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Costa YC, Delfino F, Mauro V, Charask A, Fairman E, Macín SM, Perea J, D'Imperio H, Fernández A, Barrero C. ARGEN SHOCK: Mortality related to the use of Swan Ganz and to the hemodynamic pattern found in patients with AMICS. Curr Probl Cardiol 2024; 49:102418. [PMID: 38281675 DOI: 10.1016/j.cpcardiol.2024.102418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/30/2024]
Abstract
The Swan Ganz Catheter (SGC) allows us to diagnose different types of cardiogenic shock (CS). OBJECTIVES 1) Determine the frequency of use of SGC, 2) Analyze the clinical characteristics and mortality according to its use and 3) Analyze the prevalence, clinical characteristics and mortality according to the type of Shock. METHODS The 114 patients (p) from the ARGEN SHOCK registry were analyzed. A "classic" pattern was defined as PCP > 15 mm Hg, CI < 2.2 L/min/ m2, SVR > 1,200 dynes × sec × cm-5. A "vasoplegic/mixed" pattern was defined when p did not meet the classic definition. CS due to right ventricle (RV) was excluded. RESULTS SGC was used in 35 % (n:37). There were no differences in clinical characteristics according to SGC use, but those with SGC were more likely to receive dobutamine, levosimendan, and intra aortic balloon pump (IABP). Mortality was similar (59.4 % vs 61.3 %). The pattern was "classic" in 70.2 %. There were no differences in clinical characteristics according to the type of pattern or the drugs used. Mortality was 54 % in patients with the classic pattern and 73 % with the mixed/vasoplegic pattern, but the difference did not reach statistical significance (p:0.23). CONCLUSIONS SGC is used in one third of patients with CS. Its use does not imply differences in the drugs used or in mortality. Most patients have a classic hemodynamic pattern. There are no differences in mortality or in the type of vasoactive agents used according to the CS pattern found.
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Affiliation(s)
| | - Flavio Delfino
- Research Area- Argentine Society of Cardiology, Argentina
| | - Víctor Mauro
- Research Area- Argentine Society of Cardiology, Argentina
| | - Adrián Charask
- Research Area- Argentine Society of Cardiology, Argentina
| | | | | | - Joaquín Perea
- Research Area- Argentine Society of Cardiology, Argentina
| | | | | | - Carlos Barrero
- Research Area- Argentine Society of Cardiology, Argentina
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Riccardi M, Pagnesi M, Chioncel O, Mebazaa A, Cotter G, Gustafsson F, Tomasoni D, Latronico N, Adamo M, Metra M. Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors. Eur J Heart Fail 2024; 26:411-431. [PMID: 38391010 DOI: 10.1002/ejhf.3162] [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: 10/05/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/24/2024] Open
Abstract
Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity. Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock, although its contribution has declined over the past two decades, compared with other causes. Despite some advances in cardiogenic shock management, this clinical syndrome is still burdened by an extremely high mortality. Its management is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished. With these aims, medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role. The purpose of this article is to review current evidence on the use of these medications in patients with cardiogenic shock and discuss specific clinical settings with indications to their use.
