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Ochagavía A, Palomo-López N, Fraile V, Zapata L. Hemodynamic monitoring and echocardiographic evaluation in cardiogenic shock. Med Intensiva 2024; 48:602-613. [PMID: 39097480 DOI: 10.1016/j.medine.2024.07.001] [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: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 08/05/2024]
Abstract
Cardiogenic shock (CS) is characterized by the presence of a state of tissue hypoperfusion secondary to ventricular dysfunction. Hemodynamic monitoring allows us to obtain information about cardiovascular pathophysiology that will help us make the diagnosis and guide therapy in CS situations. The most used monitoring system in CS is the pulmonary artery catheter since it provides key hemodynamic variables in CS, such as cardiac output, pulmonary artery pressure, and pulmonary artery occlusion pressure. On the other hand, echocardiography makes it possible to obtain, at the bedside, anatomical and hemodynamic data that complement the information obtained through continuous monitoring devices. CS monitoring can be considered multimodal and integrative by including hemodynamic, metabolic, and echocardiographic parameters that allow describing the characteristics of CS and guiding therapeutic interventions during hemodynamic resuscitation.
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Affiliation(s)
- Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - Nora Palomo-López
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Virginia Fraile
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Luis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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2
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Xie L, Li Y, Chen J, Luo S, Huang B. Blood Urea Nitrogen to Left Ventricular Ejection Ratio as a Predictor of Short-Term Outcome in Acute Myocardial Infarction Complicated by Cardiogenic Shock. J Vasc Res 2024:1-11. [PMID: 39312885 DOI: 10.1159/000541021] [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: 04/23/2024] [Accepted: 08/16/2024] [Indexed: 09/25/2024] Open
Abstract
INTRODUCTION Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS). METHODS 268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome. RESULTS The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125-5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456-2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05). CONCLUSION The admission BUNLVEFr provided important prognostic information for AMI-CS patients.
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Affiliation(s)
- Linfeng Xie
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Yuanzhu Li
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Chen
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Suxin Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bi Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Jentzer JC, Hibbert B. Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock. Lancet 2024; 404:992-993. [PMID: 39236724 DOI: 10.1016/s0140-6736(24)01588-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/26/2024] [Indexed: 09/07/2024]
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Benjamin Hibbert
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Abu-Much A, Grines CL, Chen S, Batchelor WB, Zhao D, Falah B, Maini AS, Redfors B, Bellumkonda L, Bharadwaj AS, Moses JW, Truesdell AG, Zhang Y, Zhou Z, Baron SJ, Lansky AJ, Basir MB, O'Neill WW, Cohen DJ. Clinical outcomes among patients with mitral valve regurgitation undergoing Impella-supported high-risk PCI. Int J Cardiol 2024; 417:132555. [PMID: 39270940 DOI: 10.1016/j.ijcard.2024.132555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/26/2024] [Accepted: 09/10/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Mitral valve regurgitation (MR) is associated with worse outcomes in patients undergoing percutaneous coronary intervention (PCI). We sought to evaluate outcomes of Impella-supported high-risk PCI (HRPCI) patients according to MR severity. METHODS Patients from the PROTECT III study undergoing Impella-supported HRPCI were stratified into 4 groups according to MR severity: No or trace MR, mild MR, moderate MR, and severe MR. Immediate PCI-related complications, major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 90 days and death at 1-year were assessed. RESULTS From March 2017 to March 2020, 631 patients who underwent Impella-supported HRPCI in the PROTECT III study had evaluable MR severity at baseline. Patients with severe MR had lower body mass indices, lower left ventricular ejection fractions (LVEFs), and were more frequently diagnosed with heart failure. The incidence of immediate PCI-related complications was similar between groups. Unadjusted 90-day MACCE and 1-year mortality rates were numerically higher in patients with severe MR compared to the other study groups yet without reaching statistical significance. In multivariable analyses, there was no significant association between the presence of severe MR for 90-day MACCE or 1-year mortality compared with other degrees of MR (adj. HR = 1.71, 95% CI [0.73, 3.98], p = 0.21; adj. HR = 1.79, 95% CI [0.86, 3.74], p = 0.12, respectively). CONCLUSIONS Impella-supported HRPCI patients with moderate or severe MR exhibited a higher prevalence of heart failure, lower LVEF, and longer hospital stays. Patients with severe MR showed numerically higher unadjusted rates of 90-day MACCE and 1-year mortality compared to other groups, however these differences did not reach statistical significance even after adjustment for potential confounders. CLINICAL TRIAL INFORMATION Trial Name: The Global cVAD Study (cVAD) ClinicalTrial.govIdentifier:NCT04136392 URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2.
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Affiliation(s)
- Arsalan Abu-Much
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Cindy L Grines
- Department of Cardiology, Northside Hospital Cardiovascular Institute, Atlanta, GA, USA
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Cornell Weill Medical Center/New York-Presbyterian, New York, NY, USA
| | - Wayne B Batchelor
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Duzhi Zhao
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Batla Falah
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Aneel S Maini
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Aditya S Bharadwaj
- Department of Cardiology, Loma Linda Medical Center, Loma Linda, CA, USA
| | - Jeffrey W Moses
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; St. Francis Hospital, Roslyn, NY, USA
| | - Alexander G Truesdell
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA; Virginia Heart, Falls Church, VA, USA
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Zhipeng Zhou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | | | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Barts Heart Centre, London and Queen Mary University of London, London, UK
| | - Mir B Basir
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - William W O'Neill
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - David J Cohen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; St. Francis Hospital, Roslyn, NY, USA.
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Jung C, Bruno RR, Jumean M, Price S, Krychtiuk KA, Ramanathan K, Dankiewicz J, French J, Delmas C, Mendoza AA, Thiele H, Soussi S. Management of cardiogenic shock: state-of-the-art. Intensive Care Med 2024:10.1007/s00134-024-07618-x. [PMID: 39254735 DOI: 10.1007/s00134-024-07618-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] [Received: 03/29/2024] [Accepted: 08/18/2024] [Indexed: 09/11/2024]
Abstract
The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.
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Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
- Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany.
