Association between advanced Killip class at presentation and impaired myocardial perfusion among patients with ST-segment elevation myocardial infarction treated with primary angioplasty and adjunctive glycoprotein IIb-IIIa inhibitors

Canada acute coronary syndrome risk score predicts no-/slow-reflow in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

The no-/slow-reflow phenomenon following primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI)is associated with poor prognosis. The early identification of high-risk patients with no-/slow-reflow is critical. This study aimed to evaluate the predictive ability of the Canada Acute Coronary Syndrome (C-ACS) risk score for no-/slow-reflow in these patients.

Methods

Patients with STEMI who underwent primary PCI were consecutively enrolled and divided into three groups based on their C-ACS scores: 0, 1, and ≥2. The C-ACS score was computed using the four clinical variables evaluated at admission (one point for each): age ≥75 years, heart rate >100 beats/min, systolic blood pressure <100 mmHg, and Killip class >1. No-/slow-reflow was defined as thrombolysis in a myocardial infarction flow grade of 0-2 after primary PCI. The predictive ability of the C-ACS score for no-/slow-reflow was evaluated using a receiver operating characteristic curve.

Results

A total of 834 patients were enrolled, of whom 109 (13.1 %) developed no-/slow-reflow. The incidence of no-/slow-reflow increased from the C-ACS 0 group to the C-ACS ≥2 group (6.1 % vs 17.7 % vs 34.3 %, respectively, p < 0.001). After multivariable adjustment, the C-ACS score was an independent predictor of no-/slow-reflow (odd ratio 2.623, 95 % confidence interval 1.948-3.532, p < 0.001). Furthermore, the C-ACS score showed good discrimination for no-/slow-reflow (area under the curve 0.707, 95 % confidence interval 0.653-0.762, p < 0.001). Further subgroup analyses indicated a significant interaction between the C-ACS score and patient sex (p for interaction = 0.011). The independent association between the C-ACS score and no-/slow-reflow was only observed in male patients (odd ratio 3.061, 95 % confidence interval 1.931-4.852, p < 0.001). During a median follow-up duration of 4.3 years, the C-ACS score was independently associated with major adverse cardiovascular events independent of the occurrence of no-/slow-reflow (p for interaction = 0.212).

Conclusion

The C-ACS risk score could independently predict the no-/slow-reflow in patients with STEMI undergoing primary PCI, particularly in male patients.

Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction

Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.

Immunohistochemical characteristics of coronary thrombi in ST-elevation myocardial infarction

Background and aims

The dynamics and implications of intracoronary thrombus constituency in patients with ST-segment elevation myocardial infarction (STEMI) are not fully understood. We evaluated the expression of CD34, CD61and factor VIII surface markers in thrombi of patients with STEMI and its association with clinical and angiographic characteristics and major adverse cardiovascular events (MACE).

Methods

Patients presenting with STEMI undergoing aspiration thrombectomy during primary percutaneous coronary intervention (pPCI) were included. Morphological, histopathological and immunohistochemical aspects of thrombi were assessed by two pathologists blinded to clinical variables and outcomes.

Results

The mean age of the 245 patients included was 58 ± 12 years old, and 70 % were men. Regarding the thrombi microscopic patterns, 61 % were classified as recent, 20 % as lytic and 19 % as organized. There were higher levels of the CD61 index in patients with a history of heart failure. Smokers presented lower CD61 positive cells and CD61 index, but this association did not remain significant after multivariable analysis. There was an inverse correlation between CD61 positive cells and CD61 index with the time from onset of pain to the first medical contact, but no other significant association amongst clinical characteristics and antigenic expression. There was higher expression of the CD61 antigen in patients with in-hospital MACE, but statistical significance was borderline (p = 0.06).

Conclusions

In this cohort of patients with STEMI, immunohistochemistry of coronary thrombus showed a significantly higher platelet content in patients with previous heart failure and a trend in those with in-hospital MACE. Thrombus' platelet content was inversely related to ischemic time.

