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De Luca L, Mistrulli R, Scirpa R, Thiele H, De Luca G. Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction. J Clin Med 2023; 12:2184. [PMID: 36983185 PMCID: PMC10051785 DOI: 10.3390/jcm12062184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
- Faculty of Medicine and Dentistry, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | - Raffaella Mistrulli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Riccardo Scirpa
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, 04289 Leipzig, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20161 Milan, Italy
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2
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Suleiman T, Scott A, Tong D, Khanna V, Kunadian V. Contemporary device management of cardiogenic shock following acute myocardial infarction. Heart Fail Rev 2021; 27:915-925. [PMID: 33655387 DOI: 10.1007/s10741-021-10088-8] [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] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
Despite advances in the overall management of acute myocardial infarction (AMI), cardiogenic shock in the setting of AMI (CS-AMI) continues to be associated with poor patient outcomes. There are multiple devices that can be used in CS-AMI to support the failing circulation, although their utility in improving outcomes as compared with conventional pharmacotherapy of vasopressors and inotropes remains to be established. This contemporary review provides an update on the evidence base for each of these techniques. In CS-AMI, acute thrombotic occlusion of a major epicardial artery leads to hypoxia and myocardial ischaemia in the territory subtended by that vessel. The resultant regional dysfunction in myocardial contractility can severely compromise stroke volume and result in acute circulatory failure, systemic hypoperfusion, lactic acidosis, multi-organ failure and ultimately death.
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Affiliation(s)
- Tariq Suleiman
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Foundation Trust, Brighton, UK.
| | - Alexander Scott
- Department of Anaesthesia and Intensive Care Medicine, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Tong
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
| | - Vikram Khanna
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK. .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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3
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Uhlig K, Efremov L, Tongers J, Frantz S, Mikolajczyk R, Sedding D, Schumann J. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11:CD009669. [PMID: 33152122 PMCID: PMC8094388 DOI: 10.1002/14651858.cd009669.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. OBJECTIVES Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. SEARCH METHODS We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. 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 (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures according to Cochrane standards. MAIN RESULTS We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. AUTHORS' CONCLUSIONS At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.
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Affiliation(s)
- Konstantin Uhlig
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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Pareek N, Kordis P, Webb I, Noc M, MacCarthy P, Byrne J. Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions. ACTA ACUST UNITED AC 2019; 14:113-123. [PMID: 31867056 PMCID: PMC6918505 DOI: 10.15420/icr.2019.3.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023]
Abstract
Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation Trust London, UK.,School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust London, UK
| | - Marko Noc
- University Medical Centre Ljubljana, Slovenia
| | - Philip MacCarthy
- School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust London, UK.,School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence King's College London, UK
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Abstract
Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.
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Affiliation(s)
- Deepak Acharya
- From the Section of Advanced Heart Failure, Mechanical Circulatory Support, and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL
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Santillo E, Migale M, Massini C, Incalzi RA. Levosimendan for Perioperative Cardioprotection: Myth or Reality? Curr Cardiol Rev 2018; 14:142-152. [PMID: 29564979 PMCID: PMC6131406 DOI: 10.2174/1573403x14666180322104015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/23/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Levosimendan is a calcium sensitizer drug causing increased contractility in the myocardium and vasodilation in the vascular system. It is mainly used for the therapy of acute decompensated heart failure. Several studies on animals and humans provided evidence of the cardioprotective properties of levosimendan including preconditioning and anti-apoptotic. In view of these favorable effects, levosimendan has been tested in patients undergoing cardiac surgery for the prevention or treatment of low cardiac output syndrome. However, initial positive results from small studies have not been confirmed in three recent large trials. AIM To summarize levosimendan mechanisms of action and clinical use and to review available evidence on its perioperative use in a cardiac surgery setting. METHODS We searched two electronic medical databases for randomized controlled trials studying levosimendan in cardiac surgery patients, ranging from January 2000 to August 2017. Metaanalyses, consensus documents and retrospective studies were also reviewed. RESULTS In the selected interval of time, 54 studies on the use of levosimendan in heart surgery have been performed. Early small size studies and meta-analyses have suggested that perioperative levosimendan infusion could diminish mortality and other adverse outcomes (i.e. intensive care unit stay and need for inotropic support). Instead, three recent large randomized controlled trials (LEVO-CTS, CHEETAH and LICORN) showed no significant survival benefits from levosimendan. However, in LEVO-CTS trial, prophylactic levosimendan administration significantly reduced the incidence of low cardiac output syndrome. CONCLUSIONS Based on most recent randomized controlled trials, levosimendan, although effective for the treatment of acute heart failure, can't be recommended as standard therapy for the management of heart surgery patients. Further studies are needed to clarify whether selected subgroups of heart surgery patients may benefit from perioperative levosimendan infusion.
