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Arfaras-Melainis A, Ventoulis I, Polyzogopoulou E, Boultadakis A, Parissis J. The current and future status of inotropes in heart failure management. Expert Rev Cardiovasc Ther 2023; 21:573-585. [PMID: 37458248 DOI: 10.1080/14779072.2023.2237869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Emergency Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
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Lescroart M, Pequignot B, Janah D, Levy B. The medical treatment of cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:114-123. [PMID: 37188116 PMCID: PMC10175741 DOI: 10.1016/j.jointm.2022.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a leading cause of mortality worldwide. CS presentation and management in the current era have been widely depicted in epidemiological studies. Its treatment is codified and relies on medical care and extracorporeal life support (ECLS) in the bridge to recovery, chronic mechanical device therapy, or transplantation. Recent improvements have changed the landscape of CS. The present analysis aims to review current medical treatments of CS in light of recent literature, including addressing excitation-contraction coupling and specific physiology on applied hemodynamics. Inotropism, vasopressor use, and immunomodulation are discussed as pre-clinical and clinical studies have focused on new therapeutic options to improve patient outcomes. Certain underlying conditions of CS, such as hypertrophic or Takotsubo cardiomyopathy, warrant specifically tailored management that will be overviewed in this review.
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Affiliation(s)
- Mickael Lescroart
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Benjamin Pequignot
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Dany Janah
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
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3
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Coronary artery bypass grafting after iatrogenic coronary artery dissection: A single center eight years' experience. COR ET VASA 2023. [DOI: 10.33678/cor.2022.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Pannu A. Circulatory shock in adults in emergency department. Turk J Emerg Med 2023. [PMID: 37529784 PMCID: PMC10389095 DOI: 10.4103/2452-2473.367400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.
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Bruno RR, Wolff G, Kelm M, Jung C. Pharmacological treatment of cardiogenic shock - A state of the art review. Pharmacol Ther 2022; 240:108230. [PMID: 35697151 DOI: 10.1016/j.pharmthera.2022.108230] [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: 05/13/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.
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Affiliation(s)
- Raphael Romano Bruno
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Georg Wolff
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Duesseldorf, Germany
| | - Christian Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany.
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Bruno RR, Kelm M, Jung C. [Pharmaceutical therapy of infarct-related cardiogenic shock]. Dtsch Med Wochenschr 2022; 147:1173-1182. [PMID: 36070734 DOI: 10.1055/a-1726-0968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.
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Shankar A, Gurumurthy G, Sridharan L, Gupta D, Nicholson WJ, Jaber WA, Vallabhajosyula S. A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221075064. [PMID: 35153521 PMCID: PMC8829716 DOI: 10.1177/11795468221075064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.
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Affiliation(s)
- Aditi Shankar
- Department of Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | - Lakshmi Sridharan
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Divya Gupta
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Lim JY, Park SJ, Kim HJ, Kim HJ, Choo SJ, Chung CH, Lee JW, Park DW, Kim JB. Comparison of dopamine versus norepinephrine in circulatory shock after cardiac surgery: A randomized controlled trial. J Card Surg 2021; 36:3711-3718. [PMID: 34310744 DOI: 10.1111/jocs.15861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/31/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Although dopamine and norepinephrine are recommended as first-line agents in the treatment of shock, it is unclear which is the optimal vasoactive inotropic agent (VIA) to manage postcardiotomy circulatory shock. This single-center, randomized clinical trial aimed to investigate the efficacy and safety of dopamine versus norepinephrine in postcardiotomy circulatory shock. METHODS We randomly assigned the patients with postcardiotomy circulatory shock to receive either dopamine or norepinephrine. When shock persisted despite the dose of 20 μg/kg/min of dopamine or the dose of 0.2 μg/kg/min of norepinephrine, epinephrine or vasopressin could be added. The primary endpoint was new-onset tachyarrhythmic event during drug infusion. Secondary endpoints included requirement of additional VIAs, postoperative complications, and all-cause mortality within 30 days of drug initiation. RESULTS At the planned interim analysis of 100 patients, the boundary for the benefit of norepinephrine has been crossed, and the study was stopped early. Excluding two patients withdrawing a consent, 48 patients were assigned to dopamine and 50 patients to norepinephrine. New-onset tachyarrhythmic event occurred in 12 (25%) patients in the dopamine and one (2%) patient in the norepinephrine group (p = .009). The requirement for additional VIAs was more common in the dopamine group (p < .001). Other secondary endpoints were similar between groups. CONCLUSIONS Despite the limited study subjects with early determination, in patients with postcardiotomy circulatory shock, dopamine as a first-line vasopressor was associated with higher tachyarrhythmic events and greater need for additional VIAs compared with norepinephrine.
