title: A preliminary investigation into adrenal responsiveness and outcomes in patients with cardiogenic shock after acute myocardial infarction.
abstract: OBJECTIVE
  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 μg 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 [Δ 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 μg/dL (P=.07). Maximum difference by itself was not an independent predictor of death. Patients with a T0 TC 34 μg/dL or less and Δ max greater than 9 μg/dL appeared to have the most favorable survival (91%) when compared with the other 2 groups: T0 34 μg/dL or less and Δ max 9 μg/dL or less or T0 34 μg/dL or higher and Δ max greater than 9 μg/dL (75%; P=.8) and T0 greater than 34 μg/dL and Δ max 9 μg/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 Δ 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.
authors.affiliation: Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Maneesha M
authors.initials: MM
authors.lastname: Tol
authors.affiliation: Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia. Electronic address: kiran_shekar@health.qld.gov.au.
authors.forename: Kiran
authors.initials: K
authors.lastname: Shekar
authors.affiliation: Institute of Health and Biomedical Innovation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.
authors.forename: Adrian G
authors.initials: AG
authors.lastname: Barnett
authors.affiliation: School of Mathematical Sciences, Science and Engineering Faculty, Queensland University of Technology, Brisbane, Queensland, Australia.
authors.forename: James
authors.initials: J
authors.lastname: McGree
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia.
authors.forename: Brett C
authors.initials: BC
authors.lastname: McWhinney
authors.affiliation: Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Marc
authors.initials: M
authors.lastname: Ziegenfuss
authors.affiliation: Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia.
authors.forename: Jacobus P
authors.initials: JP
authors.lastname: Ungerer
authors.affiliation: Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: John F
authors.initials: JF
authors.lastname: Fraser
mesh_terms: D000208:Acute Disease; D000309:Adrenal Insufficiency / Q000097:blood* / Q000188:drug therapy* / Q000401:mortality; D000368:Aged; D015415:Biomarkers / Q000097:blood; D003366:Cosyntropin / Q000008:administration & dosage*; D005260:Female; D006728:Hormones / Q000008:administration & dosage*; D017052:Hospital Mortality; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D010865:Pilot Projects; D011379:Prognosis; D011446:Prospective Studies; D012770:Shock, Cardiogenic / Q000097:blood* / Q000188:drug therapy / Q000401:mortality; D012772:Shock, Septic / Q000401:mortality; D013997:Time Factors
chemical_list: D015415:Biomarkers; D006728:Hormones; D003366:Cosyntropin; D006854:Hydrocortisone
keywords: Acute myocardial infarction; Cardiogenic shock; Corticotropin stimulation test; Plasma cortisol; Relative adrenal insufficiency