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Affiliation(s)
- Mauro Riccardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | - Alexandre Mebazaa
- Université Paris Cité, Inserm MASCOT, AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, Paris, France
| | | | - Finn Gustafsson
- Heart Centre, Department of Cardiology, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Brescia, Italy
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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3
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Jentzer JC, Pöss J, Schaubroeck H, Morrow DA, Hollenberg SM, Mebazaa A. Advances in the Management of Cardiogenic Shock. Crit Care Med 2023; 51:1222-1233. [PMID: 37184336 DOI: 10.1097/ccm.0000000000005919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVES To review a contemporary approach to the management of patients with cardiogenic shock (CS). DATA SOURCES We reviewed salient medical literature regarding CS. STUDY SELECTION We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials. DATA EXTRACTION We extracted salient study results and scientific statement recommendations regarding the management of CS. DATA SYNTHESIS Professional society recommendations were integrated with evaluated studies. CONCLUSIONS CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Janine Pöss
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Alexandre Mebazaa
- Department of Anesthesia & Critical Care, Université Paris Cité, APHP, Inserm MASCOT, FHU PROMICE, Paris, France
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4
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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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Tavazzi G, Rossello X, Grand J, Gierlotka M, Sionis A, Ahrens I, Hassager C, Price S. Epidemiology, monitoring, and treatment strategy in cardiogenic shock. A multinational cross-sectional survey of ESC-acute cardiovascular care association research section. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:706-711. [PMID: 35941730 DOI: 10.1093/ehjacc/zuac087] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/26/2022] [Accepted: 07/10/2022] [Indexed: 11/13/2022]
Abstract
AIMS Cardiogenic shock (CS) is a life-threatening condition burdened by mortality in up to 50% of cases. Few recommendations exist with intermediate-low level of evidence on CS management and no data on adherence across centres exist. We performed a survey to frame CS management at multinational level. METHODS AND RESULTS An international cross-sectional survey was created and approved by European Society of Cardiology-Acute Cardiovascular Care Association board. A total of 337 responses from 60 countries were obtained. Data were assessed by the hospital level of care of the participants. The most common cause of CS was AMI (AMI-CS-79.9%) with significant difference according to hospital levels (P = 0.001), followed by acutely decompensated heart failure (HF) (13.4%), myocarditis (3.5%), and de novo HF (1.75%). In 37.8%, percutaneous coronary intervention (PCI) is performed to all CS-patients as a standard approach, whereas 42.1% used PCI if electrocardiogram suggestive of ischaemia and 20.1% only if Universal definition of myocardial infarction criteria are fulfilled. Management (catecholamine titration and mechanical circulatory support escalation) is driven by mean arterial pressure (87.1%), echocardiography (84.4%), and lactate levels (83.4%). Combination of vasopressor and inotrope is chosen with the same frequency (37.7%) than inotrope alone as first-line pharmacological therapy (differences amongst hospital levels; P > 0.5). Noradrenaline is first-line vasopressor (89.9%) followed by dopamine (8.5%), whereas dobutamine is confirmed as the first-line inotrope (65.9%). CONCLUSION Cardiogenic shock management is heterogenous and often not adherent to current recommendations. Quality improvement on an international level with evidence-based quality indicators should be developed to standardize diagnostic and therapeutic pathways.
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Affiliation(s)
- Guido Tavazzi
- Department of Medical, Surgical, Diagnostic and Pediatric Science, University of Pavia, Pavia, Italy.,Anesthesiology and Intensive Care Unit, 18631 Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Facultat de Medicina, Universitat de les Illes Balears (UIB), Palma, Illes Balears, Spain
| | - Johannes Grand
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marek Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Alessandro Sionis
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu I Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Jakobstreet 27-31, Cologne 50678, Germany
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanna Price
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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Udesen NLJ, Helgestad OKL, Josiassen J, Hassager C, Højgaard HF, Linde L, Kjaergaard J, Holmvang L, Jensen LO, Schmidt H, Ravn HB, Møller JE. Vasoactive pharmacological management according to SCAI class in patients with acute myocardial infarction and cardiogenic shock. PLoS One 2022; 17:e0272279. [PMID: 35925990 PMCID: PMC9352108 DOI: 10.1371/journal.pone.0272279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 07/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background Vasoactive treatment is a cornerstone in treating hypoperfusion in cardiogenic shock following acute myocardial infarction (AMICS). The purpose was to compare the achievement of treatment targets and outcome in relation to vasoactive strategy in AMICS patients stratified according to the Society of Cardiovascular Angiography and Interventions (SCAI) shock classification. Methods Retrospective analysis of patients with AMICS admitted to cardiac intensive care unit at two tertiary cardiac centers during 2010–2017 with retrieval of real-time hemodynamic data and dosages of vasoactive drugs from intensive care unit databases. Results Out of 1,249 AMICS patients classified into SCAI class C, D, and E, mortality increased for each shock stage from 34% to 60%, and 82% (p<0.001). Treatment targets of mean arterial blood pressure > 65mmHg and venous oxygen saturation > 55% were reached in the majority of patients; however, more patients in SCAI class D and E had values below treatment targets within 24 hours (p<0.001) despite higher vasoactive load and increased use of epinephrine for each severity stage (p<0.001). In univariate analysis no significant difference in mortality within SCAI class D and E regarding vasoactive strategy was observed, however in SCAI class C, epinephrine was associated with higher mortality and a significantly higher vasoactive load to reach treatment targets. In multivariate analysis there was no statistically association between individually vasoactive choice within each SCAI class and 30-day mortality. Conclusion Hemodynamic treatment targets were achieved in most patients at the expense of increased vasoactive load and more frequent use of epinephrine for each shock severity stage. Mortality was high regardless of vasoactive strategy; only in SCAI class C, epinephrine was associated with a significantly higher mortality, but the signal was not significant in adjusted analysis.
