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Bilchenko AO, Gritsenko OV, Kolisnyk VO, Rafalyuk OI, Pyzhevskii AV, Myzak YV, Besh DI, Salo VM, Chaichuk SO, Lehoida MO, Danylchuk IV, Polivenok IV. Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022. Front Cardiovasc Med 2024; 11:1377969. [PMID: 38606380 PMCID: PMC11007039 DOI: 10.3389/fcvm.2024.1377969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Background Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world. Materials and methods The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients. Results We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS. Conclusions Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.
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Affiliation(s)
- Anton O. Bilchenko
- Department of Prevention and Treatment of Emergency Conditions, L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | - Olga V. Gritsenko
- Department of Interventional Cardiology, V.T. Zaitcev Institute of General and Urgent Surgery of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | | | - Oleg I. Rafalyuk
- Department of Interventional Radiology, Lviv Regional Clinical Treatment and Diagnostic Cardiology Center, Lviv, Ukraine
| | - Andrii V. Pyzhevskii
- Department of Interventional Radiology, Lviv Regional Clinical Treatment and Diagnostic Cardiology Center, Lviv, Ukraine
| | - Yaroslav V. Myzak
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
| | - Dmytro I. Besh
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
- Department of Family Medicine, Danylo Halytsky National Medical University, Lviv, Ukraine
| | - Victor M. Salo
- Department of Interventional Radiology, 1st Territorial Medical Union, Lviv, Ukraine
| | - Sergii O. Chaichuk
- Department of Interventional Cardiology, Oleksandrivska Clinical Hospital, Kyiv, Ukraine
| | - Mykhailo O. Lehoida
- Department of Cardiology, Vinnytsia Regional Clinical Treatment and Diagnostic Center of Cardiovascular Pathology, Vinnytsia, Ukraine
| | - Ihor V. Danylchuk
- Department of Cardiology, Vinnytsia Regional Clinical Treatment and Diagnostic Center of Cardiovascular Pathology, Vinnytsia, Ukraine
| | - Ihor V. Polivenok
- Department of Interventional Cardiology, V.T. Zaitcev Institute of General and Urgent Surgery of the National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
- Department of Therapy No 1, Kharkiv National Medical University, Kharkiv, Ukraine
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Dogan EM, Axelsson B, Jauring O, Hörer TM, Nilsson KF, Edström M. Intra-aortic and Intra-caval Balloon Pump Devices in Experimental Non-traumatic Cardiac Arrest and Cardiopulmonary Resuscitation. J Cardiovasc Transl Res 2023; 16:948-955. [PMID: 36481982 PMCID: PMC10480270 DOI: 10.1007/s12265-022-10343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
Intra-aortic balloon pump (IABP) use during CPR has been scarcely studied. Intra-caval balloon pump (ICBP) may decrease backward venous flow during CPR. Mechanical chest compressions (MCC) were initiated after 10 min of cardiac arrest in anesthetized pigs. After 5 min of MCC, IABP (n = 6) or ICBP (n = 6) was initiated. The MCC device and the IABP/ICBP had slightly different frequencies, inducing a progressive peak pressure phase shift. IABP inflation 0.15 s before MCC significantly increased mean arterial pressure (MAP) and carotid blood flow (CBF) compared to inflation 0.10 s after MCC and to MCC only. Coronary perfusion pressure significantly increased with IABP inflation 0.25 s before MCC compared to inflation at MCC. ICBP inflation before MCC significantly increased MAP and CBF compared to inflation after MCC but not compared to MCC only. This shows the potential of IABP in CPR when optimally synchronized with MCC. The effect of timing of intra-aortic balloon pump (IABP) inflation during mechanical chest compressions (MCC) on hemodynamics. Data from12 anesthetized pigs.