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Affiliation(s)
- Ju Young Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Anam Hospital, University of Korea College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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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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Abstract
PURPOSE OF REVIEW Data and interventional trials regarding vasopressor and inotrope use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In this article, we review the current use of vasopressor and inotrope agents during cardiogenic shock. RECENT FINDINGS Two recent Cochrane analyses concluded that there was not sufficient evidence to prove that any one vasopressor or inotrope was superior to another in terms of mortality. A recent RCT and a meta-analysis on individual data suggested that norepinephrine may be preferred over epinephrine in patients with cardiogenic shock . For inotrope agents, when norepinephrine fails to restore perfusion, dobutamine represents the first-line agent. Levosimendan is a calcium sensitizer agent, which improves acute hemodynamics, albeit with uncertain effects on mortality. SUMMARY When blood pressure needs to be restored, norepinephrine is a reasonable first-line agent. Dobutamine is the first-line inotrope agent wheraes levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers. Current information regarding comparative effective outcomes is nonetheless sparse and their use should be limited as a temporary bridge to recovery, mechanical circulatory support or heart transplantation.
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Succar L, Sulaica EM, Donahue KR, Wanat MA. Management of Anticoagulation with Impella® Percutaneous Ventricular Assist Devices and Review of New Literature. J Thromb Thrombolysis 2020; 48:284-291. [PMID: 30877619 DOI: 10.1007/s11239-019-01837-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cardiogenic shock is a life-threatening condition that may occur secondary to a variety of cardiac conditions, and may require temporary support with percutaneous ventricular devices like the Impella®. Anticoagulation in patients with Impella® devices can often be complicated due to unpredictable purge flow rates, pre-existing coagulopathy, or heparin allergies. The purpose of this article is to discuss the various options for anticoagulation in the setting of Impella®. The article will also describe recent updates (2014-current) in literature surrounding anticoagulation therapy for Impella® devices. At total of 228 articles were initially obtained through the PubMed search, with inclusion of 6 articles. A total of 51 patients had data in the six studies that were included in the review. Heparin for anticoagulation in the purge solution, at two different dextrose concentrations (5% and 20%), was associated with similar therapeutic activated partial thromboplastin time rates, thrombotic and bleeding events. One case series described the use of argatroban in the purge solution for anticoagulation in two patients with suspected heparin-induced thrombocytopenia, without bleeding or thrombotic complications. Pump thrombosis was not reported in any of the six studies. Anticoagulation in the setting of mechanical circulatory support devices is a challenging aspect of critical care. Institutions should have set protocols that clearly define the options for anticoagulation. Future studies that look at longer durations of support and possible operation of the Impella® device with a heparin-free purge solution are needed.
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Affiliation(s)
- Luma Succar
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Elisabeth M Sulaica
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew A Wanat
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA.
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA.
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van Dort DIM, Peij KRAH, Manintveld OC, Hoeks SE, Morshuis WJ, van Royen N, Ten Cate T, Geuzebroek GSC. Haemodynamic efficacy of microaxial left ventricular assist device in cardiogenic shock: a systematic review and meta-analysis. Neth Heart J 2019; 28:179-189. [PMID: 31811556 PMCID: PMC7113339 DOI: 10.1007/s12471-019-01351-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The Impella percutaneous mechanical circulatory support device is designed to augment cardiac output and reduce left ventricular wall stress and aims to improve survival in cases of cardiogenic shock. In this meta-analysis we investigated the haemodynamic effects of the Impella device in a clinical setting. We systematically searched all articles in PubMed/Medline and Embase up to July 2019. The primary outcomes were cardiac power (CP) and cardiac power index (CPI). Survival rates and other haemodynamic data were included as secondary outcomes. For the critical appraisal, we used a modified version of the U.S. Department of Health and Human Services quality assessment form. The systematic review included 12 studies with a total of 596 patients. In 258 patients the CP and/or CPI could be extracted. Our meta-analysis showed an increase of 0.39 W [95% confidence interval (CI): 0.24, 0.54], (p = 0.01) and 0.22 W/m2 (95% CI: 0.18, 0.26), (p < 0.01) for the CP and CPI, respectively. The overall survival rate was 56% (95% CI: 0.50, 0.62), (p = 0.09). The quality of the studies was moderate, mostly due to the presence of confounders. Our study suggests that in patients with cardiogenic shock, Impella support seems effective in augmenting CP(I). This study merely investigates the haemodynamic effectiveness of the Impella device and does not reflect the complete clinical impact for the patient.