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | | | - Susanna Price
- Division of Heart, Lung and Critical Care, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Cardiology, Lund, Sweden
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia
| | - Clement Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
- REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | | | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network (UHN), Women's College Hospital, University of Toronto, Toronto Western Hospital, Toronto, Canada
- University of Paris Cité, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Paris, France
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Ostadal P, Belohlavek J. What is cardiogenic shock? New clinical criteria urgently needed. Curr Opin Crit Care 2024; 30:319-323. [PMID: 38841985 PMCID: PMC11224559 DOI: 10.1097/mcc.0000000000001172] [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] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods. RECENT FINDINGS Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure. SUMMARY Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.
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Affiliation(s)
- Petr Ostadal
- Department of Cardiology, Second Faculty of Medicine, Charles University and Motol University Hospital
| | - Jan Belohlavek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Schaubroeck H, Rossberg M, Thiele H, Pöss J. ICU management of cardiogenic shock before mechanical support. Curr Opin Crit Care 2024; 30:362-370. [PMID: 38872375 DOI: 10.1097/mcc.0000000000001182] [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 Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS). RECENT FINDINGS Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock. SUMMARY Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.
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Affiliation(s)
| | - Michelle Rossberg
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Janine Pöss
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Beaini H, Chunawala Z, Cheeran D, Araj F, Wrobel C, Truby L, Saha A, Thibodeau JT, Farr M. Cardiogenic Shock: Focus on Non-Cardiac Biomarkers. Curr Heart Fail Rep 2024:10.1007/s11897-024-00676-8. [PMID: 39078556 DOI: 10.1007/s11897-024-00676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE OF REVIEW To examine the evolving multifaceted nature of cardiogenic shock (CS) in the context of non-cardiac biomarkers that may improve CS management and risk stratification. RECENT FINDINGS There are increasing data highlighting the role of lactate, glucose, and other markers of inflammation and end-organ dysfunction in CS. These biomarkers provide a more comprehensive understanding of the concurrent hemo-metabolic and cellular disturbances observed in CS and offer insights beyond standard structural and functional cardiac assessments. Non-cardiac biomarkers both refine the diagnostic accuracy and improve the prognostic assessments in CS. Further studies revolving around novel biomarkers are warranted to support more targeted and effective therapeutic and management interventions in these high-risk patients.
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Affiliation(s)
- Hadi Beaini
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Zainali Chunawala
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Daniel Cheeran
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Dallas Veteran's Administration Hospital, Dallas, TX, USA
| | - Faris Araj
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Christopher Wrobel
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Lauren Truby
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Amit Saha
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Jennifer T Thibodeau
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA
- Parkland Memorial Hospital, Dallas, TX, USA
| | - Maryjane Farr
- Department of Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Dallas, TX, 75235, USA.
- Parkland Memorial Hospital, Dallas, TX, USA.
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Elsaeidy AS, Taha AM, Abuelazm M, Soliman Y, Ali MA, Alassiri AK, Shaikhkhalil H, Abdelazeem B. Efficacy and safety of extracorporeal membrane oxygenation for cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:362. [PMID: 39014315 PMCID: PMC11251331 DOI: 10.1186/s12872-024-03917-9] [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: 12/01/2023] [Accepted: 05/02/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been presented as a potential therapeutic option for patients with cardiogenic shock complicating myocardial infarction (CS-MI). We aimed to investigate the efficacy and safety of ECMO in CS-MI. METHODS A systematic review and meta-analysis synthesizing evidence from randomized controlled trials obtained from PubMed, Embase, Cochrane, Scopus, and Web of Science until September 2023. We used the random-effects model to report dichotomous outcomes using risk ratio and continuous outcomes using mean difference with a 95% confidence interval. Finally, we implemented a trial sequential analysis to evaluate the reliability of our results. RESULTS We included four trials with 611 patients. No significant difference was observed between ECMO and standard care groups in 30-day mortality with pooled RR of 0.96 (95% CI: 0.81-1.13, p = 0.60), acute kidney injury (RR: 0.65, 95% CI: 0.41-1.03, p = 0.07), stroke (RR: 1.16, 95% CI: 0.38-3.57, p = 0.80), sepsis (RR: 1.06, 95% CI: 0.77-1.47, p = 0.71), pneumonia (RR: 0.99, 95% CI: 0.58-1.68, p = 0.96), and 30-day reinfarction (RR: 0.95, 95% CI: 0.25-3.60, p = 0.94). However, the ECMO group had higher bleeding events (RR: 2.07, 95% CI: 1.44-2.97, p < 0.0001). CONCLUSION ECMO did not improve clinical outcomes compared to the standard of care in patients with CS-MI but increased the bleeding risk.
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Gédéon T, Zolotarova T, Eisenberg MJ. The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a narrative review. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae051. [PMID: 38974874 PMCID: PMC11227219 DOI: 10.1093/ehjopen/oeae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/29/2024] [Accepted: 06/14/2024] [Indexed: 07/09/2024]
Abstract
Aims Cardiogenic shock (CS) develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 50% risk of mortality. Despite the paucity of evidence regarding its benefits, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in clinical practice in patients with AMI in CS (AMI-CS). This review aims to provide an in-depth description of the four available randomized controlled trials to date designed to evaluate the benefit of VA-ECMO in patients with AMI-CS. Methods and results The literature search was conducted on PubMed, Google Scholar, and clinicaltrials.gov to identify the four relevant randomized control trials from years of inception to October 2023. Despite differences in patient selection, nuances in trial conduction, and variability in trial endpoints, all four trials (ECLS-SHOCK I, ECMO-CS, EUROSHOCK, and ECLS-SHOCK) failed to demonstrate a mortality benefit with the use of VA-ECMO in AMI-CS, with high rates of device-related complications. However, the outcome of these trials is nuanced by the limitations of each study that include small sample sizes, challenging patient selection, and high cross-over rates to the intervention group, and lack of use of left ventricular unloading strategies. Conclusion The presented literature of VA-ECMO in CS does not support its routine use in clinical practice. We have yet to identify which subset of patients would benefit most from this intervention. This review emphasizes the need for designing adequately powered trials to properly assess the role of VA-ECMO in AMI-CS, in order to build evidence for best practices.