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Affiliation(s)
| | | | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Henrik Schmidt
- Department of Cardiothoracic Anesthesia, Odense University Hospital, Odense, Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anesthesia, Odense University Hospital, Odense, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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8
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Role of medical management of cardiogenic shock in the era of mechanical circulatory support. Curr Opin Cardiol 2022; 37:250-260. [PMID: 35612937 DOI: 10.1097/hco.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize the current knowledge on the role of medical management of cardiogenic shock in the era of mechanical circulatory support based on important lessons from clinical trials and routine clinical practice, with a focus on providing practical recommendations that can improve contemporary in-hospital management. RECENT FINDINGS Despite an increasing number of invasive therapies being used to manage cardiogenic shock, evidence-based treatment regimens known to improve outcomes are limited. Medical management of cardiogenic shock includes pharmacological interventions aimed at optimizing determinants of cardiac output-contractility, preload, afterload, and heart rate. In this regard, inotropes and vasopressors remain cornerstone therapies for the management of cardiogenic shock. Norepinephrine has shown potential vasopressor advantage with compared with dopamine, and although milrinone and dobutamine are both considered appropriate first-line inotropes, there is limited data to guide selection, and a recent randomized clinical trial found no significant differences in the treatment of cardiogenic shock. SUMMARY In the absence of an evidence-based management approach to cardiogenic shock, clinical guidelines are based on expert opinion and routine clinical practice patterns. Further studies focusing on clinical outcomes among specific cardiogenic shock phenotypes are needed to better assess the clinical efficacy of these agents.
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9
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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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10
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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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11
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Kaddoura R, Elmoheen A, Badawy E, Eltawagny MF, Seif MA, Bashir K, Salam AM. Vasoactive pharmacologic therapy in cardiogenic shock: a critical review. J Drug Assess 2021; 10:68-85. [PMID: 34350058 PMCID: PMC8293961 DOI: 10.1080/21556660.2021.1930548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality. Vasoactive medications, such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output (CO) and blood pressure (BP), thus preventing multiorgan failure. Objective A critical review was conducted to analyze the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. Methods PubMed database search was conducted to identify randomized controlled trials (RCTs) on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. Results Nine studies randomized 2388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction (AMI). The studies evaluated the comparisons of norepinephrine (NE) vs. dopamine, epinephrine vs. NE, levosimendan vs. dobutamine, enoximone or placebo, and nitric oxide synthase inhibitors (NOSi) vs. placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. Conclusions The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.
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Affiliation(s)
- Rasha Kaddoura
- Heart Hospital Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Ehab Badawy
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed A Seif
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Amar M Salam
- College of Medicine, QU Health, Qatar University, Doha, Qatar.,Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
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12
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Abstract
PURPOSE OF REVIEW To discuss the use of vasopressors and inotropes in cardiogenic shock. RECENT FINDINGS The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial. SUMMARY Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.
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13
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Carsetti A, Bignami E, Cortegiani A, Donadello K, Donati A, Foti G, Grasselli G, Romagnoli S, Antonelli M, DE Blasio E, Forfori F, Guarracino F, Scolletta S, Tritapepe L, Scudeller L, Cecconi M, Girardis M. Good clinical practice for the use of vasopressor and inotropic drugs in critically ill patients: state-of-the-art and expert consensus. Minerva Anestesiol 2021; 87:714-732. [PMID: 33432794 DOI: 10.23736/s0375-9393.20.14866-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Vasopressors and inotropic agents are widely used in critical care. However, strong evidence supporting their use in critically ill patients is lacking in many clinical scenarios. Thus, the Italian Society of Anesthesia and Intensive Care (SIAARTI) promoted a project aimed to provide indications for good clinical practice on the use of vasopressors and inotropes, and on the management of critically ill patients with shock. A panel of 16 experts in the field of intensive care medicine and hemodynamics has been established. Systematic review of the available literature was performed based on PICO questions. Basing on available evidence, the panel prepared a summary of evidence and then wrote the clinical questions. A modified semi-quantitative RAND/UCLA appropriateness method has been used to determine the appropriateness of specific clinical scenarios. The panel identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock. High level of agreement exists among the panel members about appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock.
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Affiliation(s)
- Andrea Carsetti
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy - .,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy -
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, Section of Anesthesia, Analgesia, Intensive Care and Emergency, Paolo Giaccone Polyclinic Hospital, University of Palermo, Palermo, Italy
| | - Katia Donadello
- Anesthesia and Intensive Care B Unit, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Careggi University Hospital, Florence, Italy
| | - Massimo Antonelli
- Department of Anesthesiology Emergency and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Francesco Forfori
- Department of Anesthesia and Intensive Care, University of Pisa, Pisa Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Pisana University Hospital, Pisa, Italy
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luigi Tritapepe
- Anesthesia and Intensive Care Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luigia Scudeller
- Scientific Direction, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Milan, Italy and Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, Modena University Hospital, Modena, Italy
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14
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Sazgar M, Golikhatir I, Pashaee SM, Tirandaz F, Firouzian A, miniahidashti H. Norepinephrine with dopamine infusion on the end-tidal carbon dioxide (ETco2) pressure in patients with septic shock. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:580-585. [PMID: 34820066 PMCID: PMC8590414 DOI: 10.22088/cjim.12.4.580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/24/2020] [Accepted: 01/05/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Septic shock is a critical medical condition and immediate intervention is required as well as hemodynamic stability using fluid and vasopressor. Direct relationship between changes in ETco2 and changes in the cardiac output. We evaluated the study by comparing the effect of using norepinephrine or dopamine on ETco2 of patients with septic shock. METHODS A clinical trial study was performed on 138 patients with primary diagnosis of septic shock. 70 patients received norepinephrine and 68 patients received dopamine. Patients' end tidal carbon dioxide (ETco2), mean arterial pressure (MAP), pulse rate (PR), arterial blood gas (ABG) levels in two groups were measured and compared at baseline and after 30 and 120 minutes after inotrope infusion. Variables were compared by means of an unpaired student t-test, an unadjusted chi-square test. RESULTS 138 patients, 70 treated with norepinephrine infusion and 68 with dopamine infusion were included in the study. ETco2 level significantly increased within 120 minutes of treatment in the norepinephrine group (31.10±9.65) compared to the dopamine group (23.71±9.66) (P=0.001). MAP significantly decreased in the group of norepinephrine 30 minutes after treatment (71.71±20.460) (P=0.014) and pulse rate also significantly decreased in the norepinephrine group compared to the dopamine group in 30 minutes (98.07±10.63 vs 106.43±13.54) and 120 minutes (91.15±6.18 vs 103.51±2057) after treatment (P=0.001). CONCLUSION Tissue perfusion and fluid responsiveness of the shock in the norepinephrine group showed improvement. Using ETco2 as a measure for determining volume assessment in patients undergoing mechanical ventilation by septic shock is applicable.
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Affiliation(s)
- Mohammad Sazgar
- Department of Emergency Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Iraj Golikhatir
- Department of Emergency Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Fatemeh Tirandaz
- Department of Emergency Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abolfazl Firouzian
- Department of Anesthesiology, Division of Intensive Care Unit, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamed miniahidashti
- Department of Emergency Medicine, Mazandaran University of Medical Sciences, Sari, Iran,Correspondence: Hamed Aminiahidashti; Imam Khomeini Hospital, Amirmazandari Bolivar, Sari, Iran. E-mail: , Tel: 0098 1133361700, Fax: 0098 1133361700
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15
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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
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16
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Li CJ, Wu KH, Chen CC, Law YY, Chuang PC, Chen YC. Comparison of Dopamine and Norepinephrine Use for the Treatment of Hypotension in Out-Of-Hospital Cardiac Arrest Patients with Return of Spontaneous Circulation. Emerg Med Int 2020; 2020:7951025. [PMID: 38264544 PMCID: PMC10805545 DOI: 10.1155/2020/7951025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 01/25/2024] Open
Abstract
In patients experiencing out-of-hospital cardiac arrest (OHCA), hypotension is common after return of spontaneous circulation (ROSC). Both dopamine and norepinephrine are recommended as inotropic therapeutic agents. This study aimed to determine the impact of the use of these two medications on hypotension. This is a multicenter retrospective cohort study. OHCA patients with ROSC were divided into three groups according to the post resuscitation inotropic agent used for treatment in the emergency department, namely, dopamine, norepinephrine, and dopamine and norepinephrine combined therapy. Thirty-day survival and favorable neurologic performance were analyzed among the three study groups. The 30-day survival and favorable neurologic performance rates in the three study groups were 12.5%, 13.0%, and 6.8% as well as 4.9%, 4.3%, and 1.2%, respectively. On controlling the potential confounding factors by logistic regression, there was no difference between dopamine and norepinephrine treatment in survival and neurologic performance (adjusted odds ratio (aOR): 1.0, 95% confidence interval (CI) 0.48-2.06; aOR: 0.8, 95% CI: 0.28-2.53). The dopamine and norepinephrine combined treatment group had worse outcome (aOR: 0.6, 95% CI: 0.35-1.18; aOR: 0.2, 95% CI: 0.05-0.89). In conclusion, there was no significant difference in post-ROSC hypotension treatment between dopamine and norepinephrine in 30-day survival and favorable neurologic performance rates.
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Affiliation(s)
- Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Chih Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yat-Yin Law
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Orthopedics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6 W. Sec., Jiapu Rd., Puzih, Chiayi County 613, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
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17
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Chioncel O, Parissis J, Mebazaa A, Thiele H, Desch S, Bauersachs J, Harjola V, Antohi E, Arrigo M, Gal TB, Celutkiene J, Collins SP, DeBacker D, Iliescu VA, Jankowska E, Jaarsma T, Keramida K, Lainscak M, Lund LH, Lyon AR, Masip J, Metra M, Miro O, Mortara A, Mueller C, Mullens W, Nikolaou M, Piepoli M, Price S, Rosano G, Vieillard‐Baron A, Weinstein JM, Anker SD, Filippatos G, Ruschitzka F, Coats AJ, Seferovic P. Epidemiology, pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1315-1341. [DOI: 10.1002/ejhf.1922] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - John Parissis
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
- National Kapodistrian University of Athens Medical School Athens Greece
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP Paris France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Johann Bauersachs
- Department of Cardiology & Angiology, Hannover Medical School Hannover Germany
| | - Veli‐Pekka Harjola
- Emergency Medicine University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Elena‐Laura Antohi
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Mattia Arrigo
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Tuvia B. Gal
- Department of Cardiology, Rabin Medical Center Petah Tiqwa Israel
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University Vilnius Lithuania
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Daniel DeBacker
- Department of Intensive Care CHIREC Hospitals, Université Libre de Bruxelles Brussels Belgium
| | - Vlad A. Iliescu
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Ewa Jankowska
- Department of Heart Disease Wroclaw Medical University, University Hospital, Center for Heart Disease Wroclaw Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences Linköping University Linköping Sweden
- Julius Center University Medical Center Utrecht Utrecht The Netherlands
| | - Kalliopi Keramida
- National Kapodistrian University of Athens Medical School Athens Greece
- Department of Cardiology Attikon University Hospital Athens Greece
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota Murska Sobota Slovenia
- Faculty of Medicine, University of Ljubljana Ljubljana Slovenia
| | - Lars H Lund
- Heart and Vascular Theme, Karolinska University Hospital Stockholm Sweden
- Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Alexander R. Lyon
- Imperial College London National Heart & Lung Institute London UK
- Royal Brompton Hospital London UK
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona Barcelona Spain
- Hospital Sanitas CIMA Barcelona Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University of Brescia Brescia Italy
| | - Oscar Miro
- Emergency Department Hospital Clinic, Institut d'Investigació Biomèdica August Pi iSunyer (IDIBAPS) Barcelona Spain
- University of Barcelona Barcelona Spain
| | - Andrea Mortara
- Department of Cardiology Policlinico di Monza Monza Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Basel Switzerland
| | - Wilfried Mullens
- Department of Cardiology Ziekenhuis Oost Genk Belgium
- Biomedical Research Institute Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek Belgium
| | - Maria Nikolaou
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, Emergency Department Guglielmo da Saliceto Hospital, Piacenza, University of Parma; Institute of Life Sciences, Sant'Anna School of Advanced Studies Pisa Italy
| | - Susana Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust London UK
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana Rome Italy
| | - Antoine Vieillard‐Baron
- INSERM U‐1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ Villejuif France
- University Hospital Ambroise Paré, AP‐, HP Boulogne‐Billancourt France
| | - Jean M. Weinstein
- Cardiology Department Soroka University Medical Centre Beer Sheva Israel
| | - Stefan D. Anker
- Department of Cardiology (CVK) Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin Berlin Germany
- Charité Universitätsmedizin Berlin Germany
| | - Gerasimos Filippatos
- University of Athens, Heart Failure Unit, Attikon University Hospital Athens Greece
- School of Medicine, University of Cyprus Nicosia Cyprus
| | - Frank Ruschitzka
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- Pharmacology, Centre of Clinical and Experimental Medicine IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine University of Belgrade Belgrade, Serbia
- Serbian Academy of Sciences and Arts Belgrade Serbia
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18