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Affiliation(s)
- Elpidio Santillo
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Monica Migale
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Carlo Massini
- Cardiac, Thoracic and Vascular Surgery Ward, Salus Hospital-GVM Care & Research, Reggio Emilia, Italy
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Nguyen LS, Squara P, Amour J, Carbognani D, Bouabdallah K, Thierry S, Apert-Verneuil C, Moyne A, Cholley B. Intravenous ivabradine versus placebo in patients with low cardiac output syndrome treated by dobutamine after elective coronary artery bypass surgery: a phase 2 exploratory randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:193. [PMID: 30115103 PMCID: PMC6097391 DOI: 10.1186/s13054-018-2124-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 07/10/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Low cardiac output syndrome (LCOS) is a severe condition which can occur after cardiac surgery, especially among patients with pre-existing left ventricular dysfunction. Dobutamine, its first-line treatment, is associated with sinus tachycardia. This study aims to assess the ability of intravenous ivabradine to decrease sinus tachycardia associated with dobutamine infused for LCOS after coronary artery bypass graft (CABG) surgery. METHODS In a phase 2, multi-center, single-blind, randomized controlled trial, patients with left ventricular ejection fraction below 40% presenting sinus tachycardia of at least 100 beats per minute (bpm) following dobutamine infusion for LCOS after CABG surgery received either intravenous ivabradine or placebo (three ivabradine for one placebo). Treatment lasted until dobutamine weaning or up to 48 h. The primary endpoint was the proportion of patients achieving a heart rate (HR) in the 80- to 90-bpm range. Secondary endpoints were invasive and non-invasive hemodynamic parameters and arrhythmia events. RESULTS Nineteen patients were included. More patients reached the primary endpoint in the ivabradine than in the placebo group (13 (93%) versus 2 (40%); P = 0.04). Median times to reach target HR were 1.0 h in the ivabradine group and 5.7 h in the placebo group. Ivabradine decreased HR (112 to 86 bpm, P <0.001) while increasing cardiac index (P = 0.02), stroke volume (P <0.001), and systolic blood pressure (P = 0.03). In the placebo group, these parameters remained unchanged from baseline. In the ivabradine group, five patients (36%) developed atrial fibrillation (AF) and one (7%) was discontinued for sustained AF; two (14%) were discontinued for bradycardia. CONCLUSION Intravenous ivabradine achieved effective and rapid correction of sinus tachycardia in patients who received dobutamine for LCOS after CABG surgery. Simultaneously, stroke volume and systolic blood pressure increased, suggesting a beneficial effect of this treatment on tissue perfusion. TRIAL REGISTRATION European Clinical Trials Database: EudraCT 2009-018175-14 . Registered February 2, 2010.
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Affiliation(s)
- Lee S Nguyen
- Critical Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Pierre Squara
- Critical Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Julien Amour
- Anesthesiology and Critical Care Medicine, Hôpital de la Pitié-Salpétrière, AP-HP, and Université Pierre et Marie Curie, Paris, France
| | - Daniel Carbognani
- Anesthesiology and Critical Care Medicine, Institut Mutualiste Monsouris, Paris, France
| | - Kamel Bouabdallah
- Anesthesiology and Critical Care Medicine, Institut Mutualiste Monsouris, Paris, France
| | - Stéphane Thierry
- Anesthesiology and Critical Care Medicine, Centre Cardiologique du Nord, Saint-Denis, France
| | | | - Aurélie Moyne
- Institut de Recherches Internationales Servier, Suresnes, France
| | - Bernard Cholley
- Anesthesiology and Critical Care Medicine Department, Hôpital Européen Georges Pompidou, AP-HP, and Université Paris Descartes-Sorbonne Paris Cité, Paris, France.
