Consequences of PPCI (primary percutaneous coronary intervention) in patients with ST-

egment elevated Acute Myocardial Infarction accompanied or unaccompanied cardiac shock

receiving adjuvant medical therapy.

bjective: This research was carried out to find the Consequences of PPCI (Primary percutaneous coronary
ervention) in patients with ST-segment elevated Acute Myocardial Infarction accompanied or unaccompanied by
rdiac shock receiving adjuvant therapy abciximab and dual antiplatelet therapy Prasugrel and ticagrelor

ethodology. : A cross-sectional study was carried out 9th August 2017 -10th August 2018. Cardiogenic Shock and
on-Cardiogenic Shock Patients with STEMI were included in the study. Patients were split into Cardiogenic Shock
d Non-cardiogenic Shock groups. Cardiogenic Shock patients were further cleaved into survived and died, groups.
e patients who survived and discharge from the hospital following Primary PCI were placed in the survived group
d Cardiac shock (CS) died group included all patients who expire in hospital admitted for primary PCI The medical
erapy used in patients was Abciximab. Some patients were receiving dual antiplatelet therapy Prasugrel and
agrelor.

sult: The sample consist of 280 patients. 240 were with non-cardiogenic shock and 45 were with cardiogenic shock.
patients with non-CS and 21 with CS were diabetic.23 patients in non-CS and 12 in CS were hypertensive .19
tients in CS and 5 in CS were having underline renal disease. 7 patients in Non-CS and 6 patients in CS were with
patic disease The 160 patients were chronic smokers. The mean first medical contact time to transfer time for Non-
S and CS were 29min and 35 min respectively. In Non-CS results were 90% with primary percutaneous intervention
rrelate to 76% patients with cardiogenic shock ( p = 0.015).Mortality by August 2018 was 20 ( 45%) in CS patients
d 9 (4%) in Non-CS patients.(p < 0.05).This study proves that post-procedure Hb, administration of
opamine/Dobutamine at the time of admission, PH and GFR are predictors of the mortality in patients with STEMI in
th cardiogenic and Non-cardiogenic Shock

nclusion: Rate of the morality of MI in patients with CS was higher than those with Non-CS.
 troduction:

ronary artery disease is a considerable public health problem in Pakistan as many people experience an acute
yocardial experience and undergo percutaneous coronary intervention each year. Because of the high risk of
orbidity and mortality associated with acute myocardial infarction, it is the principal focus of cardiology therapeutics.
ost of the patients hospitalized with acute MI died because of a Cardiac shock. Patients presenting with cardiogenic
ock co-morbid MI do not undergo revascularization either because of lack of efficacy claim or lack of facilities at the
spital. Cardiac shock co-morbid with acute myocardial infarction in 7% to 8% of patients resulting in the mortality
e of 70% to 80% 6.
ute myocardial is defined as myocardial necrosis caused by the ischemic syndrome. It can be classified on the
anifestation of the ST-segment elevation on the ECG.10.Cardiac Shock is a characterized by end-organ decrease blood
w and reduced cardiac output. 9 .
e intent of this research was to find the consequences of PPCI ( primary percutaneous coronary intervention) in
tients with ST-segment elevated Acute Myocardial Infarction accompanied or unaccompanied by cardiogenic shock
ceiving adjuvant therapy

ethodology:

uration and Place of Study:

cross-sectional study was carried out between 9th August 2017 -10th August 2018 in National Institute of
rdiovascular Diseases, Pakistan.
clusion Criteria:
tients with AMI with or without CS undergoing PPCI from the period of 2016-2017 were included in the study. The
proval for the study was granted by the hospital ethical committee after informed consent. Most of the baseline
aracteristics were similar. The patients who have chest pain with more than 24 hours of onset without ischemia were
cluded from the study.
e electrocardiograph (ECG) studies were performed to detect ST-elevated myocardial infarction. New ST-segment
vation at the J-point in two contiguous leads with cut-off points greater than 0.3 mV in men in age group of more
an 36 yrs and < 0.35 in age group more than 40 yrs or 0.15 mV to 0.25mV in women aged between 30-60yrs in leads
2–V3 and 0.2 mV in other leads was defined as Acute Myocardial Infarction.
e cardiogenic shock was diagnosed with a fall in systolic blood pressure less than 95mmHg for 20minutes with
lmonary congestion and elevated left the ventricular filling pressure. Oliguria and increased serum lactate level were
o observed in patients. The cardiac output was less than 1.5 l/min/m2 without Dopamine/Dobutamine support or 2.4
min/m2 with Dopamine/Dobutamine support.
e noncardiogenic shock was defined as the hemodynamically stable patient with a systolic blood pressure of greater
an 90mmHg with a cardiac output of more than 2 l/min/m2 with Dopamine/Dobutamine support.
e medical therapy used in patients was intravenous anticoagulant drugs include Abciximab 4 . Some patients were
ceiving dual antiplatelet therapy Prasugrel and ticagrelor 5.