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Affiliation(s)
- Emanuel M Dogan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden.
| | - Birger Axelsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Oskar Jauring
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Måns Edström
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, SE-701 85, Örebro, Sweden
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Shi Y, Wang Y, Sun X, Tang Y, Jiang M, Bai Y, Liu S, Jiang W, Yuan H, Lu Y, Cai J. Effects of mechanical circulatory support devices in patients with acute myocardial infarction undergoing stent implantation: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2021; 11:e044072. [PMID: 34187815 PMCID: PMC8245450 DOI: 10.1136/bmjopen-2020-044072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The survival benefit of using mechanical circulatory support (MCS) in patients with acute myocardial infarction (AMI) is still controversial. It is necessary to explore the impact on clinical outcomes of MCS in patients with AMI undergoing stenting. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Cochrane Library, Medline, PubMed, Web of Science, ClinicalTrials.gov and Clinicaltrialsregister.eu databases were searched from database inception to February 2021. ELIGIBILITY CRITERIA Randomised clinical trials (RCTs) on MCS use in patients with AMI undergoing stent implantation were included. DATA EXTRACTION AND SYNTHESIS Data were extracted and summarised independently by two reviewers. Risk ratios (RRs) and 95% CIs were calculated for clinical outcomes according to random-effects model. RESULTS Twelve studies of 1497 patients with AMI were included, nine studies including 1382 patients compared MCS with non-MCS, and three studies including 115 patients compared percutaneous ventricular assist devices (pVADs) versus intra-aortic balloon pump (IABP). Compared with non-MCS, MCS was not associated with short-term (within 30 days) (RR=0.90; 95% CI 0.57 to 1.41; I2=46.8%) and long-term (at least 6 months) (RR=0.82; 95% CI 0.57 to 1.17; I2=37.6%) mortality reductions. In the subset of patients without cardiogenic shock (CS) compared with non-MCS, the patients with IABP treatment significantly had decreased long-term mortality (RR=0.49; 95% CI 0.27 to 0.90; I2=0), but without the short-term mortality reductions (RR=0.51; 95% CI 0.22 to 1.19; I2=17.9%). While in the patients with CS, the patients with MCS did not benefit from the short-term (RR=1.09; 95% CI 0.67 to 1.79; I2=46.6%) or long-term (RR=1.00; 95% CI 0.75 to 1.33; I2=22.1%) survival. Moreover, the application of pVADs increased risk of bleeding (RR=1.86; 95% CI 1.15 to 3.00; I2=15.3%) compared with IABP treatment (RR=1.86; 95% CI 1.15 to 3.00; I2=15.3%). CONCLUSIONS In all patients with AMI undergoing stent implantation, the MCS use does not reduce all-cause mortality. Patients without CS can benefit from MCS regarding long-term survival, while patients with CS seem not.
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Affiliation(s)
- Yunmin Shi
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yujie Wang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuejing Sun
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Tang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mengqing Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuanyuan Bai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Suzhen Liu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Yuan
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yao Lu
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jingjing Cai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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McGovern L, Cosgrave J. Axial flow ventricular assist devices in cardiogenic shock complicating acute myocardial infarction. Heart 2021; 107:1856-1861. [PMID: 33811130 DOI: 10.1136/heartjnl-2020-318226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock (CS) remains the leading cause of death in patients hospitalised with acute myocardial infarction with mortality as high as 40%-50% prior to hospital discharge. The failure of inotropic therapy to maintain adequate perfusion and to prevent irreversible end-organ failure has led to attempts to improve outcomes by mechanical circulatory support (MCS) devices. Axial flow ventricular assist devices, namely Impella, are an attractive therapeutic option due to their positive haemodynamic benefits and ease of use. Despite clear beneficial haemodynamic effects, which should significantly impact on the pathophysiology of CS, there are currently no clear data to support their use in the reduction of clinical end points such as cardiac death. This review summarises and critically evaluates the current scientific evidence for the use of axial flow ventricular assist devices and highlights gaps in our understanding. Given such gaps, a consensus multidisciplinary approach, predicated on emphasising timely diagnosis and appropriate use of MCS, is vital to ensure that the right patient is paired with the right device at the right time.