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Affiliation(s)
- Tara Gédéon
- Division of Cardiology, Jewish General Hospital, McGill University, 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, QC H3T 1E2, Canada
| | - Tetiana Zolotarova
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Ste-Catherine Road, Montreal, QC H3T 1E2, Canada
| | - Mark J Eisenberg
- Division of Cardiology, Jewish General Hospital, McGill University, 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, QC H3T 1E2, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Ste-Catherine Road, Montreal, QC H3T 1E2, Canada
- Department of Medicine, McGill University, 1001 Decarie Boulevard, Suite D05-2212, Montreal, QC H4A 3J1, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Ave, Montreal, QC H3A 1Y7, Canada
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11
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Ruka M, Schupp T, Weidner K, Egner-Walter S, Forner J, Mashayekhi K, Tajti P, Ayoub M, Akin M, Behnes M, Akin I, Rusnak J. Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock. Curr Med Res Opin 2024; 40:1083-1092. [PMID: 38720658 DOI: 10.1080/03007995.2024.2353908] [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: 11/17/2023] [Accepted: 05/07/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS. METHODS Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation. RESULTS 105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = .054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = .027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007-4.774; p = .048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = .015), which, however, could not be confirmed in multivariable Cox regression. CONCLUSION The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.
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Affiliation(s)
- Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum - Bad Oeynhausen, Bad Oeynhausen, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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12
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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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13
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Kruse JM, Nee J, Eckardt KU, Wengenmayer T. [Open questions with respect to extracorporeal circulatory support 2024]. Med Klin Intensivmed Notfmed 2024; 119:346-351. [PMID: 38568446 DOI: 10.1007/s00063-024-01131-1] [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: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 05/28/2024]
Abstract
The use of extracorporeal circulatory support, both for cardiogenic shock and during resuscitation, still presents many unanswered questions. The inclusion and exclusion criteria for such a resource-intensive treatment must be clearly defined, considering that these criteria are directly associated with the type and location of treatment. For example, it is worth questioning the viability of an extracorporeal resuscitation program in areas where it is impossible to achieve low-flow times under 60 min due to local limitations. Additionally, the best approach for further treatment, including whether it is necessary to regularly relieve the left ventricle, must be explored. To find answers to some of these questions, large-scale, multicenter, randomized studies and registers must be performed. Until then this treatment must be carefully considered before use.
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Affiliation(s)
- J-M Kruse
- Medizinische Klinik mit Schwerpunkt Nephrologie und internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - J Nee
- Medizinische Klinik mit Schwerpunkt Nephrologie und internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - K-U Eckardt
- Medizinische Klinik mit Schwerpunkt Nephrologie und internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - T Wengenmayer
- Interdisziplinäre Medizinische Intensivtherapie (IMT), Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
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14
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Piccone G, Schiavoni L, Mattei A, Benedetto M. Extracorporeal Life Support in Myocardial Infarction: New Highlights. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:907. [PMID: 38929524 PMCID: PMC11205984 DOI: 10.3390/medicina60060907] [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: 04/05/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Cardiogenic shock (CS) is a potentially severe complication following acute myocardial infarction (AMI). The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in these patients has risen significantly over the past two decades, especially when conventional treatments fail. Our aim is to provide an overview of the role of VA-ECMO in CS complicating AMI, with the most recent literature highlights. Materials and Methods: We have reviewed the current VA-ECMO practices with a particular focus on CS complicating AMI. The largest studies reporting the most significant results, i.e., overall clinical outcomes and management of the weaning process, were identified in the PubMed database from 2019 to 2024. Results: The literature about the use of VA-ECMO in CS complicating AMI primarily has consisted of observational studies until 2019, generating the need for randomized controlled trials. The EURO-SHOCK trial showed a lower 30-day all-cause mortality rate in patients receiving VA-ECMO compared to those receiving standard therapy. The ECMO-CS trial compared immediate VA-ECMO implementation with early conservative therapy, with a similar mortality rate between the two groups. The ECLS-SHOCK trial, the largest randomized controlled trial in this field, found no significant difference in mortality at 30 days between the ECMO group and the control group. Recent studies suggest the potential benefits of combining left ventricular unloading devices with VA-ECMO, but they also highlight the increased complication rate, such as bleeding and vascular issues. The routine use of VA-ECMO in AMI complicated by CS cannot be universally supported due to limited evidence and associated risks. Ongoing trials like the Danger Shock, Anchor, and Recover IV trials aim to provide further insights into the management of AMI complicated by CS. Conclusions: Standardizing the timing and indications for initiating mechanical circulatory support (MCS) is crucial and should guide future trials. Multidisciplinary approaches tailored to individual patient needs are essential to minimize complications from unnecessary MCS device initiation.
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Affiliation(s)
- Giulia Piccone
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy;
| | - Lorenzo Schiavoni
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Campus-Bio-Medico, Via Alvaro del Portillo 200, 00127 Roma, Italy;
| | - Alessia Mattei
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Campus-Bio-Medico, Via Alvaro del Portillo 200, 00127 Roma, Italy;
| | - Maria Benedetto
- Cardio-thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy;
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15
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Zeymer U, Heer T, Ouarrak T, Akin I, Noc M, Stepinska J, Oldroyd K, Serpytis P, Montalescot G, Huber K, Windecker S, Savonitto S, Vrints C, Schneider S, Desch S, Thiele H. Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:335-346. [PMID: 38349233 DOI: 10.1093/ehjacc/zuae020] [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: 10/03/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 05/09/2024]
Abstract
AIMS We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. METHODS AND RESULTS In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. CONCLUSION In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.