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Patel H, Nazeer H, Yager N, Schulman-Marcus J. Cardiogenic Shock: Recent Developments and Significant Knowledge Gaps. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:15. [PMID: 29478105 DOI: 10.1007/s11936-018-0606-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Patients with cardiogenic shock (CS) continue to have high rates of morbidity and mortality. We aimed to describe current principles in the management of CS including coronary revascularization, medical management, mechanical circulatory support, and supportive care. RECENT FINDINGS Revascularization is still recommended, but trials have not found a benefit in the revascularization of nonculprit artery lesions. New mechanical circulatory support options are available, but optimal use remains uncertain. Overall improvement in outcomes appears to have plateaued. There remain substantial knowledge gaps about the management of CS. The ideal timing and selection criteria for mechanical support remain under-developed. There has been little systematic study to inform medical management or supportive care of this patient population. A more expansive research focus is necessary to improve the care of CS.
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Affiliation(s)
- Hiren Patel
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Haider Nazeer
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Neil Yager
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA.
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9
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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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10
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Van Matre ET, Ho KC, Lyda C, Fullmer BA, Oldland AR, Kiser TH. Extended Stability of Epinephrine Hydrochloride Injection in Polyvinyl Chloride Bags Stored in Amber Ultraviolet Light-Blocking Bags. Hosp Pharm 2017; 52:570-573. [PMID: 29276291 DOI: 10.1177/0018578717721121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: The objective of this study was to evaluate the stability of epinephrine hydrochloride in 0.9% sodium chloride in polyvinyl chloride bags for up to 60 days. Methods: Dilutions of epinephrine hydrochloride to concentrations of 16 and 64 µg/mL were performed under aseptic conditions. The bags were then placed into ultraviolet light-blocking bags and stored at room temperature (23°C-25°C) or under refrigeration (3°C-5°C). Three samples of each preparation and storage environment were analyzed on days 0, 30, 45, and 60. Physical stability was performed by visual examination. The pH was assessed at baseline and upon final degradation evaluation. Sterility of the samples was not assessed. Chemical stability of epinephrine hydrochloride was evaluated using high-performance liquid chromatography. To determine the stability-indicating nature of the assay, degradation 12 months following preparation was evaluated. Samples were considered stable if there was less than 10% degradation of the initial concentration. Results: Epinephrine hydrochloride diluted to 16 and 64 µg/mL with 0.9% sodium chloride injection and stored in amber ultraviolet light-blocking bags was physically stable throughout the study. No precipitation was observed. At days 30 and 45, all bags had less than 10% degradation. At day 60, all refrigerated bags had less than 10% degradation. Overall, the mean concentration of all measurements demonstrated less than 10% degradation at 60 days at room temperature and under refrigeration. Conclusion: Epinephrine hydrochloride diluted to 16 and 64 µg/mL with 0.9% sodium chloride injection in polyvinyl chloride bags stored in amber ultraviolet light-blocking bags was stable up to 45 days at room temperature and up to 60 days under refrigeration.
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Affiliation(s)
| | - Kang C Ho
- University of Colorado Hospital, Aurora, USA
| | - Clark Lyda
- University of Colorado Hospital, Aurora, USA
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11
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Prondzinsky R, Hirsch K, Wachsmuth L, Buerke M, Unverzagt S. Vasopressors for acute myocardial infarction complicated by cardiogenic shock. Med Klin Intensivmed Notfmed 2017; 114:21-29. [DOI: 10.1007/s00063-017-0378-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/03/2017] [Accepted: 07/31/2017] [Indexed: 11/30/2022]
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12
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Price S, Platz E, Cullen L, Tavazzi G, Christ M, Cowie MR, Maisel AS, Masip J, Miro O, McMurray JJ, Peacock WF, Martin-Sanchez FJ, Di Somma S, Bueno H, Zeymer U, Mueller C. Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure. Nat Rev Cardiol 2017; 14:427-440. [PMID: 28447662 PMCID: PMC5767080 DOI: 10.1038/nrcardio.2017.56] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.