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Wang W, Yang F, Lin X, Zhong Q, Li Z, Chen X, Wang J, He K. The Preference, Effect, and Prognosis of Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock Patients: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6656926. [PMID: 33542922 PMCID: PMC7840249 DOI: 10.1155/2021/6656926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUNDS Intra-aortic balloon counterpulsation is increasingly used in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to explore the preference, effect, and prognosis of intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock patients. METHODS Data of acute myocardial infarction complicated by cardiogenic shock patients at the Fourth Medical Center of PLA General Hospital were collected retrospectively. A propensity score was calculated with a logistic regression which contained clinically meaningful variables and variables selected by Lasso and then used to match the control group. The cumulative incidence curve and Gray's test were employed to analyse the effect and prognosis of intra-aortic balloon counterpulsation on mortality. RESULTS A total of 1962 acute myocardial infarction cases admitted between May 2015 and November 2018 were identified, and 223 cases with acute myocardial infarction complicated by cardiogenic shock were included as the study cohort, which contained 34 cases that received IABP and 189 cases that did not receive IABP. Patients with higher alanine aminotransferase (OR = 1.93, 95% CI 1.29-2.98), higher triglyceride (OR = 3.71, 95% CI 1.87-7.95), and higher blood glucose (OR = 1.08, 95% CI 0.99-1.18) had a higher probability of receiving intra-aortic balloon counterpulsation. In the propensity score matching analysis, 34 cases received intra-aortic balloon counterpulsation and 102 matched controls were included in the comparison. By comparing the cumulative incidence of in-hospital mortality, there was no statistically significant difference between the intra-aortic balloon counterpulsation group and matched control group (P = 0.454). CONCLUSION The use of intra-aortic balloon counterpulsation may not improve the prognosis of the acute myocardial infarction complicated by cardiogenic shock patients.
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Affiliation(s)
- Wenjun Wang
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Feifei Yang
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xixiang Lin
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qin Zhong
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zongren Li
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xu Chen
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, Netherlands
| | - Kunlun He
- Key Laboratory of Ministry of Industry and Information Technology of Biomedical Engineering and Translational Medicine, Chinese PLA General Hospital, Beijing 100853, China
- Translational Medical Research Center, Chinese PLA General Hospital, Beijing 100853, China
- Medical Artificial Intelligence Research Center, Chinese PLA General Hospital, Beijing 100853, China
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Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2018; 1:CD009669. [PMID: 29376560 PMCID: PMC6491099 DOI: 10.1002/14651858.cd009669.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. OBJECTIVES To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). AUTHORS' CONCLUSIONS Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.
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Affiliation(s)
- Julia Schumann
- Martin‐Luther‐University Halle‐WittenbergDepartment of Anaesthesiology and Surgical Intensive CareHalle/SaaleGermany
| | - Eva C Henrich
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Hellen Strobl
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Roland Prondzinsky
- Carl von Basedow Klinikum MerseburgCardiology/Intensive Care MedicineWeisse Mauer 42MerseburgGermany06217
| | - Sophie Weiche
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Holger Thiele
- University Clinic Schleswig‐Holstein, Campus LübeckMedical Clinic II (Kardiology, Angiology, Intensive Care Medicine)Ratzeburger Allee 160LubeckD‐23538Germany
| | - Karl Werdan
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Stefan Frantz
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Susanne Unverzagt
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
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Horn P, Kelm M, Westenfeld R. Integration of medical therapy and mechanical circulatory support in the management of acute heart failure. Arch Med Sci 2016; 12:1317-1323. [PMID: 27904524 PMCID: PMC5108375 DOI: 10.5114/aoms.2015.51700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 02/01/2015] [Indexed: 01/06/2023] Open
Abstract
Acute heart failure is still characterized by poor prognosis with high mortality. Diagnosis is based on clinical symptoms and hemodynamic measurements. Early coronary revascularization in cardiogenic shock complicating myocardial infarction improves outcome. The further contemporary therapeutic options in the management of acute heart failure are limited to a merely symptomatic effect with relief of dyspnea, reduction of volume overload and improvement of hemodynamic parameters by vasodilators (in hypertension) or inotropic and vasopressor agents (in hypotension). However, so far no medical therapy has been shown to positively affect clinical outcomes of patients with acute heart failure. Early identification of impending circulatory collapse coupled with rapid implementation of mechanical circulatory support may contribute to mortality reduction as a combined concept of the management of acute heart failure.
