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Impact of Chronic Total Coronary Occlusion Location on Long-term Survival After Percutaneous Coronary Intervention Effect of Smoking on Outcomes of Primary PCI in Patients With STEMI Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement Decreased inspired oxygen stimulates de novo formation of coronary collaterals in adult heart 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Impact of door-to-balloon time on long-term mortality in high- and low-risk patients with ST-elevation myocardial infarction Association between Coronary Collaterals and Myocardial Viability in Patients with a Chronic Total Occlusion Relationship between therapeutic effects on infarct size in acute myocardial infarction and therapeutic effects on 1-year outcomes: A patient-level analysis of randomized clinical trials

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JOURNAL：ACC Article Link

SCAI Clinical Expert Consensus Statement on Cardiogenic Shock

Vikas Aggarwal, MBBS, MPH , FACC

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The following are key points to remember from this summary of the Society for Cardiovascular Angiography and Interventions (SCAI) Clinical Expert Consensus Statement on the Classification of Cardiogenic Shock (CS). The document is endorsed by the American College of Cardiology, American Heart Association, Society of Critical Care Medicine, and Society of Thoracic Surgeons:

A system describing stages of CS from “A to E” is proposed. The purpose of this proposed classification of CS is to enable clear communication regarding patient status and to allow clinical trials to appropriately differentiate CS patient subsets.

Stage A:Patient who is“at risk”for CS but is not experiencing signs or symptoms of CS (e.g., someone with non–ST-segment elevation myocardial infarction (NSTEMI). This patient is warm and perfusing, and has normal cardiac index and no sign of volume overload or hypoperfusion.
Stage B: “beginning”shock or compensated shock where a patient may be volume overloaded, tachycardic, and/or hypotensive but no evidence of hypoperfusion on physical exam or laboratory studies.
Stage C is“classic”CS: Stage B patient with evidence of hypoperfusion on physical exam and laboratory studies “Cold and Wet.” Invasive hemodynamics (if available) demonstrate the classic depressed cardiac index associated with CS.
Stage D is“deteriorating”: Stage C plus failure of initial interventions in restoring adequate perfusion in 30 minutes and further escalation is required. Escalation is an increase in the number or intensity of intravenous therapies to address hypoperfusion, or addition of mechanical circulatory support after the initial 30-minute period of observation and treatment.
Stage E is“extremis”: Patient is highly unstable, often with circulatory collapse and/or refractory cardiac arrest with ongoing cardiopulmonary resuscitation (CPR). They are being supported by multiple simultaneous acute interventions including extracorporeal membrane oxygenation (ECMO)-facilitated CPR (eCPR).

Additionally, the(A)modifier for cardiac arrest is applied to describe those who suffer a cardiac arrest irrespective of duration (treated with chest compressions or direct current cardioversion). Accordingly, a patient may be in stage B_A shock, indicating stage B with a cardiac arrest complicating the clinical picture (e.g., a patient who presents with ventricular fibrillation in the setting of acute MI and rapidly stabilizes with prompt defibrillation).

Other key points highlighted are:

Troponin T is an independent prognostic indicator of adverse outcomes and can be used as a patient risk-stratifying tool. Elevation of troponin in CS may identify patients who present late.
Arterial lactate is preferable since venous lactate is generally higher than arterial lactate and the 2.0 mmol/L cut-off is best established for arterial lactate.
A low serum bicarbonate level is a better predictor of 30-day mortality than the highest recorded lactate level.
A low B-type natriuretic peptide (BNP) level argues against CS in the setting of hypotension; however, an elevated BNP level does not establish the diagnosis, as any form of cardiac ventricular or atrial stress may elevate levels of this peptide.
It is recommended to use a pulmonary artery catheter in the diagnosis and management of CS patients, along with rapidly transferring those requiring a higher level of care to an experienced shock center.
Mixed shock patients have features suggestive of systemic inflammation, with or without proven infection. Such systemic vasodilation exacerbates systemic hypoperfusion and decreases coronary perfusion pressure. The potential for mixed shock emphasizes the importance of invasive hemodynamic monitoring.

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SCAI Clinical Expert Consensus Statement on Cardiogenic Shock

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