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Affiliation(s)
- Uwe Zeymer
- Department of Cardiology, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, 67063 Ludwigshafen, Germany
- Stiftung Institut für Herzinfarktforschung, Bremserstraße 79, 67063 Ludwigshafen, Germany
| | - Tobias Heer
- Department of Cardiology, München Klinik Neuperlach, Academic Teaching Hospital, LMU University of Munich, Oskar-Maria-Graf-Ring 51, 81737 Munich, Germany
| | - Taoufik Ouarrak
- Stiftung Institut für Herzinfarktforschung, Bremserstraße 79, 67063 Ludwigshafen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Marko Noc
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Janina Stepinska
- Department of Cardiology, Institute of Cardiology, Warsaw, Poland
| | - Keith Oldroyd
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Pranas Serpytis
- Department of Cardiology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Giles Montalescot
- Department of Cardiology, ACTION Study Group, Sorbonne Université Paris 6, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Kurt Huber
- Department of Cardiology, Wilhelminenspital, Vienna, Austria
- Department of Cardiology, Medical School, Sigmund Freud University, Vienna, Austria
| | - Stephan Windecker
- Department of Cardiology, University of Bern, Inselspital, Bern, Switzerland
| | | | - Christiaan Vrints
- Department of Cardiology, Universitair Ziekenhuis Antwerp, Antwerp, Belgium
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung, Bremserstraße 79, 67063 Ludwigshafen, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig, University Hospital, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University Hospital, Leipzig, Germany
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16
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Zhou X, Tan W, Liu M, Liu N. Predicting the mortality of patients with cardiogenic shock after coronary artery bypass grafting. Perfusion 2024; 39:807-815. [PMID: 36935559 DOI: 10.1177/02676591231161275] [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] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Cardiogenic shock (CS) is a critical condition and the leading cause of mortality after coronary artery bypass grafting (CABG). To define the risk factors for CS in patients who undergo CABG and create a risk-predictive model is crucial. METHODS In this observational study, we retrospectively evaluated consecutive patients who underwent CABG between January 2018 and October 2022 at Beijing Anzhen Hospital. A total of 496 patients were enrolled and categorized into the training (396 cases) and internal test (100 cases) sets. The variables significantly associated with mortality (p < 0.05) were analyzed using logistic regression analyses. RESULTS The E/A ratio at admission, postoperative brain natriuretic peptide, postoperative arterial lactate, two or more arrhythmias at the same time after CABG, and carotid artery stenosis at admission were identified as independent prognostic factors for in-hospital mortality after multivariate logistic regression analysis. The CS after CABG score (ACCS) was established and three classes of ACCS, named classes I (ACCS, <20), II (ACCS, 20-30), and III (ACCS, >30), made up the risk model. The ACCS showed better discrimination with an AUROC of 0.937 (95% confidence interval, 0.982-0.892) and calibration with the Hosmer-Lemeshow test (X2 = 5.854 with 8 df; p = 0.664). In addition, tenfold cross-validation demonstrated that the mean misdiagnosis rate was 5.56% and the lowest misdiagnosis rate was 6.38%. CONCLUSION The ACCS score represents a risk-predictive model for in-hospital mortality of patients with CS after CABG in acute care settings. Patients identified as class III may have a worse prognosis.
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Affiliation(s)
- Xiaozheng Zhou
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen Tan
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Maomao Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Lee KH, Harrison W, Chow KL, Lee M, Kerr AJ. Cardiogenic Shock Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: Outcomes and Predictors of Mortality (ANZACS-QI 73). Heart Lung Circ 2024; 33:450-459. [PMID: 38453606 DOI: 10.1016/j.hlc.2024.01.009] [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: 12/09/2023] [Revised: 12/22/2023] [Accepted: 01/01/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND & AIMS Cardiogenic shock (CS) is a serious complication of acute myocardial infarction (MI) and is associated with significant mortality. We describe a contemporary, real-world cohort of patients with ST-elevation MI (STEMI) and CS, including 30-day mortality and clinically relevant predictors of mortality. METHODS All patients presenting with STEMI who were treated with percutaneous coronary intervention (PCI) in New Zealand (2016 to 2020) were identified from the Aotearoa New Zealand All Cardiology Services Quality Improvement (ANZACS-QI) registry and stratified based on their Killip class on arrival to the cardiac catheterisation laboratory. Primary outcome was 30-day all-cause mortality. Multivariable analysis was used to identify predictors of mortality prior to PCI and to develop a mortality scoring system. RESULTS In total, 6,649 patients were identified, including 192 (2.9%) Killip IV (CS) patients. Thirty-day mortality was 47.5% in patients with CS, 14.6% in those with heart failure without shock, and 3% in those without heart failure. Independent predictors of 30-day mortality for patients with CS were: estimated glomerular filtration rate <60 mL/min/1.73m2 (relative risk [RR] 1.89, 95% confidence interval [CI] 1.39-2.58), cardiac arrest (RR 1.54, 95% CI 1.15-2.06), diabetes (RR 1.31, 95% CI 1.01-1.70), female sex (RR 1.32, 95% CI 1.01-1.72), femoral arterial access (RR 1.42, 95% CI 1.06-1.90) and left main stem culprit (RR 2.16, 95% CI 1.65-2.84). A multivariable Shock score was developed which predicts 30-day mortality with good global discrimination (area under the curve 0.79, 95% CI 0.73-0.85). CONCLUSION In this national cohort, the 30-day mortality for STEMI patients presenting with CS treated with PCI remains high, at nearly 50%. The ANZACS-QI Shock score is a promising tool for mortality risk stratification prior to PCI but requires further validation.
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Affiliation(s)
- Kyu Hyun Lee
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand.
| | - Wil Harrison
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand
| | - Kok Lam Chow
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand
| | - Mildred Lee
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Andrew J Kerr
- Cardiology Department Middlemore Hospital, Middlemore, New Zealand; Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
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18
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Schupp T, Rusnak J, Egner-Walter S, Ruka M, Dudda J, Bertsch T, Müller J, Mashayekhi K, Tajti P, Ayoub M, Akin I, Behnes M. Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry. Clin Res Cardiol 2024; 113:626-641. [PMID: 37093246 DOI: 10.1007/s00392-023-02196-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/28/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI). BACKGROUND Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. METHODS Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching. RESULTS 273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528). CONCLUSION AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Bad Neustadt a. d. Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohammed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum-Bad, Oeynhausen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany.