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Affiliation(s)
- Susanna Price
- Royal Brompton &Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield St &Bowen Bridge Road, Herston, Queensland 4029, Australia
| | - Guido Tavazzi
- University of Pavia Intensive Care Unit 1st Department, Fondazione Policlinico IRCCS San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Klinikum Nürnberg, Prof.-Ernst-Nathan-Straße 1, 90419 Nürnberg, Germany
| | - Martin R Cowie
- Department of Cardiology, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, California 92161, USA
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral, Hospital Sant Joan Despí Moisès Broggi and Hospital General de l'Hospitalet, University of Barcelona, Grand Via de las Corts Catalanes 585, 08007 Barcelona, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de Barcelona, Carrer de Villarroel 170, 08036 Barcelona, Spain
| | - John J McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Scurlock Tower, 1 Baylor Plaza, Houston, Texas 77030, USA
| | - F Javier Martin-Sanchez
- Emergency Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, Calle del Prof Martín Lagos, 28040 Madrid, Spain
| | - Salvatore Di Somma
- Emergency Department, Sant'Andrea Hospital, Faculty of Medicine and Psychology, LaSapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares and Department of Cardiology, Hospital 12 de Octubre, Avenida de Córdoba, 28041 Madrid, Spain
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Bremserstraße 79, 67063 Ludwigshafen am Rhein, Germany
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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Fuchs C, Ertmer C, Rehberg S. Effects of vasodilators on haemodynamic coherence. Best Pract Res Clin Anaesthesiol 2016; 30:479-489. [DOI: 10.1016/j.bpa.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
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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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Puymirat E, Fagon JY, Aegerter P, Diehl JL, Monnier A, Hauw‐Berlemont C, Boissier F, Chatellier G, Guidet B, Danchin N, Aissaoui N. Cardiogenic shock in intensive care units: evolution of prevalence, patient profile, management and outcomes, 1997–2012. Eur J Heart Fail 2016; 19:192-200. [DOI: 10.1002/ejhf.646] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/16/2016] [Accepted: 07/19/2016] [Indexed: 12/16/2022] Open
Affiliation(s)
- Etienne Puymirat
- Assistance Publique des Hôpitaux de Paris (AP‐HP)Hôpital Européen Georges Pompidou Cardiologie, and Université Paris 5 Paris France
| | - Jean Yves Fagon
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
| | - Philippe Aegerter
- AP‐HP, Hôpital Ambroise ParéUnité de Recherche Clinique et Département de Santé Publique Boulogne Billancourt France
- UVSQ, UMR‐S 1168 Université Versailles St‐Quentin‐en‐Yvelines France
- INSERM, U1168 VIMA Villejuif France
| | - Jean Luc Diehl
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
| | - Alexandra Monnier
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
| | - Caroline Hauw‐Berlemont
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
| | - Florence Boissier
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
| | - Gilles Chatellier
- AP‐HP, Hôpital Européen Georges Pompidou Unité de Recherche Clinique and Centre d'Investigation Epidémiologique 4 Paris France
| | - Bertrand Guidet
- AP‐HP, Hôpital Saint Antoine Intensive Care Unit and INSERM U444 Paris France
| | - Nicolas Danchin
- Assistance Publique des Hôpitaux de Paris (AP‐HP)Hôpital Européen Georges Pompidou Cardiologie, and Université Paris 5 Paris France
| | - Nadia Aissaoui
- AP‐HP, Hôpital Européen Georges Pompidou Intensive Care Unit and Université Paris 5 Paris France
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16
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Tarvasmäki T, Lassus J, Varpula M, Sionis A, Sund R, Køber L, Spinar J, Parissis J, Banaszewski M, Silva Cardoso J, Carubelli V, Di Somma S, Mebazaa A, Harjola VP. Current real-life use of vasopressors and inotropes in cardiogenic shock - adrenaline use is associated with excess organ injury and mortality. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:208. [PMID: 27374027 PMCID: PMC4931696 DOI: 10.1186/s13054-016-1387-1] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/14/2016] [Indexed: 01/11/2023]
Abstract