Development and Validation of a Clinical and Laboratory-Based Nomogram for Predicting Coronary Microvascular Obstruction in NSTEMI Patients After Primary PCI

Objective

Cardiac microvascular obstruction (CMVO) remains a severe complication in non-ST elevation myocardial infarction (NSTEMI) patients with reperfusion therapy. We aimed at developing and validating the nomogram to predict the possibility of CMVO after primary percutaneous coronary intervention (PCI) by integrating clinical and laboratory-based information.

Methods

A total of 325 patients undergoing primary PCI for NSTEMI were recruited and divided into the training cohort (n=226) and the validating cohort (n = 99). The development of the nomogram was based on independent predictors of CMVO, and these variables were selected by multivariable logistic regression analysis.

Results

Independent predictors contained in nomogram were identified by multivariable logistic regression analysis, and these independent predictors included neutrophils (OR 1.166, 95% CI 1.044–1.303, P<0.01), hemoglobin (OR 1.037, 95% CI 1.013–1.062, P<0.01), triglyceride (OR 1.343, 95% CI 1.059; 1.704, P=0.015), Killip grade (OR 2.190, 95% CI 1.065–4.503, P=0.033), high thrombus load (OR 3.146, 95% CI 1.424–6.952, P<0.01), no-reflow (OR 3.142, 95% CI 1.419–6.955, P<0.01) and ischemic postconditioning (OR 0.445, 95% CI 0.209–0.944, P=0.035). The nomogram accurately predicted the presentation of CMVO in both the training set and validating set (AUC, 0.835 and 0.881, respectively). The results predicted by nomogram were confirmed to be highly consistent with the results of DE-CMR, both the training and validating cohorts, by Calibration plot and Hosmer-Lemeshow test. Decision curve analysis (DCA) also suggested that the nomogram was applicable in the clinic.

Conclusion

The nomogram showed good performance in predicting CMVO, and it could help clinicians optimize the clinical treatments to improve the prognosis of NSTEMI patients.

NT-proBNP level before primary PCI and risk of poor myocardial reperfusion: Insight from the On-TIME II trial

BACKGROUND

N-terminal fragment of the brain natriuretic peptide prohormone (NT-proBNP), a marker for neurohumoral activation, has been associated with adverse outcome in patients with myocardial infarction. NT-proBNP levels may reflect extensive ischemia and microvascular damage, therefore we investigated the potential association between baseline NT-proBNP level and ST-resolution (STR), a marker of myocardial reperfusion, after primary percutaneous coronary intervention (pPCI).

METHODS

we performed a post-hoc analysis of the On-TIME II trial (which randomized ST-elevation myocardial infarction (STEMI) patients to pre-hospital tirofiban administration vs placebo). Patients with measured NT-proBNP before angiography were included. Multivariate logistic-regression analyses was performed to investigate the association between baseline NTproBNP level and STR one hour after pPCI.

RESULTS

Out of 984 STEMI patients, 918 (93.3%) had NT-proBNP values at baseline. Patients with STR <70% had higher NT-proBNP values compared to patients with complete STR (>70%) [Mean ±SD 375.2 ±1021.7 vs 1007.4 ±2842.3, Median (IQR) 111.7 (58.4-280.0) vs 168.0 (62.3-601.3), P <.001]. At multivariate logistic regression analysis, independent predictors associated with higher risk of poor myocardial reperfusion (STR <70%) were: NT-proBNP (OR 1.17, 95%CI 1.04-1.31, P = .009), diabetes mellitus (OR 1.87, 95%CI 1.14-3.07, P = .013), anterior infarct location (OR 2.74, 95% CI 2.00-3.77, P <.001), time to intervention (OR 1.06, 95%CI 1.01-1.11, P = .021), randomisation to placebo (OR 1.45, 95%CI 1.05-1.99, P = .022).

CONCLUSIONS

In STEMI patients, higher baseline NT-proBNP level was independently associate with higher risk of poor myocardial reperfusion, supporting the potential use of NT-proBNP as an early marker for risk stratification of myocardial reperfusion after pPCI in STEMI patients.

