N-terminal-pro-B-type natriuretic peptide in cardiogenic shock: a marker ready for prime time or a therapeutic target?

摘要

Although the incidence of car-diogenic shock (CS) remained stable at 7% to 9% in all acute myocardial infarction (AMI) admissions into the early part of this decade (1), reports suggest a decrease in the most recent period-a decrease attributed to a marked increase in the utilization of interventional therapy as well as improvements in medical therapy (2, 3). When shock secondary to ventricular pump failure does occur, early revascu-larization improves long-term survival and is therefore now the recommended therapy when it can be performed within 18 hours of shock onset (4). Nonetheless, mortality remains high, with even the most positive registries reporting in-hospital rates in the 40% range for patients selected for percutaneous coronary intervention. Although percutaneous coronary intervention techniques and associated antiplatelet and anticoagulant pharmacotherapy have improved and continue to improve since the publication of the should we emergently revas-cularize occluded coronary arteries in cardiogenic shock trial, these advances have not led and are unlikely to lead to dramatic improvements in outcome. Although mechanical assist, in particular with the intra-aortic balloon pump, now constitutes an American Heart Association/American College of Cardiology indication in the setting of CS, this consensus indication is based on data from registries with all of their caveats and limitations, and one positive subgroup analysis of a small negative trial (5). Furthermore, any possible additional benefits of left ventricular assist devices are as yet unproven (6, 7).