Background Vasopressors and inotropes remain a cornerstone in stabilization of the severely impaired hemodynamics and cardiac output in cardiogenic shock (CS). The aim of this study was to analyze current real-life use of these medications, and their impact on outcome and on changes in cardiac and renal biomarkers over time in CS. Methods The multinational CardShock study prospectively enrolled 219 patients with CS. The use of vasopressors and inotropes was analyzed in relation to the primary outcome, i.e., 90-day mortality, with propensity score methods in 216 patients with follow-up data available. Changes in cardiac and renal biomarkers over time until 96 hours from baseline were analyzed with linear mixed modeling. Results Patients were 67 (SD 12) years old, 26 % were women, and 28 % had been resuscitated from cardiac arrest prior to inclusion. On average, systolic blood pressure was 78 (14) and mean arterial pressure 57 (11) mmHg at detection of shock. 90-day mortality was 41 %. Vasopressors and/or inotropes were administered to 94 % of patients and initiated principally within the first 24 hours. Noradrenaline and adrenaline were given to 75 % and 21 % of patients, and 30 % received several vasopressors. In multivariable logistic regression, only adrenaline (21 %) was independently associated with increased 90-day mortality (OR 5.2, 95 % CI 1.88, 14.7, p = 0.002). The result was independent of prior cardiac arrest (39 % of patients treated with adrenaline), and the association remained in propensity-score-adjusted analysis among vasopressor-treated patients (OR 3.0, 95 % CI 1.3, 7.2, p = 0.013); this was further confirmed by propensity-score-matched analysis. Adrenaline was also associated, independent of prior cardiac arrest, with marked worsening of cardiac and renal biomarkers during the first days. Dobutamine and levosimendan were the most commonly used inotropes (49 % and 24 %). There were no differences in mortality, whether noradrenaline was combined with dobutamine or levosimendan. Conclusion Among vasopressors and inotropes, adrenaline was independently associated with 90-day mortality in CS. Moreover, adrenaline use was associated with marked worsening in cardiac and renal biomarkers. The combined use of noradrenaline with either dobutamine or levosimendan appeared prognostically similar. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1387-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tuukka Tarvasmäki
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, PO Box 340, 00029 HUS, Helsinki, Finland.
| | - Johan Lassus
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Varpula
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Reijo Sund
- Department of Social Research, Faculty of Social Sciences, Centre for Research Methods, University of Helsinki, Helsinki, Finland
| | - Lars Køber
- Rigshospitalet, Copenhagen University Hospital, Division of Heart Failure, Pulmonary Hypertension and Heart Transplantation, Copenhagen, Denmark
| | - Jindrich Spinar
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic
| | - John Parissis
- Heart Failure Clinic and Secondary Cardiology Department, Attikon University Hospital, Athens, Greece
| | - Marek Banaszewski
- Institute of Cardiology, Intensive Cardiac Therapy Clinic, Warsaw, Poland
| | - Jose Silva Cardoso
- Department of Cardiology, University of Porto, CINTESIS, Porto Medical School, São João Hospital Center, Porto, Portugal
| | - Valentina Carubelli
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Salvatore Di Somma
- Department of Medical Sciences and Translational Medicine, University of Rome Sapienza, Emergency Medicine Sant'Andrea Hospital, Rome, Italy
| | - Alexandre Mebazaa
- INSERM U942, Hopital Lariboisiere, APHP and University Paris Diderot, Paris, France
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, PO Box 340, 00029 HUS, Helsinki, Finland
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17
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Nieminen MS, Buerke M, Cohen-Solál A, Costa S, Édes I, Erlikh A, Franco F, Gibson C, Gorjup V, Guarracino F, Gustafsson F, Harjola VP, Husebye T, Karason K, Katsytadze I, Kaul S, Kivikko M, Marenzi G, Masip J, Matskeplishvili S, Mebazaa A, Møller JE, Nessler J, Nessler B, Ntalianis A, Oliva F, Pichler-Cetin E, Põder P, Recio-Mayoral A, Rex S, Rokyta R, Strasser RH, Zima E, Pollesello P. The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion. Int J Cardiol 2016; 218:150-157. [PMID: 27232927 DOI: 10.1016/j.ijcard.2016.05.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 01/09/2023]
Abstract
Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.