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Affiliation(s)
- Patrick Horn
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Düsseldorf, Germany
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Unverzagt S, Hirsch K, Prondzinsky R. Vasopressors and predominantly vasoconstrictive drugs for acute myocardial infarction complicated by cardiogenic shock. Hippokratia 2016. [DOI: 10.1002/14651858.cd011582.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Susanne Unverzagt
- Martin Luther University Halle-Wittenberg; Institute of Medical Epidemiology, Biostatistics and Informatics; Magdeburge Straße 8 Halle/Saale Germany 06097
| | - Katharina Hirsch
- Martin Luther University Halle-Wittenberg; Institute of Medical Epidemiology, Biostatistics and Informatics; Magdeburge Straße 8 Halle/Saale Germany 06097
| | - Roland Prondzinsky
- Carl von Basedow Klinikum Merseburg; Cardiology/Intensive Care Medicine; Weisse Mauer 42 Merseburg Germany 06217
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9
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Mao CT, Wang JL, Chen DY, Tsai ML, Lin YS, Cherng WJ, Wang CH, Wen MS, Hsieh IC, Hung MJ, Chen CC, Chen TH. Benefits of Intraaortic Balloon Support for Myocardial Infarction Patients in Severe Cardiogenic Shock Undergoing Coronary Revascularization. PLoS One 2016; 11:e0160070. [PMID: 27483439 PMCID: PMC4970797 DOI: 10.1371/journal.pone.0160070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/13/2016] [Indexed: 01/30/2023] Open
Abstract
Background Prior studies have suggested intraaortic balloon pump (IABP) have a neutral effect on acute myocardial infarction (AMI) patients with cardiogenic shock (CS). However, the effects of IABP on patients with severe CS remain unclear. We therefore investigated the benefits of IABP in AMI patients with severe CS undergoing coronary revascularization. Methods and Results This study identified 14,088 adult patients with AMI and severe CS undergoing coronary revascularization from Taiwan’s National Health Insurance Research Database between January 1, 1997 and December 31, 2011, dividing them into the IABP group (n = 7044) and the Nonusers group (n = 7044) after propensity score matching to equalize confounding variables. The primary outcomes included myocardial infarction(MI), cerebrovascular accidents or cardiovascular death. In-hospital events including dialysis, stroke, pneumonia and sepsis were secondary outcomes. Primary outcomes were worse in the IABP group than in the Nonusers group in 1 month (Hazard ratio (HR) = 1.97, 95% confidence interval (CI) = 1.84–2.12). The MI rate was higher in the IABP group (HR = 1.44, 95% CI = 1.16–1.79), and the cardiovascular death was much higher in the IABP group (HR = 2.07, 95% CI = 1.92–2.23). The IABP users had lower incidence of dialysis (8.5% and 9.5%, P = 0.04), stroke (2.6% and 3.8%, P<0.001), pneumonia (13.9% and 16.5%, P<0.001) and sepsis (13.2% and 16%, P<0.001) during hospitalization than Nonusers. Conclusion The use of IABP in patients with myocardial infarction and severe cardiogenic shock undergoing coronary revascularization did not improve the outcomes of recurrent myocardial infarction and cardiovascular death. However, it did reduce the incidence of dialysis, stroke, pneumonia and sepsis during hospitalization.
