A preliminary investigation into adrenal …

Tol, M. M., et al. (2014). "A preliminary investigation into adrenal responsiveness and outcomes in patients with cardiogenic shock after acute myocardial infarction." Journal of Critical Care 29(3): 6.

Purpose: This study investigated the significance of baseline cortisol levels and adrenal response to corticotropin in shocked patients after acute myocardial infarction (AMI). Methods: A short corticotropin stimulation test was performed in 35 patients with cardiogenic shock after AMI by intravenously injecting of 250 mu g of tetracosactrin (Synacthen). Blood samples were obtained at baseline (T0) before and at 30 (T30) and 60 (T60) minutes after the test to determine plasma total cortisol (TC) and free cortisol concentrations. The main outcome measure was in-hospital mortality and its association with T0 TC and maximum response to corticotropin (maximum difference [Delta max] in cortisol levels between T0 and the highest value between T30 and T60). Results: The in-hospital mortality was 37%, and the median time to death was 4 days (interquartile range, 3-9 days). There was some evidence of an increased mortality in patients with T0 TC concentrations greater than 34 mu g/dL (P = .07). Maximum difference by itself was not an independent predictor of death. Patients with a T0 TC 34 mu g/dL or less and Delta max greater than 9 mu g/dL appeared to have the most favorable survival (91%) when compared with the other 2 groups: T0 34 mu g/dL or less and Delta max9 mu g/dL or less or T0 34 mu g/dL or higher and Delta max greater than 9 mu g/dL (75%; P = .8) and T0 greater than 34 mu g/dL and. max 9 mu g/dL or less (60%; P = .02). Corticosteroid therapy was associated with an increased mortality (P = .03). There was a strong correlation between plasma TC and free cortisol (r = 0.85). Conclusions: A high baseline plasma TC was associated with a trend toward increased mortality in patients with cardiogenic shock post-AMI. Patients with lower baseline TC, but with an inducible adrenal response, appeared to have a survival benefit. A prognostic system based on basal TC and Delta max similar to that described in septic shock appears feasible in this cohort. Corticosteroid therapy was associated with adverse outcomes. These findings require further validation in larger studies. (C) 2014 Elsevier Inc. All rights reserved.