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Affiliation(s)
| | - Michael Buerke
- Department of Internal Medicine II, St. Marien Hospital Siegen, Siegen, Germany
| | | | - Susana Costa
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - István Édes
- Department of Cardiology, University of Debrecen, Debrecen, Hungary
| | - Alexey Erlikh
- Laboratory of Clinical Cardiology, Scientific Research Institute of Physical-Chemical Medicine, Moscow, Russia
| | - Fatima Franco
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy
| | | | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Trygve Husebye
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Igor Katsytadze
- Cardiological Intensive Care Unit, Alexandrovski Central Clinical Hospital, Kiev, Ukraine
| | - Sundeep Kaul
- Department of Intensive Care and Respiratory Medicine, The Royal Brompton & Harefield Hospitals NHS Trust, London, UK
| | - Matti Kivikko
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
| | - Giancarlo Marenzi
- Cardiological Intensive Care Unit, Cardiological Center Monzino, Milan, Italy
| | - Josep Masip
- Department of Intensive Care Medicine, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
| | - Simon Matskeplishvili
- Department of Cardiology, University Clinic, Lomonosov Moscow State University, Moscow, Russia
| | - Alexandre Mebazaa
- Department of Anaesthesia and Burn and Critical Care, Saint-Louis-Lariboisière Hospital, AP-HP, University Paris-Diderot, Paris, France
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Denmark
| | - Jadwiga Nessler
- Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Bohdan Nessler
- Jagiellonian University Medical College, Faculty of Health Sciences, Division of Rescue Medicine, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Argyrios Ntalianis
- Department of Cardiology, Alexandra General Hospital of Athens, Athens, Greece
| | - Fabrizio Oliva
- Department of Cardiology II, Niguarda Ca' Granda Hospital, Milan, Italy
| | | | - Pentti Põder
- Department of Cardiology, North Estonia Medical Center, Tallinn, Estonia
| | | | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Rokyta
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University Prague, Czech Republic
| | - Ruth H Strasser
- University of Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
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18
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Joseph J, Patterson T, Arri S, McConkey H, Redwood SR. Primary Angioplasty For Patients in Cardiogenic Shock: Optimal Management. Interv Cardiol 2016; 11:39-43. [PMID: 29588703 DOI: 10.15420/icr.2016.11.1.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cardiogenic shock complicates approximately 5-10 % of all MI events and remains the most common cause of death among MI cases. Over the past few decades, the mortality rate associated with cardiogenic shock has decreased with the introduction of early revascularisation, although there are limited data for patients with triple-vessel disease and left main stem disease. In more recent years, there have been a number of advances in the mechanical circulatory support devices that can help improve the haemodynamics of patients in cardiogenic shock. Despite these advances, together with progress in the use of inotropes and vasopressors, cardiogenic shock remains associated with high morbidity and mortality rates. This review will outline the management of cardiogenic shock complicating acute MI with a smajor focus on revascularisation techniques and the use of mechanical circulatory support devices.