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Affiliation(s)
- Chun-Tai Mao
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jian-Liang Wang
- Division of Cardiology, Landseed Hospital, Pingzhen City, Taiwan
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Lung Tsai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wen-Jin Cherng
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chao-Hung Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan, and Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail:
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10
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Spence N, Abbott JD. Coronary Revascularization in Cardiogenic Shock. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 18:1. [DOI: 10.1007/s11936-015-0423-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Spiro J, Doshi SN. Use of left ventricular support devices during acute coronary syndrome and percutaneous coronary intervention. Curr Cardiol Rep 2015; 16:544. [PMID: 25326728 DOI: 10.1007/s11886-014-0544-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In an effort to improve outcomes in percutaneous coronary intervention (PCI), percutaneous ventricular assist devices (PVADs) have been investigated in (1) high-risk PCI, (2) acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) and (3) in AMI without CS. PCI has become an increasing complex due to an ageing population with complex disease and the frequent presence of impaired LV function. Patients undergoing high-risk PCI in these circumstances are prone to acute cardiovascular collapse. Additionally, mortality in AMI complicated by CS remains high. Lastly, LV support during AMI may reduce infarct size and therefore preserve LV function. At present, four commercially available devices exist: intra-aortic balloon pump counterpulsation (IABP), Impella, TandemHeart and extracorporeal membrane oxygenation (ECMO). These devices are employed in an effort to increase cardiac output, mean arterial pressure (MAP) and coronary perfusion and to reduce pulmonary capillary wedge pressure (PCWP). The mechanism of action differs with each device, and there are advantages and disadvantages. In this update, we discuss recent data describing the use of PVADs to support patients with AMI with or without cardiogenic shock and during high-risk PCI. We focus on the unique features of each device, highlighting strengths, weaknesses and frequently encountered complications, which may be important when tailoring the most appropriate PVAD therapy to an individual patient's need.
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Affiliation(s)
- Jon Spiro
- Department of Cardiology, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
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Sintek MA, Gdowski M, Lindman BR, Nassif M, Lavine KJ, Novak E, Bach RG, Silvestry SC, Mann DL, Joseph SM. Intra-Aortic Balloon Counterpulsation in Patients With Chronic Heart Failure and Cardiogenic Shock: Clinical Response and Predictors of Stabilization. J Card Fail 2015; 21:868-76. [PMID: 26164215 DOI: 10.1016/j.cardfail.2015.06.383] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/19/2015] [Accepted: 06/29/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this work was to characterize the clinical response and identify predictors of clinical stabilization after intra-aortic balloon counterpulsation (IABP) support in patients with chronic systolic heart failure in cardiogenic shock before implantation of a left ventricular assist device (LVAD). BACKGROUND Limited data exist regarding the clinical response to IABP in patients with chronic heart failure in cardiogenic shock. METHODS We identified 54 patients supported with IABP before LVAD implantation. Criteria for clinical decompensation after IABP insertion and before LVAD included the need for more advanced temporary support, initiation of mechanical ventilation or dialysis, increase in vasopressors/inotropes, refractory ventricular arrhythmias, or worsening acidosis. The absence of these indicated stabilization. RESULTS Clinical decompensation after IABP occurred in 23 patients (43%). Both patients who decompensated and those who stabilized had similar hemodynamic improvements after IABP support, but patients who decompensated required more vasopressors/inotropes. Clinical decompensation after IABP was associated with worse outcomes after LVAD implantation, including a 3-fold longer intensive care unit stay and 5-fold longer time on mechanical ventilation (P < .01 for both). Although baseline characteristics were similar between groups, right and left ventricular cardiac power indexes (cardiac power index = cardiac index × mean arterial pressure/451) identified patients who were likely to stabilize (area under the receiver operating characteristic curve = 0.82). CONCLUSIONS Among patients with chronic systolic heart failure who develop cardiogenic shock, more than one-half of patients stabilized with IABP support as a bridge to LVAD. Baseline measures of right and left ventricular cardiac power, reflecting work performed for a given flow and pressure, may allow clinicians to identify patients with sufficient contractile reserve who will be likely to stabilize with an IABP versus those who may need more aggressive ventricular support.
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Affiliation(s)
- Marc A Sintek
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Mark Gdowski
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Brian R Lindman
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Michael Nassif
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Kory J Lavine
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Eric Novak
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Richard G Bach
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | | | - Douglas L Mann
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Susan M Joseph
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri.