Prognostic Value of Total Bilirubin in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Coronary Intervention

Background: Bilirubin, a natural product of heme catabolism, has antioxidant and anti-inflammatory activities and is inversely associated with stable coronary artery disease. However, the relationship between the bilirubin levels and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PPCI) remains unknown. This study aimed to establish a score model based on bilirubin for predicting major adverse cardiovascular events (MACEs) and stratify patients to the level of care. Methods and Results: Data of 4,151 consecutive patients with STEMI who underwent PPCI were evaluated, and 3,708 cases were analyzed. The total bilirubin (TBil) levels were measured during admission, and the study population was divided into two groups. The high TBil group (n = 143) comprised patients who had a TBil level of ≥22 μmmol/L, and the low TBil group (n = 3,565) comprised patients who had a TBil level of <22 μmmol/L. The median follow-up period was 754 days (2.066 years). The MACE was significantly lower in the high TBil group than in the low TBil group (3.5% vs. 11.0%, p = 0.001). In the multivariate Cox regression analysis, a significant association was noted between the TBil levels and adjusted risk of MACE (hazard ratio, 0.279; 95% confidence interval, 0.088-0.877; p = 0.029). A prediction score model composed of TBil, age, hypertension history, and other eight variables was developed, with scores ranging from 0 to 500. The scores categorized patients into low-, medium-, and high-risk categories. The cumulative survival rate was significantly higher in the low-risk group than in the medium- and high-risk groups for MACE, all-cause death, cardiac death, recurrent myocardial infarction, and ischemic stroke (p < 0.001, p < 0.001, p < 0.001, p = 0.030, and p = 0.001, respectively). The area under the curve of the TBil score was 0.768; this was significantly greater in the pairwise comparison with the Global Registry of Acute Coronary Events score (p = 0.0012). Conclusion: The new prediction score model based on TBil could be used in clinical practice to support risk stratification as recommended in the clinical guidelines.

Development and Validation of Risk Nomogram Model Predicting Coronary Microvascular Obstruction in Patients with ST-Segment Elevation Myocardial Infarction (STEMI) Undergoing Primary Percutaneous Catheterization

Background

Coronary microvascular functional and structural obstruction (CMVO) remains a major complication in patients with ST-segment elevation myocardial infarction (STEMI). This study was designed to develop and validate a nomogram model to predict CMVO risk during primary percutaneous catheterization procedure.

Material/Methods

Starting January 2014 to December 2016, a cohort of eligible candidates were enrolled and divided into a training or a validation database. Each database was divided into MO or NMO subgroups based on TIMI myocardial perfusion grade results after recanalization. Independent factors were identified by multivariate logistic regression, from which the nomogram was plotted. The echocardiography measurement of the left ventricular ejection fraction (LVEF) was arranged within 7 days after the procedure.

Results

A nomogram was built for CMVO risk prediction for the first time. There were 446 participants in the training database with 319 cases in the NMO subgroup and 127 participants in the MO subgroup. The validation database included 99 participants with 25 cases in the NMO subgroup and 74 in the MO subgroup. The risk model was developed by 6 independently significant factors: age, symptom onset to balloon time, Killip classification, admission activated clotting time, neutrophil/lymphocyte ratio, and glucose value. Internal receiver operating characteristic displayed favorable performance with concordance index of 0.925, while external validation area under curve was 0.939. There were significant differences in LVEF values during hospitalization between the subgroups of each database (both P<0.001).

Conclusions

The nomogram model consisting of 6 factors could predict CMVO risk accurately for STEMI patients undergoing primary percutaneous catheterization.

Safety and efficacy of prourokinase injection in patients with ST-elevation myocardial infarction: phase IV clinical trials of the prourokinase phase study