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19
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Patsalis N, Kreutz J, Chatzis G, Fichera CF, Syntila S, Choukeir M, Griewing S, Schieffer B, Markus B. Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference? Clin Res Cardiol 2024; 113:602-611. [PMID: 38261027 PMCID: PMC10954998 DOI: 10.1007/s00392-024-02377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices may stabilize patients with severe cardiogenic shock (CS) following myocardial infarction (MI). However, the canonical understanding of hemodynamics related to the determination of the native cardiac output (CO) does not explain or support the understanding of combined left and right MCS. To ensure the most optimal therapy control, the current principles of hemodynamic measurements during biventricular support should be re-evaluated. METHODS Here we report a protocol of hemodynamic optimization strategy during biventricular MCS (VA-ECMO and left ventricular Impella) in a case series of 10 consecutive patients with severe cardiogenic shock complicating myocardial infarction. During the protocol, the flow rates of both devices were switched in opposing directions (+ / - 0.7 l/min) for specified times. To address the limitations of existing hemodynamic measurement strategies during biventricular support, different measurement techniques (thermodilution, Fick principle, mixed venous oxygen saturation) were performed by pulmonary artery catheterization. Additionally, Doppler ultrasound was performed to determine the renal resistive index (RRI) as an indicator of renal perfusion. RESULTS The comparison between condition 1 (ECMO flow > Impella flow) and condition 2 (Impella flow > VA-ECMO flow) revealed significant changes in hemodynamics. In detail, compared to condition 1, condition 2 results in a significant increase in cardiac output (3.86 ± 1.11 vs. 5.44 ± 1.13 l/min, p = 0.005) and cardiac index (2.04 ± 0.64 vs. 2.85 ± 0.69, p = 0.013), and mixed venous oxygen saturation (56.44 ± 6.97% vs. 62.02 ± 5.64% p = 0.049), whereas systemic vascular resistance decreased from 1618 ± 337 to 1086 ± 306 s*cm-5 (p = 0.002). Similarly, RRI decreased in condition 2 (0.662 ± 0.05 vs. 0.578 ± 0.06, p = 0.003). CONCLUSIONS To monitor and optimize MCS in CS, PA catheterization for hemodynamic measurement is applicable. Higher Impella flow is superior to higher VA-ECMO flow resulting in a more profound increase in CO with subsequent improvement of organ perfusion.
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Affiliation(s)
- Nikolaos Patsalis
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Julian Kreutz
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Giorgos Chatzis
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Carlo-Federico Fichera
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Styliani Syntila
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Maryana Choukeir
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Sebastian Griewing
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Bernhard Schieffer
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany
| | - Birgit Markus
- Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital of the Philipps University of Marburg, Baldinger Str., 35043, Marburg, Germany.
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20
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Hlinomaz O, Motovska Z, Kala P, Hromadka M, Precek J, Mrozek J, Červinka P, Kettner J, Matejka J, Zohoor A, Bis J, Jarkovsky J. Outcomes of patients with myocardial infarction and cardiogenic shock treated with culprit vessel-only versus multivessel primary PCI. Hellenic J Cardiol 2024; 76:1-10. [PMID: 37633488 DOI: 10.1016/j.hjc.2023.08.009] [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: 02/26/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Multivessel primary percutaneous coronary intervention (pPCI) is still often used in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and multivessel coronary disease (MVD) treated with culprit vessel-only pPCI or multivessel-pPCI during the initial procedure. MATERIAL AND METHODS From 2016 to 2020, 23,703 primary PCI patients with STEMI were included in a national all-comers registry of cardiovascular interventions. Of them, 1,213 (5.1%) patients had CS and MVD at admission to the hospital. Initially, 921 (75.9%) patients were treated with culprit vessel (CV)-pPCI and 292 (24.1%) with multivessel (MV)-pPCI. RESULTS Patients with 3-vessel disease and left main disease had a higher probability of being treated with MV-pPCI than patients with 2-vessel disease and patients without left main disease (28.5% vs. 18.6%; p < 0.001 and 37.7% vs. 20.6%; p < 0.001). Intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and other mechanical circulatory support systems were more often used in patients with MV-pPCI. Thirty (30)-day and 1-year all-cause mortality rates were similar in the CV-pPCI and MV-pPCI groups (odds ratio, 1.01; 95% confidence interval [CI] 0.77 to 1.32; p = 0.937 and 1.1; 95% CI 0.84 to 1.44; p = 0.477). The presence of 3-vessel disease and the use of ECMO were the strongest adjusted predictors of 30-day and 1-year mortality. CONCLUSIONS Our data from an extensive all-comers registry suggests that selective use of MV-pPCI does not increase the all-cause mortality rate in patients with CS-STEMI and MVD compared to CV-pPCI.
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Affiliation(s)
- Ota Hlinomaz
- International Clinical Research Center and Department of Cardioangiology, St. Anne University Hospital and Masaryk University, Brno, Czech Republic
| | - Zuzana Motovska
- Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Petr Kala
- University Hospital Brno and Faculty of Medicine of Masaryk University, Department of Internal Medicine and Cardiology, Brno, Czech Republic
| | - Milan Hromadka
- University Hospital and Faculty of Medicine, Pilsen, Czech Republic
| | - Jan Precek
- University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Jan Mrozek
- University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | | | - Jiri Kettner
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Matejka
- Regional Hospital, Pardubice, Czech Republic
| | | | - Josef Bis
- University Hospital and Faculty of Medicine, Hradec Kralové, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses of Masaryk University, Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, Czech Republic
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21
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Yue L, Xiao L, Zhang X, Niu L, Wen Y, Li X, Wang Y, Xing G, Li G. Comparative efficacy of Chinese herbal injections in patients with cardiogenic shock (CS): a systematic review and Bayesian network meta-analysis of randomized controlled trials. Front Pharmacol 2024; 15:1348360. [PMID: 38476325 PMCID: PMC10927829 DOI: 10.3389/fphar.2024.1348360] [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: 12/02/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Background: Cardiogenic shock (CS) is the primary cause of death in patients suffering acute myocardial infarction. As an emerging and efficacious therapeutic approach, Chinese herbal injections (CHIs) are gaining significant popularity in China. However, the optimal CHIs for treating CS remain uncertain. Method: We searched eight databases from inception to 30 September 2023. Subsequently, we conducted the Bayesian network meta-analysis (NMA). Interventions were ranked based on the surface under the cumulative ranking curve (SUCRA) probability values. To compare the effects of CHIs on two distinct outcomes, a clustering analysis was performed. Furthermore, the quality of the studies was assessed. Results: For the study, we included 43 RCTs, encompassing 2,707 participants. The study evaluated six herbal injections, namely, Shenfu injection (SF), Shengmai injection (SM), Shenmai injection (Sm), Danshen injection (DS), Huangqi injection (HQ), and Xinmailong injection (XML). The analysis findings suggested that Sm (MD = -1.05, 95% CI: -2.10, -0.09) and SF (MD = -0.81, 95% CI: -1.40, -0.25) showed better efficacy compared to Western medicine (WM) alone in reducing in-hospital mortality. The SUCRA values revealed that Sm + WM ranked first in terms of in-hospital mortality, cardiac index (CI), and hourly urine output but second in improving left ventricular ejection fraction (LVEF) and mean arterial pressure (MAP). SF + WM, however, had the greatest impact on raising the clinical effective rate. In MAP, SM + WM came out on top. Moreover, in terms of safety, only 14 studies (31.8%), including five types of CHIs: SF, Sm, SM, HQ, and XML, observed adverse drug reactions. Conclusion: To summarize, this analysis discovered that, in terms of patients suffering from CS, CHIs + WM yielded significantly greater advantages than WM alone. Based on in-hospital mortality and the remaining outcomes, Sm performed excellently among all the involved CHIs. Systematic Review Registration: https:// www.Crd.york.ac.uk/prospero/, identifier: CRD42022347053.