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Affiliation(s)
- D I M van Dort
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - K R A H Peij
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - O C Manintveld
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - S E Hoeks
- Department of Anaesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - W J Morshuis
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - N van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - T Ten Cate
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - G S C Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Long L, Zhao HT, Shen LM, He C, Ren S, Zhao HL. Hemodynamic effects of inotropic drugs in heart failure: A network meta-analysis of clinical trials. Medicine (Baltimore) 2019; 98:e18144. [PMID: 31764856 PMCID: PMC6882628 DOI: 10.1097/md.0000000000018144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is currently no consensus on the appropriate selection of inotropic therapy in ventricular dysfunction. The objective of the study was to detect the effects of different inotropes on the hemodynamics of patients who developed low cardiac output. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched (all updated December 31, 2017). The inclusion criteria were as follows: low cardiac index (CI < 2.5 L/min/m) or New York Heart Association class II-IV, and at least 1 group receiving an inotropic drug compared to another group receiving a different inotropic/placebo treatment. The exclusion criteria were studies published as an abstract only, crossover studies, and studies with a lack of data on the cardiac index. RESULTS A total of 1402 patients from 37 trials were included in the study. Inotropic drugs were shown to increase the cardiac index (0.32, 95%CI:0.25, 0.38), heart rate (7.68, 95%CI:6.36, 9.01), and mean arterial pressure (3.17, 95%CI:1.96, 4.38) than the placebo. Overall, the pooled estimates showed no difference in terms of cardiac index, heart rate, mean arterial pressure, systemic vascular resistance, and mean pulmonary arterial pressure among the groups receiving different inotropes. CONCLUSIONS Our systematic review found that inotrope therapy is not associated with the amelioration of hemodynamics. An accurate evaluation of the benefits and risks, and selection of the correct inotropic agent is required in all clinical settings.
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Affiliation(s)
| | - Hao-tian Zhao
- Department of Ultrasound, Hebei General Hospital, Hebei, China
| | | | - Cong He
- Department of Intensive Care Unit
| | - Shan Ren
- Department of Intensive Care Unit
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Trindade F, Vitorino R, Leite-Moreira A, Falcão-Pires I. Pericardial fluid: an underrated molecular library of heart conditions and a potential vehicle for cardiac therapy. Basic Res Cardiol 2019; 114:10. [DOI: 10.1007/s00395-019-0716-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 12/17/2018] [Accepted: 01/08/2019] [Indexed: 12/16/2022]
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15
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Schumann J. Cochrane corner: inotropic agents and vasodilator strategies for cardiogenic shock or low cardiac output syndrome. Heart 2018; 105:178-179. [PMID: 30228252 DOI: 10.1136/heartjnl-2018-313854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Julia Schumann
- University Hospital Halle (Saale)/Martin Luther University Halle-Wittenberg, Clinic for Anesthesiology and Operative Intensive Medicine, Halle (Saale) 06112, Germany
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Abstract
Cardiogenic shock (CS) is a physiologic state in which cardiac pump function is inadequate to perfuse the tissues. If CS is not rapidly recognized and treated, tissue hypoperfusion can quickly lead to organ dysfunction and patient death. Evaluation of patients with suspected CS should include an electrocardiogram, chest radiograph, laboratory studies, and bedside echocardiogram. Initial resuscitation is directed toward restoring cardiac output and tissue perfusion. Mechanical circulatory support is indicated for patients with CS who do not respond to pharmacologic therapy. Ultimately, these patients should undergo emergent reperfusion therapy with either percutaneous coronary intervention or coronary artery bypass grafting.