To evaluate the safety and efficacy in terms of infarct-related artery (IRA) patency of prourokinase (proUK) injection within 6 h after symptom onset in patients with ST-elevation myocardial infarction (STEMI). A total of 1851 patients with acute myocardial infarction were enrolled to receive thrombolytic therapy with proUK. Qualifying patients were injected with 20 mg proUK intravenously followed by intravenous infusion of 30 mg proUK within 30 min. IRA was evaluated by coronary angiography at 120 min after thrombolysis. The efficacy and safety of proUK thrombolysis were analyzed in all the enrolled patients. Successful clinical reperfusion was observed in 1580 patients (85.4%). The number of leads with ST segment elevation and the amplitude of ST segment elevation were significantly reduced within 24 h after thrombolytic therapy with proUK. Eighty-three patients (4.48%) had died by the end of follow-up (7 days after thrombolysis), and the incidences of post-infarction angina, re-infarction or reocclusion, and emergency revascularization were 15.2, 4.21, and 8.27%, respectively. The most common bleeding complication was subcutaneous or mucosal bleeding and the incidence of intracranial hemorrhage was as lower as 0.32%. The fibrinolysis therapy with proUK is efficient and safe with very low rate of bleeding complications. It provides an alternative treatment options for STEMI patients especially in settings where primary PCI cannot be offered in a timely manner.

Incidence and Prognostic Impact of Respiratory Support in Patients With ST-Segment Elevation Myocardial Infarction

Data addressing the use of respiratory support in acute coronary syndromes are lacking. To address this evidence gap, we characterized prognostic impact and trends in utilization of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in patients hospitalized with ST-segment elevation myocardial infarction (STEMI) from 2002 through 2013 using the National Inpatient Sample. Multivariate logistic regression was performed to identify patient, hospital, and clinical characteristics associated with requiring IMV or NIV within 24 hours of hospitalization. Multivariate Cox proportional hazards regression was used to quantify the magnitude of in-hospital mortality associated with IMV and NIV use. From 2002 to 2013, we identified 1,867,114 patients with STEMI. Age, gender, higher co-morbidity burden, and chronic pulmonary disease were significantly associated with need for respiratory support. The use of IMV and NIV increased at average annual rates of 6.6% and 14.3%, respectively (p_trend <0.001). Age- and gender-adjusted mortality rates are high but declined for patients with STEMI requiring IMV (44.7% in 2002 to 37.6% in 2013, p_trend = 0.002) and NIV (11.6% in 2002 to 6.8% in 2013, p_trend <0.001). Compared to patients with STEMI with no ventilation need, a requirement for IMV or NIV was associated with increased adjusted in-hospital mortality (hazard ratio 2.5, p <0.001 and 1.7, p <0.001, respectively). In conclusion, approximately 1 in 23 patients hospitalized with STEMI will require respiratory support in the form of IMV or NIV. Patients with STEMI who require respiratory support have a high risk of death, although rates of in-hospital mortality have decreased over time.

Clinical and procedural predictors of no-reflow in patients with acute myocardial infarction after primary percutaneous coronary intervention

BACKGROUND

The treatment of acute myocardial infarction (AMI) is thought to restore antegrade blood flow in the infarct-related artery (IRA) and minimize ischemic damage to the myocardium as soon as possible. The present study aimed to identify possible clinical predictors for no-reflow in patients with AMI after primary percutaneous coronary intervention (PCI).

METHODS

A total of 312 consecutive patients with AMI who had been treated from January 2008 to December 2010 at the Cardiology Department of East Hospital, Tongji University School of Medicine were enrolled in this study. Inclusion criteria were: (i) patients underwent successfully primary PCI within 12 hours after the appearance of symptoms; or (ii) patients with ischemic chest pain for more than 12 hours after a successful primary PCI within 24 hours after appearance of symptoms. Exculsion criteria were: (i) coronary artery spasm; (ii) diameter stenosis of the culprit lesion was <50% and coronary blood flow was normal; (iii) patients with severe left main coronary or multivessel disease, who had to require emergency revascularization. According to thrombolysis in myocardial infarction (TIMI), the patients were divided into a reflow group and a no-reflow group. The clinical data, angiography findings and surgical data were compared between the two groups. Univariate and multivariate logistic regressions were used to determine the predictors for no-reflow.