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Affiliation(s)
- Linkai Yue
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Lu Xiao
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Xuemin Zhang
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Liqing Niu
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Yue Wen
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Xiaowei Li
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Ying Wang
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Guanghe Xing
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Guiwei Li
- Department of Emergency, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
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Schmitt A, Schupp T, Rusnak J, Weidner K, Ruka M, Egner-Walter S, Mashayekhi K, Tajti P, Ayoub M, Behnes M, Akin I. Association of body mass index with 30-day all-cause mortality in cardiogenic shock. Nutr Metab Cardiovasc Dis 2024; 34:426-435. [PMID: 38000994 DOI: 10.1016/j.numecd.2023.09.021] [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: 05/08/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND AND AIMS This study investigates the prognostic impact of body mass index (BMI) on the risk of 30-day all-cause mortality in patients with cardiogenic shock (CS). Due to ongoing epidemiological developments, the characteristics of patients with cardiovascular disease are consistently changing. Especially increasing rates of obesity and associated comorbidities have been observed. However, data regarding the prognostic value of BMI in patients with CS remains inconclusive. METHODS AND RESULTS Consecutive patients with CS were included from 2019 to 2021. The prognostic value of BMI (i.e., BMI 18.5-<25; 25-30 and >30 kg/m2) was analyzed using Kaplan-Meier and multivariable Cox proportional regression analyses regarding the primary endpoint of 30-day all-cause mortality. Additional risk stratification was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). 256 patients with a median BMI of 26.4 kg/m2 were included. The overall risk of 30-day all-cause mortality was 53.5%. Within the entire study cohort, BMI was not associated with the risk of 30-day all-cause mortality (log rank p ≥ 0.107). In contrast, BMI >30 kg/m2 was associated with higher risk of 30-day all-cause mortality when compared to BMI <25 kg/m2 in patients with AMI-CS (78% vs 47%; log rank p = 0.017), which was confirmed after multivariable adjustment (HR = 2.466; 95% CI 1.126-5.399; p = 0.024). However, BMI was not associated with mortality in patients with non-AMI-CS. CONCLUSION BMI >30 kg/m2 was associated with increased risk of 30-day all-cause mortality in patients with AMI-CS, but not in non-AMI-CS.
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Affiliation(s)
- Alexander Schmitt
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum - Bad Oeynhausen, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
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23
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Manzi L, Sperandeo L, Forzano I, Castiello DS, Florimonte D, Paolillo R, Santoro C, Mancusi C, Di Serafino L, Esposito G, Gargiulo G. Contemporary Evidence and Practice on Right Heart Catheterization in Patients with Acute or Chronic Heart Failure. Diagnostics (Basel) 2024; 14:136. [PMID: 38248013 PMCID: PMC10814482 DOI: 10.3390/diagnostics14020136] [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: 11/13/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Heart failure (HF) has a global prevalence of 1-2%, and the incidence around the world is growing. The prevalence increases with age, from around 1% for those aged <55 years to >10% for those aged 70 years or over. Based on studies in hospitalized patients, about 50% of patients have heart failure with reduced ejection fraction (HFrEF), and 50% have heart failure with preserved ejection fraction (HFpEF). HF is associated with high morbidity and mortality, and HF-related hospitalizations are common, costly, and impact both quality of life and prognosis. More than 5-10% of patients deteriorate into advanced HF (AdHF) with worse outcomes, up to cardiogenic shock (CS) condition. Right heart catheterization (RHC) is essential to assess hemodynamics in the diagnosis and care of patients with HF. The aim of this article is to review the evidence on RHC in various clinical scenarios of patients with HF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy; (L.M.); (L.S.); (I.F.); (D.S.C.); (D.F.); (R.P.); (C.S.); (C.M.); (L.D.S.); (G.E.)
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24
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Behnes M, Rusnak J, Egner-Walter S, Ruka M, Dudda J, Schmitt A, Forner J, Mashayekhi K, Tajti P, Ayoub M, Weiß C, Akin I, Schupp T. Effect of Admission and Onset Time on the Prognosis of Patients With Cardiogenic Shock. Chest 2024; 165:110-127. [PMID: 37579943 DOI: 10.1016/j.chest.2023.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/22/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated. RESEARCH QUESTION Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days? STUDY DESIGN AND METHODS This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses. RESULTS Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI. INTERPRETATION Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT05575856; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Alexander Schmitt
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum, Bad Oeynhausen, Germany
| | - Christel Weiß
- Institute of Biomathematics and Medical Statistics, Faculty of Medicine Mannheim, University Medical Center, Mannheim
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim.
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim
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25
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Schupp T, Rusnak J, Forner J, Dudda J, Bertsch T, Behnes M, Akin I. Platelet Count During Course of Cardiogenic Shock. ASAIO J 2024; 70:44-52. [PMID: 37831815 DOI: 10.1097/mat.0000000000002066] [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: 10/15/2023] Open
Abstract
The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.