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Affiliation(s)
- Semhar Z Tewelde
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Stanley S Liu
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, 110 South Paca Street 7-N-127, Baltimore, MD 21224, USA
| | - Michael E Winters
- Emergency Medicine/Internal Medicine/Critical Care Program, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Frederique G, Quenot JP, Kimmoun A, Cariou A, Lassus J, Harjola VP, Meziani F, Louis G, Rossignol P, Duarte K, Girerd N, Mebazaa A, Vignon P, Mattei M, Thivilier C, Perez P, Auchet T, Fritz C, Boisrame-Helme J, Mercier E, Garot D, Perny J, Gette S, Hammad E, Vigne C, Dargent A, Andreu P, Guiot P. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2018; 72:173-182. [DOI: 10.1016/j.jacc.2018.04.051] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/28/2022]
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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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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Rui Q, Jiang Y, Chen M, Zhang N, Yang H, Zhou Y. Dopamine versus norepinephrine in the treatment of cardiogenic shock: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2017; 96:e8402. [PMID: 29069037 PMCID: PMC5671870 DOI: 10.1097/md.0000000000008402] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Guidelines recommend that norepinephrine (NA) should be used to reach the target mean arterial pressure (MAP) during cardiogenic shock (CS), rather than epinephrine and dopamine (DA). However, there has actually been few studies on comparing norepinephrine with dopamine and their results conflicts. These studies raise a heat discussion. This study aimed to validate the effectiveness of norepinephrine for treating CS in comparison with dopamine. METHODS We performed a meta-analysis of randomized controlled trials (RCTs) to assess pooled estimates of risk ratio (RR) and 95% confidence interval (CI) for 28-day mortality, incidence of arrhythmic events, gastrointestinal reaction, and some indexes after treatment. RESULTS Compared with dopamine, patients receiving norepinephrine had a lower 28-day mortality (RR 1.611 [95% CI 1.219-2.129]; P < .001; P heterogeneity = .01), a lower risk of arrhythmic events (RR 3.426 [95% CI 2.120-5.510]; P < .001; P heterogeneity = .875) and a lower risk of gastrointestinal reaction (RR 5.474 [95% CI 2.917-10.273]; P < .001; P heterogeneity = 0). In subgroup analyses on 28-day mortality by causes of CS, there were more benefits from norepinephrine than dopamine in 2 subgroups. CONCLUSIONS Our analysis revealed that norepinephrine was associated with a lower 28-day mortality, a lower risk of arrhythmic events, and gastrointestinal reaction. No matter whether CS is caused by coronary heart disease or not, norepinephrine is superior to dopamine for correcting CS on the 28-day mortality.
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21
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Pan Y, Lu Z, Hang J, Ma S, Ma J, Wei M. Effects of Low-Dose Recombinant Human Brain Natriuretic Peptide on Anterior Myocardial Infarction Complicated by Cardiogenic Shock. Braz J Cardiovasc Surg 2017; 32:96-103. [PMID: 28492790 PMCID: PMC5409251 DOI: 10.21470/1678-9741-2016-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 11/28/2016] [Indexed: 01/22/2023] Open
Abstract
Introduction The mortality due to cardiogenic shock complicating acute myocardial
infarction (AMI) is high even in patients with early revascularization.
Infusion of low dose recombinant human brain natriuretic peptide (rhBNP) at
the time of AMI is well tolerated and could improve cardiac function. Objective The objective of this study was to evaluate the hemodynamic effects of rhBNP
in AMI patients revascularized by emergency percutaneous coronary
intervention (PCI) who developed cardiogenic shock. Methods A total of 48 patients with acute ST segment elevation myocardial infarction
(STEMI) complicated by cardiogenic shock and whose hemodynamic status was
improved following emergency PCI were enrolled. Patients were randomly
assigned to rhBNP (n=25) and control (n=23) groups. In addition to standard
therapy, study group individuals received rhBNP by continuous infusion at
0.005 µg kg−1 min−1 for 72 hours. Results Baseline characteristics, medications, and peak of cardiac troponin I (cTnI)
were similar between both groups. rhBNP treatment resulted in consistently
improved pulmonary capillary wedge pressure (PCWP) compared to the control
group. Respectively, 7 and 9 patients died in experimental and control
groups. No drug-related serious adverse events occurred in either group. Conclusion When added to standard care in stable patients with cardiogenic shock
complicating anterior STEMI, low dose rhBNP improves PCWP and is well
tolerated.