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Affiliation(s)
- Jubin Joseph
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Tiffany Patterson
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Satpal Arri
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Hannah McConkey
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
| | - Simon R Redwood
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas' Hospital Campus, London, UK
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19
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Soverow J, Parikh MA. Acute Myocardial Infarction/Thrombectomy. Interv Cardiol Clin 2016; 5:259-269. [PMID: 28582209 DOI: 10.1016/j.iccl.2015.12.010] [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: 12/01/2022]
Abstract
This article focuses on specialized techniques and devices used in the most challenging cases of acute myocardial infarction. Areas where high-quality evidence is either clear or absent are avoided. Controversies in the use of support or thrombectomy devices, the addition of adjunct pharmacology, and the decision to treat nonculprit lesions are discussed. Recent years have seen a shift in guidelines to downgrading the use of assist devices in cardiogenic shock and aspiration thrombectomy, whereas consideration of nonculprit coronary intervention has been revived. These changes come in the wake of a series of large, practice-changing clinical trials.
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Affiliation(s)
- Jonathan Soverow
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA.
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA
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20
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Abstract
Heart failure (HF) can rightfully be called the epidemic of the 21(st) century. Historically, the only available medical treatment options for HF have been diuretics and digoxin, but the capacity of these agents to alter outcomes has been brought into question by the scrutiny of modern clinical trials. In the past 4 decades, neurohormonal blockers have been introduced into clinical practice, leading to marked reductions in morbidity and mortality in chronic HF with reduced left ventricular ejection fraction (LVEF). Despite these major advances in pharmacotherapy, our understanding of the underlying disease mechanisms of HF from epidemiological, clinical, pathophysiological, molecular, and genetic standpoints remains incomplete. This knowledge gap is particularly evident with respect to acute decompensated HF and HF with normal (preserved) LVEF. For these clinical phenotypes, no drug has been shown to reduce long-term clinical event rates substantially. Ongoing developments in the pharmacotherapy of HF are likely to challenge our current best-practice algorithms. Novel agents for HF therapy include dual-acting neurohormonal modulators, contractility-enhancing agents, vasoactive and anti-inflammatory peptides, and myocardial protectants. These novel compounds have the potential to enhance our armamentarium of HF therapeutics.
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Affiliation(s)
- Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital Ullevål, 0407 Oslo, Norway
| | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
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21
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[Catecholamines: pro and contra]. Med Klin Intensivmed Notfmed 2015; 111:37-46. [PMID: 25804726 DOI: 10.1007/s00063-015-0011-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/28/2014] [Accepted: 12/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Catecholamines with vasopressor and inotropic effects are commonly used in intensive care medicine. The aim of this review is to explain some of the physiologic actions on which a catecholamine therapy is based, but also to elucidate the risks which are associated with an uncritical and excessive use of these drugs. SIDE EFFECTS Emphasis is placed on the myocardial damage triggered by adrenergic overstimulation. There is considerable evidence that in conditions of severe heart failure, myocardial ischemia as well as cardiogenic and septic shock especially the use of catecholamines with predominant β-adrenergic effects (epinephrine, dobutamine, dopamine) can have a negative clinical impact. A simple cardiac risk marker might be a tachycardia. ADMINISTRATION Vasopressor therapy with norepinephrine, based on individually applied perfusion parameters (e.g., urine output, lactate), however, seems justified in many conditions of shock and hemodynamic instability during deep analgosedation. In terms of a cardioprotective therapy, the administration of catecholamines, however, should always be reevaluated and titrated to the minimum deemed necessary.