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Affiliation(s)
- Tobias Schupp
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Dudda
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Michael Behnes
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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Paddock S, Meng J, Johnson N, Chattopadhyay R, Tsampasian V, Vassiliou V. The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae003. [PMID: 38313078 PMCID: PMC10836884 DOI: 10.1093/ehjopen/oeae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/29/2023] [Accepted: 01/14/2024] [Indexed: 02/06/2024]
Abstract
Aims Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of infarct-related cardiogenic shock. However, there is limited evidence regarding its beneficial impact on mortality. The aim of this study was to systematically review studies reporting the impact of VA-ECMO on mortality in patients with acute myocardial infarction complicated by cardiogenic shock. Methods and results A comprehensive search of medical databases (Cochrane Register and PubMed) was conducted. Studies that reported mortality outcomes in patients treated with VA-ECMO for infarct-related cardiogenic shock were included. The database search yielded 1194 results, of which 11 studies were included in the systematic review. Four of these studies, with a total of 586 patients, were randomized controlled trials and were included in the meta-analysis. This demonstrated that there was no significant difference in 30-day all-cause mortality with the use of VA-ECMO compared with standard medical therapy [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.65-1.27]. Meta-analysis of two studies showed that VA-ECMO was associated with a significant reduction in 12-month all-cause mortality (OR 0.31; 95% CI 0.11-0.86). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality. Conclusion Veno-arterial extracorporeal membrane oxygenation does not improve 30-day all-cause mortality in patients with cardiogenic shock following acute myocardial infarction; however, there may be significant reduction in all-cause mortality at 12 months. Further studies are needed to delineate the potential benefit of VA-ECMO in long-term outcomes. Registration The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023461740).
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Affiliation(s)
- Sophie Paddock
- Cardiology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - James Meng
- Cardiology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Nicholas Johnson
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Rahul Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
- Cardiology Department, Cambridge University Hospital, Cambridge, UK
| | - Vasiliki Tsampasian
- Cardiology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Vassilios Vassiliou
- Cardiology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
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27
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Sarma D, Jentzer JC. Cardiogenic Shock: Pathogenesis, Classification, and Management. Crit Care Clin 2024; 40:37-56. [PMID: 37973356 DOI: 10.1016/j.ccc.2023.05.001] [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] [Indexed: 11/19/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Jentzer JC, Watanabe A, Kuno T, Bangalore S, Alviar CL. Network meta-analysis of temporary mechanical circulatory support in acute myocardial infarction cardiogenic shock. Am Heart J 2023; 266:184-187. [PMID: 37591368 DOI: 10.1016/j.ahj.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/03/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
We performed a network meta-analysis of 11 published randomized clinical trials examining the use of temporary mechanical circulatory support (MCS) devices in adults with acute myocardial infarction cardiogenic shock, including 1,053 total patients with an observed in-hospital or 30-day mortality of 40.4%. None of the temporary MCS devices was associated with lower in-hospital or 30-day mortality compared with initial medical therapy or any other MCS device, either individually or in combination. These data do not support the routine use of temporary MCS devices for the purpose of reducing short-term mortality in unselected patients with acute myocardial infarction cardiogenic shock.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein Medical College, New York, NY
| | - Sripal Bangalore
- The Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, NY
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, NY
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Jentzer JC, Burstein B, Ternus B, Bennett CE, Menon V, Oh JK, Anavekar NS. Noninvasive Hemodynamic Characterization of Shock and Preshock Using Echocardiography in Cardiac Intensive Care Unit Patients. J Am Heart Assoc 2023; 12:e031427. [PMID: 37982222 PMCID: PMC10727278 DOI: 10.1161/jaha.123.031427] [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: 07/11/2023] [Accepted: 09/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE). METHODS AND RESULTS We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in-hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In-hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In-hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in-hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures. CONCLUSIONS Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.
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Affiliation(s)
| | - Barry Burstein
- Division of Cardiology, Trillium Health PartnersUniversity of TorontoTorontoOntarioCanada
| | - Bradley Ternus
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | | | - Venu Menon
- Department of Cardiovascular MedicineCleveland ClinicClevelandOH
| | - Jae K. Oh
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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Rusnak J, Schupp T, Weidner K, Ruka M, Egner-Walter S, Forner J, Bertsch T, Kittel M, Mashayekhi K, Tajti P, Ayoub M, Akin I, Behnes M. Outcome of Patients With Cardiogenic Shock and Previous Right Ventricular Impairment Represented by Decreased Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio. Am J Cardiol 2023; 207:431-440. [PMID: 37797550 DOI: 10.1016/j.amjcard.2023.08.118] [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: 02/10/2023] [Revised: 08/12/2023] [Accepted: 08/20/2023] [Indexed: 10/07/2023]
Abstract
This study investigates the prognostic impact of known decreased ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) and TAPSE in patients with cardiogenic shock (CS). In patients with pulmonary artery hypertension and in critically ill patients, decreased TAPSE and TAPSE/PASP ratio are known to be negative predictors. However, studies regarding the prognostic impact in patients with CS are limited. Consecutive patients with CS from June 2019 to May 2021 treated at a single center were included. Medical history including echocardiographic parameters such as TAPSE and PASP was documented for each patient. The primary endpoint was all-cause mortality at 30 days. Statistical analyses included univariable t test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, and Cox proportional regression analyses. A total of 90 patients with CS and measurement of TAPSE and TAPSE/PASP ratio were included. TAPSE and TAPSE/PASP ratio measured several months before intensive care unit admission were both able to predict 30-day survival in CS patients, and were both lower in 30-day nonsurvivors. TAPSE/PASP ratio <0.4 mm/mmHg (log-rank p = 0.006) and TAPSE <18 mm (log-rank p = 0.004) were associated with increased risk of 30-day all-cause mortality. After multivariable adjustment, TAPSE/PASP ratio <0.4 mm/mmHg was not able to predict 30-day all-cause mortality, whereas TAPSE <18 mm was still significantly associated with the primary endpoint (hazard ratio 2.336, confidence interval 1.067 to 5.115, p = 0.034). In consecutive patients presenting with CS, compared to TAPSE alone, previously determined TAPSE/PASP ratio did not improve risk prediction for 30-day all-cause mortality.