tient Sample :
e sample size was 285. The patients were split into two groups Cardiogenic Shock and Non-Cardiogenic Shock.
rdiogenic Shock convalescents were further divided into survived and expired, groups. The convalescents who
rvived and discharge from the hospital following Primary PCI were placed in the survived group and Cardiogenic
ock (CS) expired group included all patients who expired and were admitted in the same hospital for PPCI. Variables
re defined into a categorical and continuous. The categorical variables include co-existing states like hypertension,
abetes, smoking history, Dopamine/Dobutamine, renal and hepatic impairment, ventilator support whereas
ntinuous variable includes age, timing variables, PH, GFR.
he success of procedure was measured by the restoration of epicardial TIMI-3 flow in more than 90% of patients
lowing primary percutaneous coronary intervention without any complications dissection, perforation or
rebrovascular accident.
specially designed performance was filled up stating information regarding patient
nical examination, laboratory findings, demographic data, supplementary treatment, and angiographic characteristics.
e studies were analyzed by the SPSS version 24. Categorical variables were manifest as numbers and percentage.
ntinuous variables were manifest as mean standard deviation. The results and study were evaluated using the
cNemar test.

sult :

e study was carried out in Pakistan local population who were admitted to the hospital for the treatment STEMI for
CI. The sample size was 285. Out of which 240 were in Non-cardiogenic shock and 45 were in cardiogenic shock.
e convalescents with cardiogenic shock were of 40yrs-60yrs and non-cardiogenic shock was of 36yrs-50yrs age.
abetes was present in 87 patients with non-cardiogenic shock and 21 in cardiogenic shock. 23 patients in non-CS
d 12 in CS were hypertensive .19 patients in CS and 5 in CS were with were having underline renal disease. 7
tients in Non-CS and 6 patients in CS were with fatty liver disease. The 160 patients were chronic smokers. The CS
tients were present to first medical contact at 60 seconds and 35min in patients without CS. The radial approach was
ed in only 13 CS patients and 158 of Non-CS patients.(p = 0.001).In the non-CS group, the success was 85% and
% in CS patients. In hospitalized patients, the mortality rate was 7 (2%) in Non-CS and 11(25%) in CS patient in
st 60 days. One year mortality was 20 ( 45%) in CS patients and 9 (4%) in Non-CS patients.(p =0.0579).The
bgroup consist of patients died and survived with CS. The age of patient survived was between 45yrs to 52yrs and
ose died were between 50yrs – 60yrs. Hemoglobin, Dopamine/Dobutamine needed at the time of admission, GFR,
H were statistically significant. The door to balloon time was 85min in CS died group as compared to 69min in CS
rviving group. Total ischemic time was 169min-345min in CS survived group. ( p-value 0.245).In CS died group,
ultiple vessel diseases was observed in 8% patients whereas as in Non-CS group it was less than 3%. The success of
giography was observed in 19 vs 4 in CS survived and CS died group respectively.

ndings :

Table 1 : Baseline Characteristics in CS and Non-CS

Baseline Non- CS CS p value

Characteristic n = 240 n = 45
Table 2: Procedure s
ed Age SD 50 years 47 years 0.545
(Mean)
Chronic 135 (56%) 30 (66%) 0.745
A N C p Smokers (%)
p o S HTN (%) 23 (9%) 12 (26%) 0.783
p n v DM (%) 17 (7%) 21 ( 46%) 0.645
r - n a
Renal disease 19 (8%) 5 (11%) 0.645
o C = l
a S 4 u
(%)
c 5 e
Fatty liver 7 (3%) 6 (13%) 0.687
h n
disease (%)
=
u 2
s 4
e 0
d
 Radial 157 17 0.001
Transfemoral 83 28 0.025