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22
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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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23
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Cremers B, Link A, Werner C, Gorhan H, Simundic I, Matheis G, Scheller B, Böhm M, Laufs U. Pulsatile Venoarterial Perfusion Using a Novel Synchronized Cardiac Assist Device Augments Coronary Artery Blood Flow During Ventricular Fibrillation. Artif Organs 2014; 39:77-82. [DOI: 10.1111/aor.12413] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bodo Cremers
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
| | - Andreas Link
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
| | - Christian Werner
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
| | | | | | | | - Bruno Scheller
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
| | - Ulrich Laufs
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin; Universitätsklinikum des Saarlandes; Homburg Germany
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24
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Husebye T, Eritsland J, Arnesen H, Bjørnerheim R, Mangschau A, Seljeflot I, Andersen GØ. Association of interleukin 8 and myocardial recovery in patients with ST-elevation myocardial infarction complicated by acute heart failure. PLoS One 2014; 9:e112359. [PMID: 25390695 PMCID: PMC4229310 DOI: 10.1371/journal.pone.0112359] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/02/2014] [Indexed: 12/03/2022] Open
Abstract
Background No data from controlled trials exists regarding the inflammatory response in patients with de novo heart failure (HF) complicating ST-elevation myocardial infarction (STEMI) and a possible role in the recovery of contractile function. We therefore explored the time course and possible associations between levels of inflammatory markers and recovery of impaired left ventricular function as well as levosimendan treatment in STEMI patients in a substudy of the LEvosimendan in Acute heart Failure following myocardial infarction (LEAF) trial. Methods A total of 61 patients developing HF within 48 hours after a primary PCI-treated STEMI were randomised double-blind to a 25 hours infusion of levosimendan or placebo. Levels of IL-6, CRP, sIL-6R, sgp130, MCP-1, IL-8, MMP-9, sICAM-1, sVCAM-1 and TNF-α were measured at inclusion (median 22 h, interquartile range (IQR) 14, 29 after PCI), on day 1, day 2, day 5 and 6 weeks. Improvement in left ventricular function was evaluated as change in wall motion score index (WMSI) by echocardiography. Results Only circulating levels of IL-8 at inclusion were associated with change in WMSI from baseline to 6 weeks, r = ÷0.41 (p = 0.002). No association, however, was found between IL-8 and WMSI at inclusion or peak troponin T. Furthermore, there was a significant difference in change in WMSI from inclusion to 6 weeks between patients with IL-8 levels below, compared to above median value, ÷0.44 (IQR÷0.57, ÷0.19) vs. ÷0.07 (IQR÷0.27, 0.07), respectively (p<0.0001). Levosimendan did not affect the levels of inflammary markers compared to control. Conclusion High levels of IL-8 in STEMI patients complicated with HF were associated with less improvement in left ventricular function during the first 6 weeks after PCI, suggesting a possible role of IL-8 in the reperfusion-related injury of post-ischemic myocardium. Further studies are needed to confirm this hypothesis. Trial Registration ClinicalTrials.gov NCT00324766
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Affiliation(s)
- Trygve Husebye
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- * E-mail: and
| | - Jan Eritsland
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Harald Arnesen
- Center for Clinical Heart Research, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Reidar Bjørnerheim
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Arild Mangschau
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Ingebjørg Seljeflot
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Clinical Heart Research, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Geir Øystein Andersen
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Clinical Heart Research, Oslo University Hospital Ullevål, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
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25
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Add-on effect of chinese herbal medicine on mortality in myocardial infarction: systematic review and meta-analysis of randomized controlled trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:675906. [PMID: 23365612 PMCID: PMC3556418 DOI: 10.1155/2013/675906] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 11/16/2012] [Indexed: 11/17/2022]
Abstract
In China, Chinese herbal medicine (CHM) is widely used as an adjunct to biomedicine (BM) in treating myocardial infarction (MI). This meta-analysis of RCTs evaluated the efficacy of combined CHM-BM in the treatment of MI, compared to BM alone. Sixty-five RCTs (12,022 patients) of moderate quality were identified. 6,036 patients were given CHM plus BM, and 5,986 patients used BM only. Combined results showed clear additional effect of CHM-BM treatment in reducing all-cause mortality (relative risk reduction (RRR) = 37%, 95% CI = 28%-45%, I(2) = 0.0%) and mortality of cardiac origin (RRR = 39%, 95% CI = 22%-52%, I(2) = 22.8). Benefits remained after random-effect trim and fill adjustment for publication bias (adjusted RRR for all-cause mortality = 29%, 95% CI = 16%-40%; adjusted RRR for cardiac death = 32%, 95% CI = 15%-46%). CHM is also found to be efficacious in lowering the risk of fatal and nonfatal cardiogenic shock, cardiac arrhythmia, myocardial reinfarction, heart failure, angina, and occurrence of total heart events. In conclusion, addition of CHM is very likely to be able to improve survival of MI patients who are already receiving BM. Further confirmatory evaluation via large blinded randomized trials is warranted.
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