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13
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Unverzagt S, Hirsch K, Prondzinsky R. Vasopressors and predominantly vasoconstrictive drugs for acute myocardial infarction complicated by cardiogenic shock. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Gilotra NA, Stevens GR. Temporary mechanical circulatory support: a review of the options, indications, and outcomes. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 8:75-85. [PMID: 25674024 PMCID: PMC4317108 DOI: 10.4137/cmc.s15718] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 12/20/2022]
Abstract
Cardiogenic shock remains a challenging disease entity and is associated with significant morbidity and mortality. Temporary mechanical circulatory support (MCS) can be implemented in an acute setting to stabilize acutely ill patients with cardiomyopathy in a variety of clinical situations. Currently, several options exist for temporary MCS. We review the indications, contraindications, clinical applications, and evidences for a variety of temporary circulatory support options, including the intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), CentriMag blood pump, and percutaneous ventricular assist devices (pVADs), specifically the TandemHeart and Impella.
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Affiliation(s)
- Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gerin R Stevens
- Mechanical Circulatory Support Program, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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15
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Ye L, Zheng M, Chen Q, Li G, Deng W, Ke D. Effects of intra-aortic balloon counterpulsation pump on mortality of acute myocardial infarction. PLoS One 2014; 9:e108356. [PMID: 25268800 PMCID: PMC4182463 DOI: 10.1371/journal.pone.0108356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/28/2014] [Indexed: 11/28/2022] Open
Abstract
Background Several randomized controlled trials (RCTs) have evaluated the effect of intra-aortic balloon counterpulsation pump(IABP) on the mortality of acute myocardial infarction (AMI). Objectives To analyze the relevant RCT data on the effect of IABP on mortality and the occurrence of bleeding in AMI. Data Sources Published RCTs on the treatment of AMI by IABP were retrieved in searches of Medline, EMBASE, Cochrane and other related databases. The last search was conducted on July 20, 2014. Study Eligibility Criteria Randomized clinical trials comparing IABP to controls as treatment for AMI. Participants Patients with AMI. Synthesis Methods The primary endpoint was mortality, and the secondary endpoint was bleeding events. To account for to heterogeneity, a random-effects model was used to analyze the study data. Results Ten trials with a total population of 973 patients that were included in the analysis showed no significant difference in 2-month mortality between the IABP and the control groups. The 6-month mortality in the IABP group was not significantly lower than in the control group in the four RCTs that enrolled 59 AMI patients with CS. But in the four that enrolled AMI 66 patients without CS, the data showed opposite conclusion. Conclusions IABP cannot reduce within 2 months and 6–12 months mortality of AMI patients with CS as well as within 2 months mortality of AMI patients without CS, but can reduce 6–12 months mortality of AMI patients without CS. In addition, IABP can increase the risk of bleeding.
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Affiliation(s)
- Liwen Ye
- Department of Geriatrics Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Minming Zheng
- Chongqing Ophthalmology Research Center for the Senile, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Ophthalmology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingwei Chen
- Department of Geriatrics Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- * E-mail:
| | - Guiqion Li
- Department of Geriatrics Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Deng
- Department of Geriatrics Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dazhi Ke
- Department of Geriatrics Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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McDonough R, Ohman EM. The use of aortic counterpulsation in United States: what can we learn from administrative databases? Am Heart J 2014; 168:237-8. [PMID: 25173532 DOI: 10.1016/j.ahj.2014.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 05/24/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Ryan McDonough
- Division of Cardiovascular Medicine, Department of Medicine, and Program for Advanced Coronary Disease, Duke Clinical Research Institute, Duke University, Durham, NC
| | - E Magnus Ohman
- Division of Cardiovascular Medicine, Department of Medicine, and Program for Advanced Coronary Disease, Duke Clinical Research Institute, Duke University, Durham, NC.
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Hawkins BM, Fitzgerald-McKeon LM, Yeh RW. High-risk percutaneous coronary intervention in the era of public reporting: clinical and ethical considerations in the care of an elderly patient with critical left main disease and shock. Circulation 2014; 129:258-65. [PMID: 24421361 DOI: 10.1161/circulationaha.113.004604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Beau M Hawkins
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (B.M.H.); Division of Cardiology, Massachusetts General Hospital, Boston, MA (R.W.Y.); and Amo et Doceo Liberi Center, East Walpole, MA (L.M.F.-M.)