Table 3: Mortality in population data

Non-CS CS p value
Characteristic n= 240 n=45
s
In-hospital 7 (2%) 11(25%) 0.023
mortality
60 days 0 15 0.05
mortality
6 months 8 17 0.0534
mortality
1-year 9 20 0.0579
mortality

Table 4: Basic Characteristics in CS survived and expired group

Characteristics CS CS p-value
Survived expired
Age (Mean) 53 58 0.547
HTN 2 6 0.512
DM 3 9 0.534
Chronic smoking 3 12 0.234
HB 18 17 0.298

GFR 45 29 0.589
Dopamine/Dobutamine 11 9 0.542
The door to balloon 85 69 0.536
time(min)
Ischemic Time(mean) 275 253 0.245

scussion:
e studies showed a large scale of mortality in patients receiving PPCI with adjuvant medical therapy. One year
ortality of 45% in CS patients receiving PPCI with adjuvant medical therapy was better than historical data. This
ggests a room for improvement in CS patients undergoing PPCI with medical therapy. The medical therapy used in
tients was intravenous anticoagulant drugs include Abciximab and thrombin inhibitors bivalirudin. Some patients
re receiving dual antiplatelet therapy Prasugrel and ticagrelor. This study indicates that low mortality was observed
the patients receiving adjuvant medical therapy both with Abciximab and dual antiplatelet therapy Prasugrel and
agrelor high mortality rate was observed in patients with CS who have underlying diabetes mellitus, hypertension,
tory of the hepatic disease and renal failure, old age, use of inotropic agents and ventilators. This study indicates the
both cardiogenic shock and non-cardiogenic shock patients for 60days and 1year. For the first 60 days, the mortality
e was low with adjuvant medical therapy in STEMI cardiogenic shock patients. With previous studies which use
ombolytic therapy only, outcomes improve in patients with Primary PCCI. In hospitalized patients, the mortality rate
s 7 (2%) in Non-CS and 11(25%) in CS patient in first 60 days. One year mortality was 20 ( 45%) in CS patients
 d 9 (4%) in Non-CS patients There was an increase in the number of death in cardiogenic shock patients which
ghlight the use of revascularization in these patients.Great consideration is required in term of revascularization to
anage cardiogenic shock in patients with STEMI. Diabetes was more common in cardiogenic shock patients in our
dy population. This was also assisted by the other studies 7. The expired group has high diabetes.Diabetes has
tistical significance in my results.Some of the previous studies suggest that Diabetes is more common in patient with
S than without CS 3.My studies were supported by another study which suggests that high mortality rate in patients
th diabetes and STEMI 2.Renal and hepatic impairment also show significant results.The mortality was high in really
d fatty liver patients.My study was supported by another study done on fatty liver and STEMI and is associated with
gh mortality11..Renal impairment and complications of morbidity were supported by the study 12. The overall
ortality remains high in CS patients in 1 year .this study mortality rate is better than recently done in the Malaysian
pulation by Shehzeb et al. We documented the restoration of the TIMI flow grade was better in CS patients The use
adjuvant medical therapy has improved survival rate in CS patients as shown by the study 4.Survival at 1 year was
cumented by the use of the Primary percutaneous intervention done by the radial approach. Less mortality was
served with radial approach Primary percutaneous intervention. The cardiogenic shock is associated with the poor
ripheral perfusion, so transfemoral as a standard approach in patients. Radial approach association with less mortality
partly explained by this. Some of the patients undergo transfemoral route rather than a transradial route for PPCI. I
o documented that the CS patients were present to first medical contact at 60 seconds and 35min in patients without
S. The door to balloon time was non-significant in GS and non-CS patients. The transfer time was more for CS
tient may be because of stabilizing patient state by stat dopamine/dobutamine, ventilator etc. The door to balloon
me was less than 110 min in 20% of Non-CS patients as compared to 30% CS patients. In CS patients we further
alyze the data by dividing two groups that are expired and survived. The expired that is 10( 20%) have risk factors
mortality. I find out that low PH, underlying renal disease leading to decreased GFR, number, and type of inotropic
ent used, Hemoglobin level post PCI, door to balloon time and ischemic time were the independent risk factors for
ortality. The mean age was 45 years in survived group and 55 years in the expired group. This study was consistent
th the Global Registry of Acute Coronary Events 1.Multiple vessel diseases were present in the expired CS patients
th total occlusion of the infarct artery. I predict that artificial mechanical ventilator is the independent predictor of
gher mortality.These patients were presented with an additional risk of restorable neurological injury and metabolic
turbances which at most times is not cleared at PPCI.hypothermia is not well controlled in these patients.This study
dicates improvement in the life of patients with CS with adjuvant therapy Abciximab and dual antiplatelet therapy
asugrel and ticagrelor.This study uses intra-aortic balloon pump as an independent variable of the mortality.The uses
adjuvant antithrombotic therapy can also support this fact.A meta-analysis study suggests the improvement is
tients with antithrombotic therapy with PPCI rather than alone in PPCI 8. Decline renal function is also associated
th poor outcome in CS patients.This study indicates many predictors for the AMI patients undergoing PPCI with
juvant antithrombotic therapy and dual antiplatelet therapy.These predictors should be the focus when planning a
ure intervention.