RESULTS

Fifty-four (17.3%) of the patients developed NR phenomenon after primary PCI. Univariate analysis showed that age, time from onset to reperfusion, systolic blood pressure (SBP) on admission, Killip class of myocardial infarction, intra-aortic balloon pump (IABP) use before primary PCI, TIMI flow grade before primary PCI, type of occlusion, thrombus burden on baseline angiography, target lesion length, reference luminal diameter and method of reperfusion were correlated with no-reflow (P<0.05 for all). Multiple logistic regression analysis identified that age >65 years [OR=1.470, 95% confidence interval (CI) 1.460-1.490, P=0.007], long time from onset to reperfusion >6 hours (OR=1.270, 95%CI 1.160-1.400, P=0.001), low SBP on admission <100 mmHg (OR=1.910, 95%CI 1.018-3.896, P=0.004), IABP use before PCI (OR= 1.949, 95%CI 1.168-3.253, P=0.011), low (≤1) TIMI flow grade before primary PCI (OR=1.100, 95%CI 1.080-1.250, P<0.001), high thrombus burden (OR=1.600, 95%CI 1.470-2.760, P=0.030), and long target lesion (OR=1.948, 95%CI 1.908-1.990, P=0.019) on angiography were independent predictors of no-reflow.

CONCLUSION

The occurrence of no-reflow after primary PCI for acute myocardial infarction can predict clinical, angiographic and procedural features.

[Incidence, associated factors, and follow-up of hospital heart failure complicating acute anterior myocardial infarction successfully treated by primary angioplasty]

Heart failure (HF) complicating acute myocardial infarction (AMI) is of poor prognosis and is often associated with patient's characteristics and success of reperfusion strategies. However, few data is available regarding the high-risk subgroup of patients with anterior AMI treated successfully by primary angioplasty. The aim of the study was to assess the incidence, associated factors, and the future of HF occurring during hospitalisation, in the setting of anterior AMI treated successfully by primary angioplasty.

METHODS

Eighty-five consecutive patients with anterior AMI treated successfully by primary angioplasty (final angiographic TIMI flow grade=3, without residual stenosis) were included. Clinical, biochemical, angiographic, and echocardiographic data were prospectively collected and compared between patients with (Killip 2 and 3) and without HF during hospitalisation.

RESULTS

Fifteen patients had HF (18%) during hospitalisation and 70 did not. By comparison to patients without HF, patients with HF were more frequently diabetics, had troponin peak and CPK, leucocytes count, and fasting glucose higher, LVEF and wall motion score index in the left anterior descending territory (WMSi-lad) poorer, and a lower non-invasive coronary flow reserve (CFR) in the LAD 24hours after angioplasty (all, P<0.05). In multivariate analysis, fasting glucose, leucocytes count after angioplasty, CFR and WMSi-lad were independently associated with HF, even after adjusting with angiographic variables (all, P<0.05). At 6months, patients with HF had less recovery of LV function and higher frequency of adverse LV remodelling (58% versus 20%, P<0.01) by comparison to patients without HF.

CONCLUSION

In conclusion, HF is not uncommon even after successful primary angioplasty for anterior AMI (nearly one patient out of 5), is associated with hyperglycaemia and inflammation, a poor microvascular reperfusion, and left ventricular systolic function, and is more frequently complicated by adverse LV remodelling and lack of LV recovery.

Relation of gender to infarct size in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty

Previous reports have shown that female gender is associated with impaired outcomes among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, mainly owing to a worst risk profile (more diabetes, more advanced age, and higher Killip class at presentation) compared to men. Still contrasting are data on the effect of gender on the outcome in patients with STEMI undergoing primary angioplasty. In particular, it is still unclear whether a larger infarct size might contribute to the explanation of the worse outcome in women. Therefore, the aim of the present study was to investigate gender-related differences in infarct size as evaluated by myocardial scintigraphy in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We included 830 patients with STEMI undergoing primary percutaneous coronary intervention. The infarct size was evaluated at 30 days using technetium-99m-sestamibi. A logistic regression analysis was performed to determine the relation between gender and infarct size (as percentage of patients above the median) after correction for baseline confounding factors. We also evaluated the presence of a potential age-gender interaction. A total of 183 patients (20.8%) were women. Female gender was associated with more advanced age and a greater prevalence of hypertension; previous infarction and smoking were more frequently observed in men. Female gender was associated with a smaller infarct size (p <0.001) that was confirmed after correction for baseline confounding factors (adjusted odds ratio 0.48, 95% confidence interval 0.33-0.7, p <0.001). No age-gender interaction was observed (p = 0.13). In conclusion, the results of the present study have shown that despite the presence of high-risk features at presentation, female gender was associated with a smaller infarct size than that in men, without any interaction between age and gender.