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18
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Altayyar S, Rochwerg B, Alnasser S, Al-Omari A, Baw B, Fox-Robichaud A, Alhazzani W. Intra-aortic balloon pump in patients with cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis of randomized trials (protocol). Syst Rev 2014; 3:24. [PMID: 24620783 PMCID: PMC4008254 DOI: 10.1186/2046-4053-3-24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/25/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction. Despite significant advancements in health technology and research, hospital mortality approaches 50%. The intra-aortic balloon pump is a mechanical hemodynamic assist device that has been used for over 40 years in the management of patients with cardiogenic shock. A recent randomized trial suggests that the use of intra-aortic balloon pumps does not reduce mortality in patients with ischemic cardiogenic shock. METHODS We plan to search MEDLINE, EMBASE, and the Cochrane Trial Registry for potentially eligible randomized trials that compare the use of intra-aortic balloon pump with no mechanical device support in patients with cardiogenic shock. No date, language or journal limitations will be applied. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria. Data abstraction will be done independently and in duplicate. We plan to use RevMan software to generate pooled estimates across included studies, using the previously published method of DerSimonian and Laird. We will report pooled estimates as risk ratios with 95% confidence intervals for binary outcomes, and as mean differences with 95% confidence intervals for continuous outcomes. We will assess the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DISCUSSION The aim of this systematic review and meta-analysis is to summarize the available evidence on the efficacy of the intra-aortic balloon pump in cardiogenic shock. Systematic review registration: PROSPERO CRD42014007056.
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Affiliation(s)
| | | | | | | | | | | | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada.
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Unverzagt S, Wachsmuth L, Hirsch K, Thiele H, Buerke M, Haerting J, Werdan K, Prondzinsky R. Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2014:CD009669. [PMID: 24385385 DOI: 10.1002/14651858.cd009669.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The recently published German-Austrian S3 Guideline for the treatment of infarct related cardiogenic shock (CS) revealed a lack of evidence for all recommended therapeutic measures. OBJECTIVES To determine the effects in terms of efficacy, efficiency and safety of cardiac care with inotropic agents and vasodilator strategies versus placebo or against each other for haemodynamic stabilisation following surgical treatment, interventional therapy (angioplasty, stent implantation) and conservative treatment (that is no revascularization) on mortality and morbidity in patients with acute myocardial infarction (AMI) complicated by CS or low cardiac output syndrome (LCOS). SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), EMBASE (Ovid) and ISI Web of Science, registers of ongoing trials and proceedings of conferences in January 2013. Reference lists were scanned and experts in the field were contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in patients with AMI complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed according to the published protocol. All trials were analysed individually. Hazard ratios (HRs) and odds ratios with 95% confidence intervals (CI) were extracted but not pooled because of high heterogeneity between the control group interventions. MAIN RESULTS Four eligible, very small studies were identified from a total of 4065 references. Three trials with high overall risk of bias compared levosimendan to standard treatment (enoximone or dobutamine) or placebo. Data from a total of 63 participants were included in our comparisons, 31 were treated with levosimendan and 32 served as controls. Levosimendan showed an imprecise survival benefit in comparison with enoximone based on a very small trial with 32 participants (HR 0.33; 95% CI 0.11 to 0.97). Results from the other similarly small trials were too imprecise to provide any meaningful information about the effect of levosimendan in comparison with dobutamine or placebo. Only small differences in haemodynamics, length of hospital stay and the frequency of major adverse cardiac events or adverse events overall were found between study groups.Only one small randomised controlled trial with three participants was found for vasodilator strategies (nitric oxide gas versus placebo) in AMI complicated by CS or LCOS. This study was too small to draw any conclusions on the effects on our key outcomes. AUTHORS' CONCLUSIONS At present there are no robust and convincing data to support a distinct inotropic or vasodilator drug based therapy as a superior solution to reduce mortality in haemodynamically unstable patients with CS or low cardiac output complicating AMI.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburge Straße 8, Halle/Saale, Germany, 06097
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Werdan K, Russ M, Buerke M, Prondzinsky R, Dietz S. Evidence-based Management of Cardiogenic Shock After Acute Myocardial Infarction. Interv Cardiol 2013; 8:73-80. [PMID: 29588754 PMCID: PMC5808586 DOI: 10.15420/icr.2013.8.2.73] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/15/2013] [Indexed: 12/29/2022] Open
Abstract
Guidelines for evidence-based management of patients with cardiogenic shock after acute myocardial infarction focuses on early revascularisation of the occluded coronary artery as well as on support of cardiac failure and improvement of impaired organ perfusion. Also of great importance is effective treatment of shock complications, especially acute respiratory failure and other forms of multiple organ dysfunction syndrome (MODS). Cardiovascular therapy has to be accompanied by best general intensive care of these critically ill patients with high mortality. Most lives can be saved by early revascularisation, and this class I recommendation has a high level of evidence. So far, most of the other guideline recommendations are of low evidence level, in most cases based on expert opinions. Recently, the Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP SHOCK II) trial with 600 patients has shown that adjunctive IABP therapy - for long a class I recommendation - does not reduce 30-day and six-month motality.