commendation :
rther studies should be focussed on hypothermia influences on the cardiogenic shock with or without neurological
ult. It was evident from this study that cardiogenic shock patients have multiple vessel diseases. It further needs to
dy which treatment option is best from them. The micro level mechanism involves in the alleviation of mortality rate
patients with antithrombotic and antiplatelet therapy is need to be studied further.

mitation:
is study sample was relatively small. The cross-section sample was selected by nonrandomized observation. There
s no invasive method used for the CS definition. When applying to the general population the cardiogenic shock was
all.
nclusion:
e mortality rate was high in STEMI patients with CS as compared to Non-CS. Although the angioplasty was
ccessful in Non-CS patients, the CS patients survive to have a good survival rate.
 ferences :

Awad HH, Anderson FA Jr., Gore JM, Goodman SG, Goldberg RJ. Cardiogenic shock complicating acute coronary
ndromes: insights from the Global Registry
Acute Coronary Events. Am Heart J 2012;163:963–71.

Claessen B, Hoebers L, Schaaf R, et al. Prevalence and impact of a chronic total occlusion in a non-infarct-related
ery on long-term mortality in diabetic patients with ST-elevation myocardial infarction.BJM 2010,96(24).

Gasior M, Pres D, Gierlotka M, et al. The influence of diabetes on in-hospital and long-term mortality in patients with
yocardial infarction complicated by
rdiogenic shock: results from the PL-ACS registry.Kardiol Pol 2012; 70:1215–24

Gyongyosi M, Domanovits H, Benzer W, Haugk, et al.Use of abciximab prior to primary angioplasty in STEMI
ults in early recanalization of the infarct-related artery and improved myocardial tissue reperfusion – results of the
ustrian multi-center randomized ReoPro-BRIDGING Study. European Heart Journal 2004; 25(23): 2125-2133.

Franchi F, Roillini F,Angiolillo D. Antithrombotic therapy for patients with STEMI undergoing primary PCI.Nature
view Cardiology 2017;14:361-379.

Khashan MY, Pinsky MR. Does intra-aortic balloon support for myocardial infarction with cardiogenic shock
prove outcome? Crit Care 2013;17(2):30.

Mahmood Zuhdi SA, Wan Ahmad WA, Zaki RA,Mariapun J, Ali RA, Sari NM, et.al. Acute coronary syndrome in
e elderly: the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry. Singapore
ed J. 2016 Apr; 57(4): 191–197.

Romeo F, Acconcia MC, Sergi D, et al. The outcome of intra-aortic balloon pump support in acute myocardial
arction complicated by cardiogenic shock according to the
pe of revascularization: a comprehensive meta-analysis.Am Heart J 2013;165:679–92.

Thiele H ,Steffen O, Ingo D, Suzanne W, et al., Management of cardiogenic shock. European Heart Journal
15;36(20):1223-1230.

.Thygesen K, Alpert JS, Jaffe AS, et al.Third Universal Definition of Myocardial Infarction.Am J of cardiology
12;60:15:81–98.

.Vincent W,Wong G, Kwok G, et al.Coronary artery disease and cardiovascular outcomes in patients with non-
oholic fatty liver disease.Heart 2011;60(12).

.Wi J, Young GK, Kim JS, et al. Impact of contrast-induced acute kidney injury with transient or persistent renal
sfunction on long-term outcomes of patients with acute myocardial infarction undergoing percutaneous coronary
ervention. Heart 2011;97:1753-1757

. Zeb S, Omar AF, Ali RS, et al. Outcomes in patients with cardiogenic shock following primary percutaneous
ronary intervention. Pak Heart J 2018; 51
3):196-203