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Affiliation(s)
- Yesheng Pan
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - ZhiGang Lu
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Jingyu Hang
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Shixin Ma
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Jian Ma
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Meng Wei
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
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22
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Ko BS, Drakos SG, Welt FGP, Shah RU. Controversies and Challenges in the Management of ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock. Interv Cardiol Clin 2017; 5:541-549. [PMID: 28582002 DOI: 10.1016/j.iccl.2016.06.010] [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: 11/28/2022]
Abstract
The prognosis in ST-elevation myocardial infarction has improved with coronary care units, revascularization, and anticoagulant strategies; however, cardiogenic shock (CS) remains a highly fatal condition. Controversies remain about optimal pharmacologic therapies, revascularization strategies, the role of mechanical circulatory support (MCS), and evidence-based patient selection. The current informed consent paradigm for clinical trials creates challenges testing treatments in CS patients, who are too ill to consent and require immediate treatment. Several trials are underway comparing revascularization strategies and MCS options. Although the prognosis is grim, careful, new and existing treatments could change the course of this condition in the coming years.
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Affiliation(s)
- Byung-Soo Ko
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Frederick G P Welt
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
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Sorajja P, Borlaug BA, Dimas VV, Fang JC, Forfia PR, Givertz MM, Kapur NK, Kern MJ, Naidu SS. SCAI/HFSA clinical expert consensus document on the use of invasive hemodynamics for the diagnosis and management of cardiovascular disease. Catheter Cardiovasc Interv 2017; 89:E233-E247. [PMID: 28489331 DOI: 10.1002/ccd.26888] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/20/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Paul Sorajja
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Vasiliki V Dimas
- Childrens Health Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Paul R Forfia
- Section of Cardiology, Temple University, Philadelphia, Pennsylvania
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Navin K Kapur
- Division of Cardiology, Tufts University School of Medicine, Boston, Massachusetts
| | - Morton J Kern
- Cardiology Services, University of California Irvine, Irvine, California
| | - Srihari S Naidu
- Division of Cardiology, Westchester Medical Center, Valhalla, New York
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Sorajja P, Borlaug BA, Dimas V, Fang JC, Forfia PR, Givertz MM, Kapur NK, Kern MJ, Naidu SS. Executive summary of the SCAI/HFSA clinical expert consensus document on the use of invasive hemodynamics for the diagnosis and management of cardiovascular disease. Catheter Cardiovasc Interv 2017; 89:1294-1299. [DOI: 10.1002/ccd.27036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/25/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Paul Sorajja
- Minneapolis Heart Institute at Abbott Northwestern Hospital; Minneapolis Minnesota
| | | | - Vivian Dimas
- University of Texas Southwestern Medical Center; Dallas Texas
| | - James C. Fang
- University of Utah School of Medicine; Salt Lake City Utah
| | | | | | - Navin K. Kapur
- Tufts University School of Medicine; Boston Massachusetts
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25
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Givertz MM, Fang JC, Sorajja P, Dimas V, Forfia PR, Kapur NK, Kern MJ, Naidu SS, Borlaug BA. Executive Summary of the SCAI/HFSA Clinical Expert Consensus Document on the Use of Invasive Hemodynamics for the Diagnosis and Management of Cardiovascular Disease. J Card Fail 2017; 23:487-491. [PMID: 28454731 DOI: 10.1016/j.cardfail.2017.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/25/2017] [Indexed: 01/02/2023]
Affiliation(s)
| | - James C Fang
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Paul Sorajja
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Vivian Dimas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Navin K Kapur
- Tufts University School of Medicine, Boston, Massachusetts
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Choc cardiogénique sévère : quel régime thérapeutique médicamenteux optimal ? Intérêt de l’association vasopresseurs–inotropes avec effet vasodilatateur. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1260-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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: 37] [Impact Index Per Article: 4.6] [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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