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Affiliation(s)
- Jonas Rusnak
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Tobias Schupp
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, MEDICLIN Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Hemostaseology and Internal Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; European Center for Angioscience (ECAS) and German Centre for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
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von Lewinski D, Herold L, Bachl E, Bugger H, Glantschnig T, Kolesnik E, Verheyen N, Benedikt M, Wallner M, von Lewinski F, Schmidt A, Harb S, Ablasser K, Sacherer M, Scherr D, Manninger-Wünscher M, Pätzold S, Gollmer J, Zirlik A, Toth GG. Outcomes of ECLS-SHOCK Eligibility Criteria Applied to a Real-World Cohort. J Clin Med 2023; 12:6988. [PMID: 38002602 PMCID: PMC10672386 DOI: 10.3390/jcm12226988] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) exhibits high (~50%) in-hospital mortality. The recently published Extracorporeal life Support in Cardiogenic Shock (ECLS-SHOCK) trial demonstrated the neutral effects of the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on all-cause death, as well as on all secondary outcomes in subjects presenting with myocardial-infarction (MI)-related CS. Here, we compared ECLS-SHOCK eligibility criteria with a real-world cohort of CS patients. METHODS AND RESULTS ECLS-SHOCK eligibility criteria were applied to a prospective single-center CS registry (the PREPARE CS registry) consisting of 557 patients who were consecutively admitted to the catheterization laboratory (cath lab) of the Medical University of Graz, Austria, due to CS (SCAI C-E). Overall use of mechanical circulatory support (MCS) in this cohort was 19%. Sixty-nine percent of the entire cohort had MI-related CS, 38% of whom would have met ECLS-SHOCK eligibility criteria, thus representing only 27% of the PREPARE CS registry. Exclusion from the ECLS-SHOCK trial was based on patients with initial lactate values below 3 mmol/L (n = 168; 43.6%), aged over 80 years (n = 65; 16.9%), and with a duration of cardiopulmonary resuscitation (CPR) exceeding 45 min (n = 22; 5.7%). The 30-day mortality of patients of the PREPARE CS registry who met the ECLS-SHOCK eligibility criteria was 57.0%, compared to 48.4% of patients in the ECLS-SHOCK trial. The patients' baseline characteristics, however, differed considerably with respect to type of infarction, age, and gender. CONCLUSIONS In a real-world cohort of patients with MI-related CS, only 38% of patients met the eligibility criteria of the ECLS-SHOCK trial. Thus, the impact of the use of VA-ECMO on outcome parameters in MI-related CS, as observed in the ECLS-SHOCK trial, may differ in a more heterogeneous real-world CS population of the PREPARE CS registry.
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Affiliation(s)
- Dirk von Lewinski
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Lukas Herold
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Eva Bachl
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Heiko Bugger
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Theresa Glantschnig
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Ewald Kolesnik
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Nicolas Verheyen
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Martin Benedikt
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Markus Wallner
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Friederike von Lewinski
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8036 Graz, Austria
| | - Albrecht Schmidt
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Stefan Harb
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Klemens Ablasser
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Michael Sacherer
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Daniel Scherr
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Martin Manninger-Wünscher
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Sascha Pätzold
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Johannes Gollmer
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Andreas Zirlik
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
| | - Gabor G. Toth
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; (E.B.); (H.B.); (E.K.); (N.V.); (M.W.); (A.S.); (S.H.); (M.S.); (D.S.); (M.M.-W.); (S.P.); (J.G.); (G.G.T.)
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Jalil S, Ahmed A, Abdalla M, Al-Hijji M. Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report. Eur Heart J Case Rep 2023; 7:ytad553. [PMID: 38025122 PMCID: PMC10681707 DOI: 10.1093/ehjcr/ytad553] [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: 02/11/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023]
Abstract
Background Rheumatic fever is still a major cause of mitral valve (MV) stenosis in the developing world. Few patients with critical rheumatic MV stenosis can present with acute cardiogenic shock (CS) that requires urgent treatment with circulatory support and definitive valvular repair or replacement. Case summary A 37-year-old gentleman was admitted with heart failure, CS Society for Cardiovascular Angiography and Interventions D, and atrial fibrillation with a rapid ventricular response. He had no prior medical history. He had multiple organ failures and required intubation, two DC shocks of 200 joules without haemodynamic improvement, continuous renal replacement therapy, and medical and mechanical circulatory support using extracorporeal membrane oxygenation (ECMO). His echocardiography showed severe rheumatic mitral stenosis (mitral valve area 2D of 0.7 cm2, mean diastolic gradient of 17 mmHg, Wilkins score 7). His Society of Thoracic Surgery score and EuroScore were 50.1% and 12.1%, respectively. Thus, a percutaneous transcatheter mitral commissurotomy (PTMC) was decided as the definitive treatment in a multidisciplinary team meeting. Following the procedure, the patient's circulatory support was gradually weaned off, and he was successfully extubated with a marked improvement in his renal functions. The patient achieved a complete recovery without any long-term sequelae. Discussion Cardiogenic shock related to severe rheumatic MV stenosis requires multidisciplinary team management with prompt diagnosis, initiation of the most appropriate mechanical support device (e.g. ECMO or tandem heart), and relief of the MV obstruction. Percutaneous transcatheter mitral commissurotomy can be the preferred option in this setting if the valve is pliable.
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Affiliation(s)
- Syed Jalil
- Weill Cornell Medicine, College of Medicine, Qatar Foundation, Doha, Qatar
| | - Ashraf Ahmed
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mahmoud Abdalla
- Department of Cardiac Anesthesia, Hamad Medical Corporation, Heart Hospital, Doha, Qatar
| | - Mohammed Al-Hijji
- Weill Cornell Medicine, College of Medicine, Qatar Foundation, Doha, Qatar
- Department of Structural Cardiology, Hamad Medical Corporation, Heart Hospital, Doha, Qatar
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Krychtiuk KA, Speidl WS. Initial haemodynamic assessment of cardiogenic shock: back to basics? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:661-662. [PMID: 37672666 DOI: 10.1093/ehjacc/zuad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Walter S Speidl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Fraccaro C, Karam N, Möllmann H, Bleiziffer S, Bonaros N, Teles RC, Carrilho Ferreira P, Chieffo A, Czerny M, Donal E, Dudek D, Dumonteil N, Esposito G, Fournier S, Hassager C, Kim WK, Krychtiuk KA, Mehilli J, Pręgowski J, Stefanini GG, Ternacle J, Thiele H, Thielmann M, Vincent F, von Bardeleben RS, Tarantini G. Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:634-651. [PMID: 37624587 PMCID: PMC10587846 DOI: 10.4244/eij-d-23-00473] [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: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.
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Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicole Karam
- Heart Valves Unit, Georges Pompidou European Hospital, Université Paris Cité, INSERM, Paris, France
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | | | - Nikolaos Bonaros
- Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental (HSC), Carnaxide, Portugal and Comprehensive Health Research Center (CHRC), Nova Medical School, Lisbon, Portugal
| | - Pedro Carrilho Ferreira
- Cardiology Department, