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Varma B, Katz JN, Alviar CL. Building a cardiogenic shock response team: key considerations necessary to improve outcomes. Curr Opin Crit Care 2024; 30:354-361. [PMID: 38872365 DOI: 10.1097/mcc.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
PURPOSE OF REVIEW This review provides key information about cardiogenic shock (CS) teams, including published evidence and practical recommendations to create a CS team and program. RECENT FINDINGS CS is a complex disease process with a high in-hospital mortality rate ranging from 30% to 70% according to recent registries and randomized studies. The explanation for the elevated rates is likely multifactorial, including the various etiologies of cardiogenic shock as well as delays in recognition and deployment of appropriate therapies. Accordingly, the use of cardiogenic shock team has been implemented with the aim of improving outcomes in these patients. The CS team typically consists of members with critical care or cardiac critical care expertise, heart failure, cardiothoracic surgery, and interventional cardiology. A number of retrospective studies have now supported the benefits of a CS team, particularly in selecting the appropriate candidates for tailored mechanical circulatory support therapies and providing interventions in a timely manner, which have translated into improved outcomes. SUMMARY CS teams provides a platform for expedited recognition of CS and timely, standardized, and multidisciplinary discussions regarding appropriate management and care.
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Affiliation(s)
- Bhavya Varma
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
| | - Jason N Katz
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
- Bellevue Hospital Center, New York, New York, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
- Bellevue Hospital Center, New York, New York, USA
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2
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Kayali F, Agbobu T, Moothathamby T, Jubouri YF, Jubouri M, Abdelhaliem A, Ghattas SNS, Rezk SSS, Bailey DM, Williams IM, Awad WI, Bashir M. Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support. Expert Rev Med Devices 2024; 21:755-764. [PMID: 39087797 DOI: 10.1080/17434440.2024.2380330] [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: 01/31/2024] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices. AREAS COVERED This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes. EXPERT OPINION Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy.
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Affiliation(s)
- Fatima Kayali
- University Hospitals Sussex N.H.S. Foundation Trust, Sussex, UK
| | | | - Thurkga Moothathamby
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Amr Abdelhaliem
- Vascular and Endovascular Surgery, Royal Blackburn Hospital, Blackburn, UK
| | | | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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Diaz-Arocutipa C, Moreno G, Gil DG, Nieto S, Romo M, Vicent L. EFFECT OF PULMONARY ARTERY CATHETERIZATION IN PATIENTS WITH NONISCHEMIC CARDIOGENIC SHOCK: A NATIONWIDE ANALYSIS. Shock 2024; 62:186-192. [PMID: 38661168 DOI: 10.1097/shk.0000000000002371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
ABSTRACT Background: Pulmonary artery catheterization (PAC) has been widely used in critically ill patients, yielding mixed results. Prior studies on cardiogenic shock (CS) predominantly included patients with acute myocardial infarction. This study aims to examine the effect of PAC use in patients with nonischemic CS. Methods: This retrospective cohort study employed data from the National Inpatient Sample database, including weighted hospitalizations of adult patients with nonischemic CS during 2017 to 2019. In-hospital outcomes were compared between groups using inverse probability of treatment weighting. Results: A total of 303,970 patients with nonischemic CS were included, of whom 17.5% received a PAC during their hospitalization. The median age was 67 years (interquartile range: 57-77) and 61% were male. After inverse probability of treatment weighting, patients in the PAC group had significantly lower in-hospital mortality (24.8% vs. 35.3%, P < 0.001), renal replacement therapy (10.7% vs. 12.4%, P = 0.002), in-hospital cardiac arrest (7.1% vs. 9.6%, P < 0.001), and mechanical ventilation (44.6% vs. 50.4%, P < 0.001) compared to non-PAC group. In contrast, the PAC group had higher use of intra-aortic balloon pump (15.4% vs. 3.4%, P < 0.001), percutaneous ventricular assist devices (12.6% vs. 2.6%, P < 0.001), extracorporeal membrane oxygenation (3.9% vs. 2.5%, P < 0.001), and heart transplantation (2.1% vs. 0.4%, P < 0.001). Conclusion: In the real-world setting, invasive hemodynamic monitoring with PAC in patients with nonischemic CS is associated with survival benefits and a reduction in adverse events, including reduced need for renal replacement therapy, mechanical ventilation and risk of in-hospital cardiac arrest.
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Affiliation(s)
- Carlos Diaz-Arocutipa
- Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Perú
| | | | - David Galán Gil
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Sara Nieto
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Martín Romo
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, España
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El Hussein MT, Mushaluk C. Cardiogenic Shock: An Overview. Crit Care Nurs Q 2024; 47:243-256. [PMID: 38860953 DOI: 10.1097/cnq.0000000000000513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Cardiogenic shock (CS) is a complex and dreadful condition for which effective treatments remain unclear. The concerningly high mortality rate of CS emphasizes a need for developing effective therapies to reduce its mortality and reverse its detrimental course. This article aims to provide an updated and evidence-based review of the pathophysiology of CS and the related pharmacotherapeutics with a special focus on vasoactive and inotropic agents.
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Affiliation(s)
- Mohamed Toufic El Hussein
- Author Affiliations: School of Nursing and Midwifery, Faculty of Health, Community & Education, Mount Royal University, Calgary, Canada (Dr El Hussein and Ms Mushaluk);Faculty of Nursing, University of Alberta (Dr El Hussein); and Acute Care Nurse Practitioner Medical Cardiology, Coronary Care Unit - Rockyview General Hospital, Calgary, Alberta, Canada (Dr El Hussein)
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5
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Saha A, Li S, de Lemos JA, Pandey A, Bhatt DL, Fonarow GC, Nallamothu BK, Wang TY, Navar AM, Peterson E, Matsouaka RA, Bavry AA, Das SR, Grodin JL, Khera R, Drazner MH, Kumbhani DJ. Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction. Am J Cardiol 2024; 221:19-28. [PMID: 38583700 DOI: 10.1016/j.amjcard.2024.04.002] [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: 10/21/2023] [Revised: 03/06/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the National Cardiovascular Data Registry's Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66 (interquartile range 57 to 75) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.
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Affiliation(s)
- Amit Saha
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shuang Li
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James A de Lemos
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ann Marie Navar
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Peterson
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anthony A Bavry
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sandeep R Das
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Justin L Grodin
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rohan Khera
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Biostatistics, Section of Health Informatics, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mark H Drazner
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Dharam J Kumbhani
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Merdler I, Case BC, Pahuja M, Hayat F, Isaac I, Gadodia R, Chitturi KR, Reddy PK, Cellamare M, Ben-Dor I, Waksman R. Is there additional value in adding Impella to veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00485-8. [PMID: 38782613 DOI: 10.1016/j.carrev.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Mohit Pahuja
- Section of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Fatima Hayat
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Imad Isaac
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ritika Gadodia
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Pavan K Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Matteo Cellamare
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
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7
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Warren A, McCall P, Proudfoot A, Gillon S, Abu-Arafeh A, McKnight AJ, Mudie R, Armstrong D, Tzolos E, Livesey JA, Sinclair A, Baston V, Dalzell J, Owen D, Fleming L, Scott I, Puxty A, Lee MMY, Walker F, Hobson S, Campbell E, Kinsella M, McGinnigle E, Docking R, Price G, Ramsay A, Bauld R, Herron S, Lone NI, Mills NL, Hartley L. EPidemiology Of Cardiogenic sHock in Scotland (EPOCHS): A multicentre, prospective observational study of the prevalence, management and outcomes of cardiogenic shock in Scotland. J Intensive Care Soc 2024; 25:147-155. [PMID: 38737313 PMCID: PMC11086715 DOI: 10.1177/17511437231217877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background Despite high rates of cardiovascular disease in Scotland, the prevalence and outcomes of patients with cardiogenic shock are unknown. Methods We undertook a prospective observational cohort study of consecutive patients with cardiogenic shock admitted to the intensive care unit (ICU) or coronary care unit at 13 hospitals in Scotland for a 6-month period. Denominator data from the Scottish Intensive Care Society Audit Group were used to estimate ICU prevalence; data for coronary care units were unavailable. We undertook multivariable logistic regression to identify factors associated with in-hospital mortality. Results In total, 247 patients with cardiogenic shock were included. After exclusion of coronary care unit admissions, this comprised 3.0% of all ICU admissions during the study period (95% confidence interval [CI] 2.6%-3.5%). Aetiology was acute myocardial infarction (AMI) in 48%. The commonest vasoactive treatment was noradrenaline (56%) followed by adrenaline (46%) and dobutamine (40%). Mechanical circulatory support was used in 30%. Overall in-hospital mortality was 55%. After multivariable logistic regression, age (odds ratio [OR] 1.04, 95% CI 1.02-1.06), admission lactate (OR 1.10, 95% CI 1.05-1.19), Society for Cardiovascular Angiographic Intervention stage D or E at presentation (OR 2.16, 95% CI 1.10-4.29) and use of adrenaline (OR 2.73, 95% CI 1.40-5.40) were associated with mortality. Conclusions In Scotland the prevalence of cardiogenic shock was 3% of all ICU admissions; more than half died prior to discharge. There was significant variation in treatment approaches, particularly with respect to vasoactive support strategy.
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Affiliation(s)
- Alex Warren
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Anaesthesia, Critical Care & Pain, University of Edinburgh, Edinburgh, UK
- Barts Heart Centre, London, UK
| | - Philip McCall
- Golden Jubilee National Hospital, Clydebank, UK
- Anaesthesia, Critical Care & Peri-Operative Medicine, University of Glasgow, Glasgow, UK
| | - Alastair Proudfoot
- Barts Heart Centre, London, UK
- Queen Mary University of London, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ian Scott
- Aberdeen Royal Infirmary, Aberdeen, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Nazir I Lone
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Anaesthesia, Critical Care & Pain, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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8
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Kadri AN, Alrawashdeh R, Soufi MK, Elder AJ, Elder Z, Mohamad T, Gnall E, Elder M. Mechanical Support in High-Risk Pulmonary Embolism: Review Article. J Clin Med 2024; 13:2468. [PMID: 38730997 PMCID: PMC11084514 DOI: 10.3390/jcm13092468] [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: 02/27/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Acute pulmonary embolism (PE) may manifest with mild nonspecific symptoms or progress to a more severe hemodynamic collapse and sudden cardiac arrest. A substantial thrombotic burden can precipitate sudden right ventricular strain and failure. Traditionally, systemic thrombolytics have been employed in such scenarios; however, patients often present with contraindications, or these interventions may prove ineffective. Outcomes for this medically complex patient population are unfavorable, necessitating a compelling argument for advanced therapeutic modalities or alternative approaches. Moreover, patients frequently experience complications beyond hemodynamic instability, such as profound hypoxia and multiorgan failure, necessitating assertive early interventions to avert catastrophic consequences. The existing data on the utilization of mechanical circulatory support (MCS) devices are not exhaustive. Various options for percutaneous MCS devices exist, each possessing distinct advantages and disadvantages. There is an imminent imperative to develop a tailored approach for this high-risk patient cohort to enhance their overall outcomes.
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Affiliation(s)
- Amer N. Kadri
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Razan Alrawashdeh
- Department of Medicine, Faculty of Medicine, University of Jordan, Amman 11942, Jordan
| | - Mohamad K. Soufi
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Adam J. Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Zachary Elder
- School of Medicine, American University of Caribbean, 33027 Cupecoy, Sint Maarten
| | - Tamam Mohamad
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
| | - Eric Gnall
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Mahir Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
- Corewell Health East, Dearborn Hospital, Dearborn, MI 48124, USA
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9
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Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [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: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
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Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
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10
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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11
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Barrionuevo-Sánchez MI, Ariza-Solé A, Viana-Tejedor A, Del Prado N, Rosillo N, Jorge-Pérez P, Sánchez-Salado JC, Lorente V, Alegre O, Llaó I, Martín-Asenjo R, Bernal JL, Fernández-Pérez C, Corbí-Pascual M, Pascual J, Marcos M, de la Cuerda F, Carmona J, Comin-Colet J, Elola FJ. Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:226-233. [PMID: 37925017 DOI: 10.1016/j.rec.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/11/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting. METHODS This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality. RESULTS A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047). CONCLUSIONS The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.
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Affiliation(s)
- M Isabel Barrionuevo-Sánchez
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Náyade Del Prado
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Nicolás Rosillo
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pablo Jorge-Pérez
- Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - José Carlos Sánchez-Salado
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Victòria Lorente
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Alegre
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Isaac Llaó
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - José Luis Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Área Sanitaria de Santiago y Barbanza, Instituto de Investigaciones Sanitarias de Santiago, Santiago de Compostela, A Coruña, Spain
| | | | - Júlia Pascual
- Servicio de Cardiología, Hospital Universitari Josep Trueta, Girona, Spain
| | - Marta Marcos
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco de la Cuerda
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jesús Carmona
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep Comin-Colet
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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12
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Low CJW, Ling RR, Lau MPXL, Liu NSH, Tan M, Tan CS, Lim SL, Rochwerg B, Combes A, Brodie D, Shekar K, Price S, MacLaren G, Ramanathan K. Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med 2024; 50:209-221. [PMID: 38206381 DOI: 10.1007/s00134-023-07278-3] [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: 09/01/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. METHODS We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. RESULTS We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66). CONCLUSION In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Michele Petrova Xin Ling Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel Sheng Hui Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Melissa Tan
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Shir Lynn Lim
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Pre-Hospital and Emergency Research Center, Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Alain Combes
- Service de Médecine Intensive-RéanimationInstitut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- UMRS 116, Institute of Cardio Metabolism and Nutrition, Sorbonne Universite INSERM, Paris, France
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Gold Coast, QLD, Australia
- University of Queensland, Gold Coast, QLD, Australia
- Bond University, Gold Coast, QLD, Australia
| | - Susanna Price
- Royal Brompton and Harefield Hospitals, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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13
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Bloom JE, Wong N, Nehme E, Dawson LP, Ball J, Anderson D, Cox S, Chan W, Kaye DM, Nehme Z, Stub D. Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:89-98. [PMID: 36808236 DOI: 10.1093/ehjqcco/qcad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023]
Abstract
AIMS The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). METHODS AND RESULTS This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. CONCLUSION This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shelley Cox
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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14
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Tehrani BN, Epps KC, Batchelor WB. An Uneven Playing Field: Demographic and Regionalized Disparities in Access to Device-Based Therapies for Cardiogenic Shock. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101220. [PMID: 39131975 PMCID: PMC11307875 DOI: 10.1016/j.jscai.2023.101220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 08/13/2024]
Affiliation(s)
| | - Kelly C. Epps
- Inova Schar Heart and Vascular Institute, Falls Church, Virginia
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15
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Truesdell AG, Rosner C, Fordyce CB. None of us alone is as effective as all of us together. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:831-833. [PMID: 37798086 DOI: 10.1093/ehjacc/zuad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, 2901 Telestar Court, Falls Church, VA 22042, USA
- Inova Schar Heart and Vascular Institute, 2901 Telestar Court, Falls Church, VA 22042, USA
| | - Carolyn Rosner
- Inova Schar Heart and Vascular Institute, 2901 Telestar Court, Falls Church, VA 22042, USA
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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16
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Stevenson MJ, Kenigsberg BB, Singam NSV, Papolos AI. Shock Teams: A Contemporary Review. Curr Cardiol Rep 2023; 25:1657-1663. [PMID: 37861851 DOI: 10.1007/s11886-023-01983-7] [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] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams. RECENT FINDINGS To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limited available data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.
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Affiliation(s)
- Margaret J Stevenson
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA.
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17
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Srichawla BS, Kipkorir V, Sekhon M. Clinical indications and outcomes of Impella devices for severe cardiogenic shock in COVID-19 patients: a systematic review. Ann Med Surg (Lond) 2023; 85:6115-6122. [PMID: 38098597 PMCID: PMC10718365 DOI: 10.1097/ms9.0000000000001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/11/2023] [Indexed: 12/17/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) can present with significant cardiac dysfunction, including cardiogenic shock. Mechanical circulatory support with an Impella device may be utilized in these patients to support and offload native right ventricle (RV) and left ventricle (LV) functions. This systematic review aims to describe clinical indications, management, laboratory data, and outcomes in patients with severe cardiogenic shock from COVID-19 treated with an Impella device. Methods A PRISMA-directed systematic review was performed and prospectively registered in PROSPERO. The databases accessed included PubMed/MEDLINE, Scopus, and ScienceDirect. Quality and risk of bias assessments were completed using the Joanna Briggs Institute (JBI) checklist for case reports. Results A total of 16 records were included in the qualitative synthesis; 8/16 (50%) of the patients were men. The average age was 39 years (SD: 14.7). The biventricular Impella (BiPella) approach was recorded in 3/16 (18.75%) patients. A total of 4/16 (25%) individuals required renal replacement therapy (RRT). Single-device usage was observed in three cases: 2/16 Impella CP (12.5%) and 1/16 Impella RP (6.25%). Treatment of COVID-19 myocarditis included a wide range of antivirals and immunomodulators; 8/16 (50%) cases needed ECMO (extracorporeal membrane oxygenation) support. Overall, only 2/16 (11.7%) individuals died. Conclusions Sixteen reported individuals have received an Impella implanted with a mortality rate of 11.7%. Concurrent use of RRT and ECMO implantation was often observed. Overall, the Impella device is an effective and safe strategy in the management of COVID-19-related cardiogenic shock. Future studies should include long-term results.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | | | - Manraj Sekhon
- Department of Internal Medicine, University of California Riverside School of Medicine, Riverside, California, USA
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18
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Castagna F, Viswanathan S, Chalhoub G, Ippolito P, Ovalle Ramos JA, Vukelic S, Sims DB, Madan S, Saeed O, Jorde UP. Predicting Hemodynamic Changes During Intra-Aortic Balloon Pump Support With a Longitudinal Evaluation. ASAIO J 2023; 69:977-983. [PMID: 37499684 PMCID: PMC10602221 DOI: 10.1097/mat.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
The use of intra-aortic balloon pump (IABP) has decreased in recent years due to negative outcome studies in cardiogenic shock complicating acute myocardial infarction, despite its favorable adverse-event profile. Acute hemodynamic response studies have identified potential super-responders with immediate improvements in cardiac index (CI) in heart failure patients. This single-center retrospective study aimed to predict CI and mean arterial pressure (MAP) changes throughout the entire duration of IABP support. The study analyzed 336 patients who received IABP between 2016 and 2022. Linear mixed-effect regression models were used to predict CI and MAP improvement during IABP support. The results showed that CI and MAP increases during the first days of support, and changes during IABP support varied with time and were associated with baseline parameters. Longitudinal CI change was associated with body surface area, baseline CI, baseline pulmonary artery pulsatility index, baseline need for pressors, and diabetes. Longitudinal MAP change was associated with baseline MAP, baseline heart rate, need for pressors, or inotropes. The study recommends considering these parameters when deciding if IABP is the most appropriate form of support for a specific patient. Further prospective studies are needed to validate the findings.
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Affiliation(s)
- Francesco Castagna
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Shankar Viswanathan
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - George Chalhoub
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Paul Ippolito
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Julio Andres Ovalle Ramos
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Sasa Vukelic
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Daniel B. Sims
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Shivank Madan
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Omar Saeed
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Ulrich P. Jorde
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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19
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Mohamed MO, Kinnaird T, Rab ST, Zaman S, Banerjee A, Sirker A, Mintz G, Mamas MA. Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock. Catheter Cardiovasc Interv 2023; 102:1004-1011. [PMID: 37870106 DOI: 10.1002/ccd.30859] [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: 07/27/2023] [Revised: 08/30/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). METHODS All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI. RESULTS Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55-0.75). There were no differences in other secondary outcomes between groups. CONCLUSION ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6 patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
- Institute of Health Informatics, University College London, London, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital Wales, Wales, UK
| | - Syed Tanveer Rab
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Sarah Zaman
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alex Sirker
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Gary Mintz
- Cardiovascular Research Foundation, New York, New York, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
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20
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Merdji H, Gantzer J, Bonello L, Lamblin N, Roubille F, Levy B, Champion S, Lim P, Schneider F, Cariou A, Khachab H, Bourenne J, Seronde MF, Schurtz G, Harbaoui B, Vanzetto G, Quentin C, Curtiaud A, Kurtz JE, Combaret N, Marchandot B, Lattuca B, Biendel C, Leurent G, Bataille V, Gerbaud E, Puymirat E, Bonnefoy E, Aissaoui N, Delmas C. Characteristics, management, and outcomes of active cancer patients with cardiogenic shock. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:682-692. [PMID: 37410588 DOI: 10.1093/ehjacc/zuad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
AIMS Characteristics, management, and outcomes of patients with active cancer admitted for cardiogenic shock remain largely unknown. This study aimed to address this issue and identify the determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all aetiologies. METHODS AND RESULTS FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October 2016. 'Active cancer' was defined as a malignancy diagnosed within the previous weeks with planned or ongoing anticancer therapy. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 51 (6.6%) had active cancer. Among them, the main cancer types were solid cancers (60.8%), and hematological malignancies (27.5%). Solid cancers were mainly urogenital (21.6%), gastrointestinal (15.7%), and lung cancer (9.8%). Medical history, clinical presentation, and baseline echocardiography were almost the same between groups. In-hospital management significantly differed: patients with cancers received more catecholamines or inotropes (norepinephrine 72% vs. 52%, P = 0.005 and norepinephrine-dobutamine combination 64.7% vs. 44.5%, P = 0.005), but had less mechanical circulatory support (5.9% vs. 19.5%, P = 0.016). They presented a similar 30-day mortality rate (29% vs. 26%) but a significantly higher mortality at 1-year (70.6% vs. 45.2%, P < 0.001). In multivariable analysis, active cancer was not associated with 30-day mortality but was significantly associated with 1-year mortality in 30-day survivors [HR 3.61 (1.29-10.11), P = 0.015]. CONCLUSION Active cancer patients accounted for almost 7% of all cases of cardiogenic shock. Early mortality was the same regardless of active cancer or not, whereas long-term mortality was significantly increased in patients with active cancer.
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Affiliation(s)
- Hamid Merdji
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Strasbourg university hospital, Nouvel Hôpital Civil, Medical intensive care unit, Strasbourg, France
| | - Justine Gantzer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), Strasbourg, France
| | - Laurent Bonello
- Aix-Marseille Université, F-13385 Marseille, France
- Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, F-13385 Marseille, France
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - Nicolas Lamblin
- Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, F-59000, Lille, France
| | - François Roubille
- Cardiology Department, PhyMedExp, Université de Montpellier, INSERM, CNRS, INI-CRT, CHU de Montpellier, Montpellier, France
| | - Bruno Levy
- CHRU Nancy, Réanimation Médicale Brabois, Vandoeuvre-les Nancy, France
| | - Sebastien Champion
- Clinique de Parly 2, Ramsay Générale de Santé, 21 rue Moxouris, 78150 Le Chesnay, France
| | - Pascal Lim
- Service de Cardiologie, Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France
- AP-HP, Hôpital Universitaire Henri-Mondor, F-94010 Créteil, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Assistance Publique- Hôpitaux de Paris, Centre-Université de Paris, Medical School, Paris, France
| | - Hadi Khachab
- Intensive Cardiac Care Unit, Department of Cardiology, CH d'Aix en Provence, Aix en Provence, France, Avenue des Tamaris 13616 Aix-en-Provence cedex 1, France
| | - Jeremy Bourenne
- Service de Réanimation des Urgences, Aix Marseille Université, CHU La Timone 2, Marseille, France
| | | | - Guillaume Schurtz
- Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, F-59000, Lille, France
| | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- University of Lyon, CREATIS UMR5220; INSERM U1044; INSA-15 Lyon, France
| | - Gerald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, 38700 La Tronche, France
| | - Charlotte Quentin
- Service de Reanimation Polyvalente, Centre Hospitalier Broussais St Malo, 1 rue de la Marne, 35400 St Malo, France
| | - Anais Curtiaud
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Strasbourg university hospital, Nouvel Hôpital Civil, Medical intensive care unit, Strasbourg, France
| | - Jean-Emmanuel Kurtz
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), Strasbourg, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Benjamin Marchandot
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Université de Strasbourg, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Caroline Biendel
- Intensive Cardiac Care Unit, Rangueil University Hospital, 31059 Toulouse, France
- Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, F-35000, Rennes, France
| | - Vincent Bataille
- Association pour la diffusion de la médecine de prévention (ADIMEP), Toulouse Rangueil University Hospital (CHU), Toulouse, France
| | - Edouard Gerbaud
- Intensive Cardiac Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, 5 Avenue de Magellan, 33604 Pessac, France
- Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, Hôpital Xavier Arnozan, Avenue du Haut Lévêque, 33600 Pessac, France
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, 75015 Paris, France
- Université de Paris, 75006 Paris, France
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Lyon Brom University Hospital, Lyon, France
| | - Nadia Aissaoui
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Clément Delmas
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
- Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
- Recherche et Enseignement en Insuffisance Cardiaque Avancée Assistance et Transplantation (REICATRA), Institut Saint Jacques, CHU Toulouse, Toulouse, France
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21
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Blasco-Turrión S, Plaza-Martín M, Amat-Santos IJ. Case Report: emergent percutaneous directional thrombectomy in a patient with cardiogenic shock and large mobile thrombus in the right atrium. Eur Heart J Case Rep 2023; 7:ytad428. [PMID: 37705942 PMCID: PMC10496867 DOI: 10.1093/ehjcr/ytad428] [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: 11/21/2022] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
Background New percutaneous techniques for the management of acute pulmonary embolism (PE) are emerging, but there is lack of data regarding the approach of mobile thrombus in the right chambers, with the added risk of potential thrombus dislodgement that may prevent from mechanical circulatory support devices to be implanted in unstable patients. Case summary We present the case of a 65-year-old male with cardiogenic shock of unknown aetiology, severe biventricular dysfunction, and large mobile thrombus in the right atrium. Mechanical circulatory support devices could not be implanted, and current thromboaspiration systems were either too small or not available at that time. However, the patient's condition deteriorated rapidly with thrombus in transit, hence, a novel approach was required: using a deflectable 14 Fr sheath, directional thrombectomy was performed, achieving complete extraction of the thrombi and allowing for circulatory support with extracorporeal membrane oxygenation (ECMO) to be implanted with outstanding results and progressive weaning of all intensive care measures. Discussion Despite the growing interest in the development of percutaneous strategies for acute PE, there is no evidence-based guidelines regarding the treatment of mobile right heart thrombus. Even though some cases of percutaneous right heart thrombectomy have been reported, it is still a challenging scenario, given the potential risk of thrombus dislodgement and atrial perforation. We describe a novel technique of percutaneous directional thrombectomy in a patient with cardiogenic shock of unknown aetiology and large mobile thrombi in the right atrium as a bridge to ECMO proving to be a feasible alternative to treat thrombus in transit.
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Affiliation(s)
- Sara Blasco-Turrión
- Interventional Cardiology Unit, University Clinical Hospital of Valladolid, Avda Ramón y Cajal, 3, Valladolid 47003, Spain
| | - María Plaza-Martín
- Cardiovascular Intensive Care Unit, University Clinical Hospital of Valladolid, Avda Ramón y Cajal, 3, Valladolid 47003, Spain
| | - Ignacio J Amat-Santos
- Interventional Cardiology Unit, University Clinical Hospital of Valladolid, Avda Ramón y Cajal, 3, Valladolid 47003, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), C. de Melchor Fernández Almagro, 3, Spain
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22
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Kirigaya J, Iwahashi N, Terasaka K, Takeuchi I. Prevention and management of critical care complications in cardiogenic shock: a narrative review. J Intensive Care 2023; 11:31. [PMID: 37408036 PMCID: PMC10324237 DOI: 10.1186/s40560-023-00675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era. MAIN TEXT Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies. CONCLUSIONS This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.
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Affiliation(s)
- Jin Kirigaya
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Terasaka
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
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23
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Buckel M, Proudfoot AG. Time for a rethink in cardiogenic shock: the shock to survival framework document. Br J Hosp Med (Lond) 2023; 84:1-8. [PMID: 37490447 DOI: 10.12968/hmed.2023.0139] [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: 07/27/2023]
Abstract
Cardiogenic shock remains a time-critical, complex syndrome that continues to present challenges to clinicians and healthcare systems. Despite advances in the fields of cardiovascular and critical care medicine, mortality remains high. This article summarises the recent shock to survival document, which outlined the current and ideal future state of cardiogenic shock care nationally to improve patient outcomes. Shock to survival emphasises the need for education and training in the early recognition of the hypoperfusion that is pathognomomic of cardiogenic shock. Improved provision of focused cardiac ultrasound is essential to confirm a cardiac cause. Early identification of the patient with cardiogenic shock should be supported by access to defined pathways of care, including specialist shock centres and multiprofessional teams with domain expertise and the capability to manage the myriad of causative aetiologies. Given the absence of high-quality data to inform practice nationally, robust datasets are an unmet need to inform best practice, guide design of clinical services and pathways and drive innovation through research and clinical trials.
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Affiliation(s)
- Marie Buckel
- Pan-London Intensive Care Medicine Training Programme, London, UK
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Critical Care and Perioperative Medicine Group, Queen Mary University of London, London, UK
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24
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Araki T, Kondo T, Imaizumi T, Sumita Y, Nakai M, Tanaka A, Okumura T, Yang M, Butt JH, Petrie MC, Murohara T. Relationship between the volume of cases and in-hospital mortality in patients with cardiogenic shock receiving short-term mechanical circulatory support. Am Heart J 2023; 261:109-123. [PMID: 37031832 DOI: 10.1016/j.ahj.2023.03.017] [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] [Received: 01/12/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND We examined the relationship between annual case volume at each hospital and outcome in cardiogenic shock (CS) patients receiving mechanical circulatory support (MCS) devices. METHODS This cross-sectional study used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients, 3 subcohorts were created; the intra-aortic balloon pump (IABP) alone (n = 48,643), the extracorporeal membrane oxygenation (ECMO) (n = 16,871), and the Impella cohorts (n = 696). RESULTS The median annual case volume was 13.5 (7.4-22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0-10.7) in the Impella cohort. The highest quintile for the volume of cases in the IABP alone and ECMO had the lowest in-hospital mortality (IABP alone, 25.1% in quintile 1 vs 15.2% in quintile 5; ECMO, 73.7% in quintile 1 in 67.4% in quintile 5). Adjusted ORs for in-hospital mortality decreased as case volume increased (IABP alone, 0.63 [0.58-0.68] in quintile 5; ECMO, 0.73 [0.65-0.82] in quintile 5, with the lowest quintile as reference) but did not decrease significantly in the Impella (0.90 [0.58-1.39] in tertile 3, with the lowest tertile as reference). In the continuous models with the case volume as a continuous variable, adjusted ORs for in-hospital mortality decreased to 28 IABP cases/year and 12 ECMO cases/year. They did not decrease or became almost flat above that. CONCLUSIONS Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline. Centralizing patients with refractory CS in a particular hospital might improve patient outcomes in each region.
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Affiliation(s)
- Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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25
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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26
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Choe JC, Lee SH, Ahn JH, Lee HW, Oh JH, Choi JH, Lee HC, Cha KS, Jeong MH, Angiolillo DJ, Park JS. Adjusted mortality of extracorporeal membrane oxygenation for acute myocardial infarction patients in cardiogenic shock. Medicine (Baltimore) 2023; 102:e33221. [PMID: 36930119 PMCID: PMC10019119 DOI: 10.1097/md.0000000000033221] [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: 11/30/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
Cardiogenic shock (CS) is a common cause of death following acute myocardial infarction (MI). This study aimed to evaluate the adjusted mortality of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon counterpulsation (IABP) for patients with MI-CS. We included 300 MI patients selected from a multinational registry and categorized into VA-ECMO + IABP (N = 39) and no VA-ECMO (medical management ± IABP) (N = 261) groups. Both groups' 30-day and 1-year mortality were compared using the weighted Kaplan-Meier, propensity score, and inverse probability of treatment weighting methods. Adjusted incidences of 30-day (VA-ECMO + IABP vs No VA-ECMO, 77.7% vs 50.7; P = .083) and 1-year mortality (92.3% vs 84.8%; P = .223) along with propensity-adjusted and inverse probability of treatment weighting models in 30-day (hazard ratio [HR], 1.57; 95% confidence interval [CI], 0.92-2.77; P = .346 and HR, 1.44; 95% CI, 0.42-3.17; P = .452, respectively) and 1-year mortality (HR, 1.56; 95% CI, 0.95-2.56; P = .076 and HR, 1.33; 95% CI, 0.57-3.06; P = .51, respectively) did not differ between the groups. However, better survival benefit 30 days post-ECMO could be supposed (31.6% vs 83.4%; P = .022). Therefore, patients with MI-CS treated with IABP with additional VA-ECMO and those not supported with ECMO have comparable overall 30-day and 1-year mortality risks. However, VA-ECMO-supported survivors might have better long-term clinical outcomes.
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Affiliation(s)
- Jeong Cheon Choe
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sun-Hack Lee
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jin Hee Ahn
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hye Won Lee
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jun-Hyok Oh
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jung Hyun Choi
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Han Cheol Lee
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kwang Soo Cha
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Jeonnam National University Hospital, Gwangju, Korea
| | | | - Jin Sup Park
- Department of Cardiology and Medical Research Institute, Pusan National University Hospital, Busan, Korea
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27
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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28
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Toda K, Ako J, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Nishimura T, Sato N, Shindo T, Takayama M, Yasukochi S, Shiose A, Sawa Y. Three-year experience of catheter-based micro-axial left ventricular assist device, Impella, in Japanese patients: the first interim analysis of Japan registry for percutaneous ventricular assist device (J-PVAD). J Artif Organs 2023; 26:17-23. [PMID: 35467195 DOI: 10.1007/s10047-022-01328-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
Catheter-based micro-axial ventricular assist device Impella® (Abiomed, Danvers, MA) has been used in Japanese patients with drug-refractory acute heart failure (AHF) since 2017. This is the first interim analysis of the ongoing Japan Registry for Percutaneous Ventricular Assist Device (J-PVAD) to investigate the safety and efficacy of Impella support. Between October 2017 and January 2020, 823 Japanese patients, who were treated with the Impella 2.5, CP, or 5.0 pump, were enrolled. The primary endpoints were safety profiles and cumulative 30-day survival. Among them, 44.8% of patients were acute myocardial infarction with cardiogenic shock. The Impella pumps were unable to implant in 4 patients. The Impella 2.5, CP, and 5.0 pumps were used in 72.4%, 6.2%, and 16.6%, respectively, and mean support duration was 8.1 ± 10.2 days. Combination use of Impella and venoarterial extracorporeal membrane oxygenation (VA-ECMO) was applied for 387 patients (47.3%). Pump stop occurred 22 patients (2.7%). Major adverse events included hemolysis (11.2%), hemorrhage/hematoma (6.1%), peripheral ischemia (1.6%), and stroke (1.6%). The overall 30-day survival was 62.2%. Survival of patients with single Impella support was significantly higher than patients with Impella combined with VA-ECMO support (81.1% vs 49.6%; p < 0.01), who had lower blood pressure, lower left ventricular ejection fraction, and higher degree of inotropic support. Results suggest that short-term outcome of Impella support for Japanese patients was favorable with acceptable safety profiles.
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Affiliation(s)
- Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-Oka, Suita, Osaka, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Kanagawa, Japan
| | | | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University, Ehime, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-Oka, Suita, Osaka, Japan.
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[Acute heart failure and cardiogenic shock : An update]. Herz 2023; 48:95-100. [PMID: 36695879 DOI: 10.1007/s00059-022-05159-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
Acute heart failure is a clinical syndrome resulting from elevated intracardiac filling pressures and a systemic venous congestion. In general, patients can present acutely without a history of structural cardiac disease (de novo heart failure) or with acute worsening of a pre-existing dysfunction of the right or left ventricle. The patient population is overall very inhomogeneous and as a result there is also a distinct heterogeneity with respect to the underlying cardiac pathology that leads to the acute presentation. Ultimately, ventricular dysfunction leads to increased preload and afterload resulting in decreased perfusion and retrograde congestion. The forward failure (hypoperfusion) and backwards failure (systemic congestion) can lead to impaired end organ function or even organ failure resulting in cardiogenic shock, in which sufficient organ and tissue perfusion is no longer possible. Consequently, therapeutic strategies currently focus on rectification of the underlying cardiac dysfunction, reduction of volume overload (decongestion) and hemodynamic stabilization with drugs supporting the circulation in the case of a hypoperfusion syndrome. Despite numerous new therapeutic strategies within the last two decades, the empirical data based on randomized trials is considerably less solid than in chronic heart failure, which is expressed in the almost unchanged 1‑year mortality of approximately 20-30%.
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Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices. Curr Cardiol Rep 2023; 25:213-227. [PMID: 36847990 DOI: 10.1007/s11886-023-01843-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS. RECENT FINDINGS MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy.
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Ikeda Y, Ako J, Toda K, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Nishimura T, Sato N, Shindo T, Takayama M, Yasukochi S, Shiose A, Sawa Y. Short-Term Outcomes of Impella Support in Japanese Patients With Cardiogenic Shock Due to Acute Myocardial Infarction - Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD). Circ J 2023; 87:588-597. [PMID: 36682787 DOI: 10.1253/circj.cj-22-0476] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Impella®percutaneous left ventricular assist device has been available in Japan since 2017. This is the first large-scale registry study to analyze the efficacy and safety of Impella in Japanese patients with acute myocardial infarction with cardiogenic shock (AMICS).Methods and Results: The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) has registered all consecutive Japanese patients treated with Impella. We extracted data for 593 AMICS patients from J-PVAD and analyzed 30-day survival and safety profiles. Overall 30-day survival was 63.1%. The 30-day survival of the Impella alone and Impella plus venoarterial extracorporeal membrane oxygenation (ECPELLA) groups was 80.9% and 45.7%, respectively. The Impella alone group was older and had a lower rate of cardiac arrest, milder consciousness disturbance, less inotrope use, lower serum lactate concentrations, higher B-type natriuretic peptide concentrations, and higher left ventricular ejection fraction (LVEF) than the ECPELLA group. Cox regression analysis revealed that older age and comorbid renal disturbance were common risk factors affecting 30-day mortality in both groups. Major adverse events were hemolysis (10.8%), hemorrhage/hematoma (7.6%), peripheral ischemia (4.4%), stroke (1.3%), and thrombosis (0.7%). LVEF improved in both groups during support. CONCLUSIONS AMICS treatment with Impella showed favorable 30-day survival and safety profiles. The survival rate of patients treated with Impella alone was particularly high. Further studies are needed to improve outcomes of patients with ECPELLA support.
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Affiliation(s)
- Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | | | | | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development
| | - Morimasa Takayama
- Department of Cardiovascular Internal Medicine, Sakakibara Heart Institute
| | | | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Barssoum K, Patel HP, Abdelmaseih R, Hassib M, Victor V, Mohamed A, Jazar DA, Mai S, Ibrahim F, Patel B, Baeni AE, Khalife W, Bandyopadhay D, Rai D, Chatila K. Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database. Curr Probl Cardiol 2023; 48:101584. [PMID: 36642353 DOI: 10.1016/j.cpcardiol.2023.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.
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Affiliation(s)
- Kirolos Barssoum
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Harsh P Patel
- Department cardiology, Southern Illinois University, Carbondale, IL
| | - Ramy Abdelmaseih
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Mohab Hassib
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Ahmed Mohamed
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Deaa Abu Jazar
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Steven Mai
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Fadi Ibrahim
- American University of Antigua, Antigua & Barbuda
| | - Bhavin Patel
- Department of internal medicine, Saint Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Aiham El Baeni
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Wissam Khalife
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY.
| | - Khaled Chatila
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
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Sandhyavenu H, Ullah W, Badu I, Taha A, Polam AR, Mir T, Brailovsky Y, Rajapreyar IN, Vallabhajosyula S, Alraies MC. Trends and outcomes of cardiogenic shock in Asian populations compared with non-Asian populations in the US: NIS Analysis (2002-2019). Expert Rev Cardiovasc Ther 2023; 21:67-74. [PMID: 36597921 DOI: 10.1080/14779072.2023.2162040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Current understanding of outcomes of cardiogenic shock (CS) in Asian populations is limited. We aim to study the clinical outcomes of CS in Asian population compared with non-Asians in the US. METHODS The National Inpatient Sample (NIS) database was queried between 2002-2019 to identify hospitalizations with CS. Race was classified as Asians and non-Asians. The adjusted odds ratios (aOR) for in-hospital outcomes were calculated using multivariate logistic regression analysis. RESULTS Results Of 1,573,285 CS hospitalizations, 48,398 (3%) were Asians and 1,524,887 (97%) were non-Asians between 2002-2019. Adjusted odds of in-hospital mortality (aOR 1.03, 95% CI 1.01-1.05), and use of intra-aortic balloon pump (IABP) (aOR 1.15, 95% CI 1.12-1.17) were significantly higher among Asians compared with non-Asians. The in-hospital mean cost of hospitalization was higher in Asian population ($63,787±$80,261) with CS compared with non-Asians ($56,207±$76,120, p < 0.001). The use of Impella (aOR 0.90, 95% CI 0.86-0.95) and left ventricular assist devices (LVAD) (aOR 0.71, 95% CI 0.65-0.77) were lower with no difference in the use of extracorporeal membrane oxygenation (ECMO) compared with non-Asians. CONCLUSION Asian populations with CS have higher in-hospital mortality, increased requirement of IABP and higher mean cost of hospitalization compared with non-Asians.
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Affiliation(s)
| | - Waqas Ullah
- Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Irisha Badu
- Internal Medicine, Onslow Memorial Hospital, Jacksonville, NC, USA
| | - Amro Taha
- Internal Medicine, Weiss Memorial Hospital, Chicago, IL, USA
| | | | - Tanveer Mir
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | | | | | | | - M Chadi Alraies
- Cardiology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
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Impact of shock aetiology and hospital characteristics on the clinical profile, management and prognosis of patients with non ACS-related cardiogenic shock. Hellenic J Cardiol 2023; 69:16-23. [PMID: 36334704 DOI: 10.1016/j.hjc.2022.11.001] [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: 07/02/2022] [Revised: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND A significant proportion of cases of cardiogenic shock (CS) are due aetiologies other than acute coronary syndromes (non ACS-CS). We assessed differences regarding clinical profile, management, and prognosis according to the cause of CS among nonselected patients with CS from a large nationwide database. METHODS We performed an observational study including patients admitted from the hospitals of the Spanish National Health System (SNHS) with a principal or secondary diagnosis code of CS (2016-2019). Data were obtained from the Minimum Basic Data Set (MBDS). Hospitals were classified according to the availability of cardiology related resources, as well as the availability of Intensive Cardiac Care Unit (ICCU). RESULTS A total of 10,826 episodes of CS were included, of whom 5,495 (50.8%) were non-ACS related. Non ACS-CS patients were younger (71.5 vs. 72.4 years) and had a lower burden of arteriosclerosis-related comorbidities. Non ACS-CS cases underwent less often invasive procedures and presented lower in-hospital mortality (57.1% vs. 61%,p < 0.001). The most common main diagnosis among non ACS-CS was acute decompensation of chronic heart failure (ADCHF) (35.4%). A lower risk-adjusted in-hospital mortality rate was observed in high volume hospitals (52.6% vs. 56.7%; p < 0.001), as well as in centers with ICCU (OR: 0.71; CI 95%: 0.58-0.87; p < 0.001). CONCLUSIONS More than a half of cases of CS were due to non-ACS causes. Non ACS-CS cases are a very heterogeneous group, with different clinical profile and management. Management at high-volume hospitals and availability of ICCU were associated with lower risk adjusted mortality among non ACS-CS patients.
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Sinha SS, Bohula EA, Diepen SVAN, Leonardi S, Mebazaa A, Proudfoot AG, Sionis A, Chia YW, Zampieri FG, Lopes RD, Katz JN. The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations. J Card Fail 2022; 28:1703-1716. [PMID: 35843489 DOI: 10.1016/j.cardfail.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sergio Leonardi
- Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Pavia, Italy
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, APHP Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil Intensive Care Unit, Federal University of São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Rajsic S, Breitkopf R, Bukumiric Z, Treml B. ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality. J Clin Med 2022; 11:jcm11226821. [PMID: 36431298 PMCID: PMC9698852 DOI: 10.3390/jcm11226821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality. METHODS We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria. RESULTS We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%). CONCLUSIONS Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Tan SR, Low CJW, Ng WL, Ling RR, Tan CS, Lim SL, Cherian R, Lin W, Shekar K, Mitra S, MacLaren G, Ramanathan K. Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101629. [PMID: 36295065 PMCID: PMC9605512 DOI: 10.3390/life12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.
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Affiliation(s)
- Shien Ru Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Wei Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119228, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Saikat Mitra
- Intensive Care Unit, Dandenong and Casey Hospital, Monash Health, Melbourne, VIC 3175, Australia
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
- Correspondence:
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Patlolla SH, Bhat AG, Sundaragiri PR, Cheungpasitporn W, Doshi RP, Siddappa Malleshappa SK, Pasupula DK, Jaber WA, Nicholson WJ, Vallabhajosyula S. Impact of Active and Historical Cancers on the Management and Outcomes of Acute Myocardial Infarction Complicating Cardiogenic Shock. Tex Heart Inst J 2022; 49:487440. [PMID: 36223249 PMCID: PMC9632367 DOI: 10.14503/thij-21-7598] [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: 01/25/2023]
Abstract
BACKGROUND There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with concomitant cancer. METHODS A retrospective cohort of adult AMI-CS admissions was identified from the National Inpatient Sample (2000-2017) and stratified by active cancer, historical cancer, and no cancer. Outcomes of interest included in-hospital mortality, use of coronary angiography, use of percutaneous coronary intervention, do-not-resuscitate status, palliative care use, hospitalization costs, and hospital length of stay. RESULTS Of the 557,974 AMI-CS admissions during this 18-year period, active and historical cancers were noted in 14,826 (2.6%) and 27,073 (4.8%), respectively. From 2000 to 2017, there was a decline in active cancers (adjusted odds ratio, 0.70 [95% CI, 0.63-0.79]; P < .001) and an increase in historical cancer (adjusted odds ratio, 2.06 [95% CI, 1.89-2.25]; P < .001). Compared with patients with no cancer, patients with active and historical cancer received less-frequent coronary angiography (57%, 67%, and 70%, respectively) and percutaneous coronary intervention (40%, 47%, and 49%%, respectively) and had higher do-not-resuscitate status (13%, 15%, 7%%, respectively) and palliative care use (12%, 10%, 6%%, respectively) (P < .001). Compared with those without cancer, higher in-hospital mortality was found in admissions with active cancer (45.9% vs 37.0%; adjusted odds ratio, 1.29 [95% CI, 1.24-1.34]; P < .001) but not historical cancer (40.1% vs 37.0%; adjusted odds ratio, 1.01 [95% CI, 0.98-1.04]; P = .39). AMI-CS admissions with cancer had a shorter hospitalization duration and lower costs (all P < .001). CONCLUSION Concomitant cancer was associated with less use of guideline-directed procedures. Active, but not historical, cancer was associated with higher mortality in patients with AMI-CS.
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Affiliation(s)
| | - Anusha G. Bhat
- Department of Cardiovascular Medicine, University of Maryland, Baltimore
, Department of Public Health Practice, School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Pranathi R. Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, North Carolina
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajkumar P. Doshi
- Department of Medicine, University of Nevada School of Medicine, Reno, Nevada
| | - Sudeep K. Siddappa Malleshappa
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Deepak K. Pasupula
- Department of Cardiovascular Medicine, Mercy One Medical Center, Des Moines, Iowa
| | - Wissam A. Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - William J. Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
, Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina
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Galván‐Román F, Fernández‐Herrero I, Ariza‐Solé A, Sánchez‐Salado JC, Puerto E, Lorente V, Gómez‐Lara J, Martín‐Asenjo R, Gómez‐Hospital JA, Comín‐Colet J. Prognosis of cardiogenic shock secondary to culprit left main coronary artery lesion-related myocardial infarction. ESC Heart Fail 2022; 10:111-120. [PMID: 36151843 PMCID: PMC9871657 DOI: 10.1002/ehf2.14128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 08/15/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS This study aimed to assess, in patients with cardiogenic shock secondary to unprotected left main coronary artery-related myocardial infarction (ULMCA-related AMICS), the incidence and predictors of no recovery of left ventricular function during the admission. METHODS AND RESULTS This was an observational study conducted at two tertiary care centres (2012-20). The main outcome measured was death or requirement for heart transplantation (HT) or left ventricular assist devices (LVAD) during the admission. A total of 70 patients were included. Percutaneous coronary intervention (PCI) was successful in 53/70 patients (75.7%). The combined endpoint of death or requirement of HT or LVAD during the admission occurred in 41/70 patients (58.6%). The highest incidence of the primary endpoint was observed among patients with profound shock and occluded left main coronary artery (LMCA) (20/23, 87%, P < 0.001). Although a successful PCI reduced the incidence of the event in the whole cohort (51.9% vs. 82.4% in failed PCI, P = 0.026), this association was not observed among this last group of complex patients (86.7% vs. 87.5% in failed PCI, P = 0.731). The predictive model included left ventricular ejection fraction, baseline ULMCA Thrombolysis In Myocardial Infarction flow, and severity of shock and showed an optimal ability for predicting death or requirements for HT or LVAD during the admission (area under the curve 0.865, P < 0.001). CONCLUSIONS ULMCA-related AMICS was associated with a high in-hospital mortality or need for HT or LVAD. Prognosis was especially poor among patients with profound shock and baseline occluded LMCA, with a low probability of recovery regardless of successful PCI.
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Affiliation(s)
- Francisco Galván‐Román
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - Ignacio Fernández‐Herrero
- Department of CardiologyDoce de Octubre University Hospital, Instituto de Investigación IMAS 12MadridSpain
| | - Albert Ariza‐Solé
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - José Carlos Sánchez‐Salado
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - Elena Puerto
- Department of CardiologyDoce de Octubre University Hospital, Instituto de Investigación IMAS 12MadridSpain
| | - Victòria Lorente
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - Josep Gómez‐Lara
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - Roberto Martín‐Asenjo
- Department of CardiologyDoce de Octubre University Hospital, Instituto de Investigación IMAS 12MadridSpain
| | - Joan A. Gómez‐Hospital
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
| | - Josep Comín‐Colet
- Department of CardiologyBellvitge University Hospital, L'Hospitalet de LlobregatBarcelonaSpain,Bioheart, Grup de Malalties CardiovascularsInstitut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de LlobregatFeixa Llarga s/n08907BarcelonaSpain
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Bloom JE, Nehme Z, Andrew E, Dawson LP, Fernando H, Noaman S, Stephenson M, Anderson D, Pellegrino V, Cox S, Lefkovits J, Chan W, Kaye DM, Smith K, Stub D. HOSPITAL CHARACTERISTICS ARE ASSOCIATED WITH CLINICAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK. Shock 2022; 58:204-210. [PMID: 36018300 DOI: 10.1097/shk.0000000000001974] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (<18 cases per year), hospitals in the highest volume quartile (>55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P < 0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vincent Pellegrino
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Blackburn, Victoria, Australia
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Luo C, Chen F, Liu L, Ge Z, Feng C, Chen Y. Impact of diabetes on outcomes of cardiogenic shock: A systematic review and meta-analysis. Diab Vasc Dis Res 2022; 19:14791641221132242. [PMID: 36250870 PMCID: PMC9580099 DOI: 10.1177/14791641221132242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
To provide synthesized evidence on the association of diabetes with clinical outcomes of patients with acute myocardial infarction (AMI) and associated cardiogenic shock (CS). We analyzed observational studies on patients with AMI and CS, identified through a systematic search using PubMed and Scopus databases. The main outcome was mortality and other outcomes of interest were risk of major bleeding, re-infarction, cerebrovascular adverse events, and need for revascularization. We conducted the meta-analysis with data from 15 studies. Compared to patients without diabetes, those with diabetes had an increased risk of in-hospital mortality (OR, 1.34; 95% CI, 1.17-1.54) and cerebrovascular complications (OR, 1.28; 95% CI, 1.11-1.48). We found similar risk of major bleeding (OR, 0.68; 95% CI, 0.43-1.09), re-infarction (OR, 0.98; 95% CI, 0.48-1.98) and need for re-vascularization (OR, 0.96; 95% CI, 0.75-1.22) as well as hospital stay lengths (in days) (WMD 0.00; 95% CI, -0.27-0.28; n = 4; I2 = 99.7%) in the two groups of patients. Patients with diabetes, acute MI and associated cardiogenic shock have increased risks of mortality and adverse cerebrovascular events than those without diabetes.
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Affiliation(s)
- Chao Luo
- Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Feng Chen
- Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Lingpei Liu
- Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Zuanmin Ge
- Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Chengzhen Feng
- Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Yuehua Chen
- Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
- Yuehua Chen, Department of General Practice, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, 365 Renming East Road, Jinhua, Zhejiang 321000, China.
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Curtiaud A, Delmas C, Gantzer J, Zafrani L, Siegemund M, Meziani F, Merdji H. Cardiogenic shock among cancer patients. Front Cardiovasc Med 2022; 9:932400. [PMID: 36072868 PMCID: PMC9441759 DOI: 10.3389/fcvm.2022.932400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Sophisticated cancer treatments, cardiovascular risk factors, and aging trigger acute cardiovascular diseases in an increasing number of cancer patients. Among acute cardiovascular diseases, cancer treatment, as well as the cancer disease itself, may induce a cardiogenic shock. Although increasing, these cardiogenic shocks are still relatively limited, and their management is a matter of debate in cancer patients. Etiologies that cause cardiogenic shock are slightly different from those of non-cancer patients, and management has some specific features always requiring a multidisciplinary approach. Recent guidelines and extensive data from the scientific literature can provide useful guidance for the management of these critical patients. Even if no etiologic therapy is available, maximal intensive supportive measures can often be justified, as most of these cardiogenic shocks are potentially reversible. In this review, we address the major etiologies that can lead to cardiogenic shock in cancer patients and discuss issues related to its management.
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Affiliation(s)
- Anais Curtiaud
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Clement Delmas
- Intensive Cardiac Care Unit, Cardiology Department, University Hospital of Rangueil, Toulouse, France
| | - Justine Gantzer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), Strasbourg, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique des Hôpitaux de Paris, University of Paris, Paris, France
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Hamid Merdji
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
- *Correspondence: Hamid Merdji
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Manshadi SD, Eisenberg N, Montbriand J, Luk A, Roche-Nagle G. Vascular Complications with Intra-Aortic Balloon Pump (IABP) – Experience from a large Canadian metropolitan centre. CJC Open 2022; 4:989-993. [DOI: 10.1016/j.cjco.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
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Goh AXC, Seow JC, Lai MYH, Liu N, Man Goh Y, Ong MEH, Lim SL, Ho JSY, Yeo JW, Ho AFW. Association of High-Volume Centers With Survival Outcomes Among Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2022; 5:e2214639. [PMID: 35639377 PMCID: PMC9157264 DOI: 10.1001/jamanetworkopen.2022.14639] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Although high volume of cases of out-of-hospital cardiac arrest (OHCA) is a key feature of cardiac arrest centers, which have proven survival benefit, the role of center volume as an independent variable associated with improved outcomes is unclear. Objective To assess the association of high-volume centers with survival and neurological outcomes in nontraumatic OHCA. Data Sources Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to October 11, 2021, for studies including adult patients with nontraumatic OHCA who were treated at high-volume vs non-high-volume centers. Study Selection Randomized clinical trials, nonrandomized studies of interventions, prospective cohort studies, and retrospective cohort studies were selected that met the following criteria: (1) adult patients with OHCA of nontraumatic etiology, (2) comparison of high-volume with low-volume centers, (3) report of a volume-outcome association, and (4) report of outcomes of interest. At least 2 authors independently reviewed each article, blinded to each other's decision. Data Extraction and Synthesis Data abstraction and quality assessment were independently conducted by 2 authors. Meta-analyses were performed for adjusted odds ratios (aORs) and crude ORs using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures Survival and good neurological outcomes according to the Cerebral Performance Categories Scale at hospital discharge or 30 days. Results A total of 16 studies involving 82 769 patients were included. Five studies defined high volume as 40 or more cases of OHCA per year; 3 studies defined high volume as greater than 100 cases of OHCA per year. All other studies differed in definitions. Survival to discharge or 30 days improved with treatment at high-volume centers, regardless of whether aORs (1.28 [95% CI, 1.00-1.64]) or crude ORs (1.43 [95% CI, 1.09-1.87]) were pooled. There was no association between center volume and good neurological outcomes at 30 days or hospital discharge in patients with OHCA (aOR, 0.96 [95% CI, 0.77-1.20]). Conclusions and Relevance In this meta-analysis and systematic review, care at high-volume centers was associated with improved survival outcomes, even after adjustment for potential confounders, but was not associated with improved neurological outcomes for patients with nontraumatic OHCA. More studies evaluating the relative importance of center volume compared with other variables (eg, the availability of treatment modalities) associated with survival outcomes in patients with OHCA are required.
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Affiliation(s)
- Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Cong Seow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Melvin Yong Hao Lai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nan Liu
- Center for Quantitative Medicine, Duke-NUS (National University of Singapore) Medical School, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yi Man Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Jamie Sin Ying Ho
- Academic Foundation Programme, Royal Free London NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Prehospital and Emergency Research Center, Duke-NUS Medical School, Singapore
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The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock. Curr Opin Cardiol 2022; 37:241-249. [PMID: 35612936 DOI: 10.1097/hco.0000000000000967] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. RECENT FINDINGS Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. SUMMARY Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.
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Meta-analysis Comparing the Efficacy of Dobutamine Versus Milrinone in Acute Decompensated Heart Failure and Cardiogenic Shock. Curr Probl Cardiol 2022:101245. [DOI: 10.1016/j.cpcardiol.2022.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022]
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Gorder K, Rudick S, Smith TD. Advocacy and Legislation for Regionalization Practices in the Treatment of Cardiogenic Shock: The Time Is Now. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.
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Affiliation(s)
- Kari Gorder
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
| | - Steve Rudick
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
| | - Timothy D Smith
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
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Adelsheimer A, Wang J, Lu DY, Elbaum L, Krishnan U, Cheung JW, Feldman DN, Wong SC, Horn EM, Sobol I, Goyal P, Karas MG, Kim LK. Impact of Socioeconomic Status on Mechanical Circulatory Device Utilization and Outcomes in Cardiogenic Shock. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100027. [PMID: 39132559 PMCID: PMC11307802 DOI: 10.1016/j.jscai.2022.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 08/13/2024]
Abstract
Objectives This study evaluates the impact of socioeconomic status (SES) on utilization of mechanical circulatory support (MCS) devices and outcomes in cardiogenic shock (CS). Background CS is associated with significant mortality. There is increasing use of temporary MCS devices in CS, and its impact on outcomes is currently under investigation. There is a lack of data on the effect of SES on the utilization of MCS devices in CS. Methods CS hospitalizations were obtained from the State Inpatient Databases in 2016 from 9 states representing various regions in the United States. The study had exempt institutional review board status as the database includes deidentified data. Hospitalizations were separated into SES cohorts based on the median household income of the patient residence zip code. Utilization of MCS devices and revascularization procedures along with clinical outcomes with CS were compared across the quartiles. Results There were 38,520 hospitalizations identified with CS, 42.6% of which were secondary to acute myocardial infarction. Patients from higher SES areas were significantly older but had lower burden of comorbidities. Utilization of temporary MCS devices was higher for hospitalizations from higher SES regions (frequency from the lowest SES quartile to the highest SES quartile: 21.3%, 21.5%, 23.5, and 24.1%, P < .01), though revascularization rates were similar. However, there was no significant difference in overall mortality from CS among the 4 quartiles. Patients from regions of higher SES experienced increased hospital costs. Conclusions Higher SES regions had increased use of temporary MCS. There was no difference in mortality between SES cohorts.
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Affiliation(s)
- Andrew Adelsheimer
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Joseph Wang
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Daniel Y. Lu
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Lindsay Elbaum
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Udhay Krishnan
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York, New York
| | - Jim W. Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York, New York
| | - Dmitriy N. Feldman
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York, New York
| | - S. Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Evelyn M. Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Irina Sobol
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York, New York
| | - Maria G. Karas
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Luke K. Kim
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Weill Cornell Cardiovascular Outcomes Research Group, Weill Cornell Medical College, New York, New York
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Challenges in the conduct of randomised controlled trials in cardiogenic shock complicating acute myocardial infarction. J Geriatr Cardiol 2022; 19:125-129. [PMID: 35317398 PMCID: PMC8915423 DOI: 10.11909/j.issn.1671-5411.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiogenic shock (CS) following acute myocardial infarction (AMI) is a major challenge in cardiovascular care. Mortality remains high with 40%-50% after thirty days. Randomised controlled trials (RCTs) play a key role to generate evidence on optimal care in this field. However, the number of completed or ongoing RCTs is still relatively low compared to the gaps in evidence. Challenges in the conduct of these trials are in particular the selection of patients and ethical issues in the informed consent process. When determining eligibility criteria, special attention should be paid to the severity of CS, to the inclusion of patients with cardiac arrest and to potential age limits. Median age of AMI-CS patients is increasing. Age limits are therefore controversial as it is important to include elderly patients in RCTs in order to make the results generalisable and to address the special needs of this group. As patients with AMI-CS are in most cases unable to provide informed consent themselves, a step-wise approach with acute consent by a legal representative or independent physicians and later informed consent by the patient if possible might be established depending on regularities of the respective ethical review board and country legislation. Multicenter studies should be sought to generate adequate power.
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Abstract
BACKGROUND The Impella pump has emerged as a promising tool in patients with cardiogenic shock (CS). Despite its attractive properties, there are scarce data on the specific clinical setting and the potential role of Impella devices in CS patients from routine clinical practice. METHODS This is an observational, retrospective, single center, cohort study. All consecutive patients with diagnosis of CS and undergoing support with Impella 2.5®, Impella CP® or Impella 5.0® from April 2015 to December 2020 were included. Baseline characteristics, management and outcomes were assessed according to CS severity, age and cause of CS. Main outcome measured was in-hospital mortality. RESULTS A total of 50 patients were included (median age: 59.3 ± 10 years). The most common cause of CS was acute coronary syndrome (ACS) (68%), followed by decompensation of previous cardiomyopathy (22%). A total of 13 patients (26%) had profound CS. Most patients (54%) improved pulmonary congestion at 48 h after Impella support. A total of 19 patients (38%) presented significant bleeding. In-hospital mortality was 42%. Among patients with profound CS (n = 13), five patients were previously supported with venoarterial extracorporeal membrane oxygenation. A total of eight patients (61.5%) died during the admission, and no patient achieved ventricular recovery. Older patients (≥ 67 years, n = 10) had more comorbidities and the highest mortality (70%). Among patients with ACS (n = 34), 35.3% of patients had profound CS; and in most cases (52.9%), Impella support was performed as a bridge to recovery. In contrast, only one patient from the decompensated cardiomyopathy group (n = 11) presented with profound CS. In 90.9% of these cases, Impella support was used as a bridge to cardiac transplantation. There were no cases of death. CONCLUSIONS In this cohort of real-life CS patients, Impella devices were used in different settings, with different clinical profiles and management. Despite a significant rate of complications, mortality was acceptable and lower than those observed in other series.
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