Efficacy of clotinab in acute myocardial infarction trial-ST elevation myocardial infarction (ECLAT-STEMI)

BACKGROUND

This study investigated the efficacy and the safety of the upstream glycoprotein (Gp) IIb/IIIa inhibitor (clotinab; ISU ABXIS, Seoul, Republic of Korea) under 600-mg clopidogrel pretreatment compared with provisional use in ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

A total of 786 STEMI patients were randomized to upstream use in the emergency room (ER) (n = 392) or provisional use during percutaneous coronary intervention (PCI) (n = 394). All patients were prescribed 600-mg clopidogrel in the ER. The primary endpoint was the 30-day incidence of composite events including death, nonfatal myocardial infarction, target vessel revascularization, and stroke. There was no significant difference in the events that occurred in 40 patients (10.2%) in the upstream arm and 55 patients (14.0%) in the provisional arm during the 30 days (odds ratio 0.70, 95% confidence interval 0.45-1.08). Major bleeding was higher in the upstream arm (1.5% vs. 0%, P = 0.02). However, there was a significant reduction in 30-day composite events in the upstream arm in the high-risk population (Killip class ≥II or GRACE score >140).

CONCLUSIONS

The upstream use of clotinab under a 600-mg clopidogrel loading may not significantly reduce cardiac events following primary PCI but may improve the clinical outcome in high-risk patients.

A no-reflow prediction model in patients with ST-elevation acute myocardial infarction and primary drug-eluting stenting

OBJECTIVES

This study was undertaken to assess independent no-reflow predictors in patients with ST-elevation acute myocardial infarction (STEMI) and primary drug-eluting stenting in the current interventional strategies.

DESIGN

One thousand four hundred and thirteen patients with STEMI were successfully treated with primary drug-eluting stenting within 12 h after AMI. All clinical, angiographic and procedural data were collected. Univariate and multivariate logistic regression was used to identify independent no-reflow predictors.

RESULTS

The no-reflow was found in 297 (21%) of 1413 patients. Univariate and multivariate logistic regression identified that age (>65 years, OR 1.47, 95% CI 1.46-1.49; p = 0.007), long time-to-reperfusion (>6 h, OR 1.27, 95% CI 1.16-1.40; p = 0.001), admission plasma glucose (>13.0 mmol/L, OR 1.27, 95% CI 1.16-1.40; p = 0.027), collateral circulation (0-1, OR 1.69, 95% CI 1.25-2.29; p = 0.001), pre-PCI thrombus score (≥4, OR 1.36, 95% CI 1.16-1.79; p = 0.011), and IABP use before PCI (OR 2.89, 95% CI 1.65-5.05; p < 0.0001) were independent no-reflow predictors. The no-reflow rate significantly increased as the number of independent predictors increased (0%, 6%, 15%, 25%, 40%, 50% and 100% in patients with 0, 1, 2, 3, 4, 5, and 6 independent predictors, respectively; p < 0.0001).

CONCLUSIONS

The prediction model consisted of six no-reflow predictors in patients with STEMI and primary drug-eluting stenting and should be confirmed in large-scale prospective studies.

Cardiogenic shock

The syndrome of cardiogenic shock (CS) comprises a constellation of symptoms and signs that define a subset of patients with inadequate tissue perfusion secondary to myocardial dysfunction. Careful attention to and rapid identification of patients at risk for the development of CS and those with impending CS by both hospitalists and subspecialists will help to implement the time-sensitive therapy that it requires. Physicians should gain a familiarity with the underlying pathophysiology of CS and available diagnostic tools as well as the importance of vasopressor therapy, inotropic therapy, rapid reperfusion therapy, and mechanical support.