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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19
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Jentzer JC, Hollenberg SM. Vasopressor and Inotrope Therapy in Cardiac Critical Care. J Intensive Care Med 2020; 36:843-856. [PMID: 32281470 DOI: 10.1177/0885066620917630] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven M Hollenberg
- Department of Cardiology, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Temporal Trends and Clinical Outcomes Associated with Vasopressor and Inotrope Use in The Cardiac Intensive Care Unit. Shock 2020; 53:452-459. [DOI: 10.1097/shk.0000000000001390] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Radu RI, Ahmed A, Antohi EL, Masip J, Butler J, Iliescu VA. Therapeutic Advances in the Management of Cardiogenic Shock. Am J Ther 2019; 26:e234-e247. [PMID: 30839372 PMCID: PMC6404765 DOI: 10.1097/mjt.0000000000000920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS. AREAS OF UNCERTAINTY Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies. DATA SOURCES The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study. THERAPEUTIC ADVANCES Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes. CONCLUSIONS Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.
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Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine and Indianapolis EMS, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Razvan I Radu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Ali Ahmed
- Veteran Affairs Medical Center and George Washington University, Washington DC, USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Josep Masip
- Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain; Department of Intensive Care, Consorci Sanitari Integral, Barcelona, Spain
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MI, USA
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
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Hiemstra B, Koster G, Wetterslev J, Gluud C, Jakobsen JC, Scheeren TWL, Keus F, van der Horst ICC. Dopamine in critically ill patients with cardiac dysfunction: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2019; 63:424-437. [PMID: 30515766 PMCID: PMC6587868 DOI: 10.1111/aas.13294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/18/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023]
Abstract
Background Dopamine has been used in patients with cardiac dysfunction for more than five decades. Yet, no systematic review has assessed the effects of dopamine in critically ill patients with cardiac dysfunction. Methods This systematic review was conducted following The Cochrane Handbook for Systematic Reviews of Interventions. We searched for trials including patients with observed cardiac dysfunction published until 19 April 2018. Risk of bias was evaluated and Trial Sequential Analyses were conducted. The primary outcome was all‐cause mortality at longest follow‐up. Secondary outcomes were serious adverse events, myocardial infarction, arrhythmias, and renal replacement therapy. We used GRADE to assess the certainty of the evidence. Results We identified 17 trials randomising 1218 participants. All trials were at high risk of bias and only one trial used placebo. Dopamine compared with any control treatment was not significantly associated with relative risk of mortality (60/457 [13%] vs 90/581 [15%]; RR 0.91; 95% confidence interval 0.68‐1.21) or any other patient‐centred outcomes. Trial Sequential Analyses of all outcomes showed that there was insufficient information to confirm or reject our anticipated intervention effects. There were also no statistically significant associations for any of the outcomes in subgroup analyses by type of comparator (inactive compared to potentially active), dopamine dose (low compared to moderate dose), or setting (cardiac surgery compared to heart failure). Conclusion Evidence for dopamine in critically ill patients with cardiac dysfunction is sparse, of low quality, and inconclusive. The use of dopamine for cardiac dysfunction can neither be recommended nor refuted.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Geert Koster
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Janus C. Jakobsen
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - Thomas W. L. Scheeren
- Department of Anesthesiology; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Frederik Keus
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
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Najarro G, Briggs K. Acute Myocardial Infarction, Cardiac Arrest, and Cardiac Shock in the Cardiac Care Unit. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med 2018; 55:635-646. [DOI: 10.1016/j.jemermed.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/09/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022]
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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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