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Percutaneous Assist Devices for Left Ventricular Shock. Interv Cardiol Clin 2013; 2:457-468. [PMID: 28582106 DOI: 10.1016/j.iccl.2013.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Percutaneous ventricular assist devices (PVADs) are increasingly being used for hemodynamic support in patients with cardiogenic shock as well as for patients undergoing high-risk cardiovascular procedures. The currently available PVADs for left ventricular shock are reviewed; the evidence for supporting PVAD use is discussed, and the authors' perspective on their unique clinical applications is offered.
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Werdan K, Ruß M, Buerke M, Delle-Karth G, Geppert A, Schöndube FA. Cardiogenic shock due to myocardial infarction: diagnosis, monitoring and treatment: a German-Austrian S3 Guideline. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:343-51. [PMID: 22675405 DOI: 10.3238/arztebl.2012.0343] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 02/24/2012] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Infarction-related cardiogenic shock (ICS) is usually due to left-ventricular pump failure. With a mortality of 30% to 80%, ICS is the most common cause of death from acute myocardial infarction. The S3 guideline presented here characterizes the current evidence-based treatment of ICS: early revascularization, treatment of shock, and intensive care treatment of multi-organ dysfunction syndrome (MODS) if it arises. The success or failure of treatment for MODS determines the outcome in ICS. METHODS Experts from eight German and Austrian specialty societies analyzed approximately 3600 publications that had been retrieved by a systematic literature search. Three interdisciplinary consensus conferences were held, resulting in the issuing of 111 recommendations and algorithms for this S3 guideline. RESULTS Early revascularization of the occluded vessel, usually with a percutaneous coronary intervention (PCI), is of paramount importance. The medical treatment of shock consists of dobutamine as the inotropic agent and norepinephrine as the vasopressor of choice and is guided by a combination of pressure and flow values, or by the cardiac power index. Levosimendan can be given in addition to treat catecholamine-resistant shock. For patients with ICS who are treated with PCI, the current S3 guideline differs from the European and American myocardial infarction guidelines with respect to the recommendation for intra-aortic balloon pulsation (IABP): Whereas the former guidelines give a class I recommendation for IABP, this S3 guideline states only that IABP "can" be used in this situation, in view of the poor state of the evidence. Only for patients being treated with systemic fibrinolysis is IABP weakly recommended (IABP "should" be used in such cases). With regard to the optimal intensive-care interventions for the prevention and treatment of MODS, recommendations are given concerning ventilation, nutrition, erythrocyte-concentrate transfusion, prevention of thrombosis and stress ulcers, follow-up care, and rehabilitation. DISCUSSION The goal of this S3 guideline is to bring together the types of treatment for ICS that lie in the disciplines of cardiology and intensive-care medicine, as patients with ICS die not only of pump failure, but also (and even more frequently) of MODS. This is the first guideline that adequately emphasizes the significance of MODS as a determinant of the outcome of ICS.
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Affiliation(s)
- Karl Werdan
- Department of Internal Medicine III, University Hospital of Halle (Saale), Germany.
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