently in development have the potential to reduce reperfusion injury and improve
metabolic and cellular conditions. To date, most studies of these agents have excluded
patients with cardiogenic shock, and trials are needed to specifically evaluate their use
in this subgroup of patients.
REFERENCES
1. Berger PB, Holmes DR Jr, Stebbins AL, et al. Impact of an aggressive invasive catheterization and
revascularization strategy on mortality in patients with cardiogenic shock in the Global Utilization of
Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) Trial: an
observational study. Circulation 1997;96:122–127.
2. White HD. Cardiogenic shock: a more aggressive approach is now warranted [editorial]. Eur Heart J
2000;21:1897–1901.
3. Goldberg RJ, Samad NA, Yarzebski J, et al. Temporal trends in cardiogenic shock complicating acute
myocardial infarction. N Engl J Med 1999;340:1162–1168.
4. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction com-
plicated by cardiogenic shock. N Engl J Med 1999;341:625–634.
5. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of
intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;i:397–402.
6. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in sus-
pected acute myocardial infarction: collaborative overview of early mortality and major morbidity
results from all randomised trials of more than 1000 patients. Lancet 1994;343:311–322.
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