Cardiogenic shock remains the leading cause of death in patients hospitalized for acute myocardial infarction, despite many advances encountered in the last years in reperfusion, mechanical, and pharmacological therapies addressed to stabilization of the hemodynamic condition of these critical patients. Such patients require immediate initiation of the most effective therapy, as well as a continuous monitoring in the Coronary Care Unit. Novel biomarkers have been shown to improve diagnosis and risk stratification in patients with cardiogenic shock, and their proper use may be especially important for the identification of the critical condition, leading to prompt therapeutic interventions. The aim of this review was to evaluate the current literature data on complex biomarker assessment and monitoring of patients with acute myocardial infarction complicated with cardiogenic shock in the Coronary Care Unit.

The aim of this preliminary study was to assess the effectiveness of transluminal contrast attenuation gradient (TAG) determined by computed tomographic angiography (CTA), for the evaluation of the functional significance of coronary artery stenoses in patients with acute coronary syndromes produced by vulnerable coronary plaques, and to demonstrate the correlation between this new parameter and the vulnerability markers of the culprit lesions. Material and methods: This is a preliminary pilot study on 10 patients with acute coronary syndromes– unstable angina type, who underwent CTA for the assessment of coronary lesions, followed by invasive angiography and the determination of fractional flow reserve (FFR) prior to a revascularization procedure. Patients were divided into 2 groups, according to their FFR values: Group 1 consisted of 6 patients with an FFR value <0.8 (functionally significant lesion), and Group 2 consisted of 4 patients who presented an FFR value >0.8 (functionally non-significant lesion). Results: FFR values were 0.64 ± 0.07, 95% CI: 0.5–0.7 in Group 1, and 0.86 ± 0.05, 95% CI: 0.7–0.9 in Group 2. Plaques associated with an FFR<0.8 presented a higher amount of plaque volume (192.7 ± 199.7 mm3 vs. 42.1 ± 27.3 mm3, p = 0.1), necrotic core (66.7 ± 72.9 mm3 vs. 10.0 ± 9.3 mm3, p = 0.1), and fibro-fatty tissue (29.7 ± 37.4 mm3 vs. 6.2 ± 3.8 mm3, p = 0.2). At the same time, TAG significantly correlated with the presence of a functionally significant lesion. Coronary lesions associated with low FFR presented significantly higher values of TAG along the plaque as compared with lesions with FFR values >0.8 (TAG values 22.1 ± 5.8 HU vs. 11.7 ± 2.5 HU, p = 0.01). Linear regression identified a significant correlation between TAG and FFR values as a measure of functional significance of the lesion (r = 0.7, p = 0.01). Conclusions: Contrast attenuation gradient along the culprit lesion, determined by CTA, correlates with the FFR values and with CT markers of plaque vulnerability, indicating that the presence of vulnerability features inside a coronary plaque could increase the functional significance of a coronary lesion.

Coronary artery disease represents a major cause of morbidity and mortality around the world. Unstable angina pectoris is a serious manifestation of ischemic heart disease and represents an acute condition caused by the narrowing of the coronary lumen as the result of an atheromatous plaque formation. In most cases the trigger of this process is represented by the rupture of a plaque that has become vulnerable or unstable. The first-line intracoronary imaging technique for the evaluation of plaque vulnerability is optical coherence tomography, which can measure the thickness of the fibrous cap (a significant predictor of plaque vulnerability) and can also assess other characteristics of plaque vulnerability (macrophage infiltration, lipid pool, intracoronary thrombus, or neointimal rupture). We present the case of a 67-year-old male with symptoms suggestive of unstable angina pectoris, caused by the presence of a vulnerable plaque on the left main coronary artery, where optical coherence tomography had a significant contribution in identifying the etiology of chest pain.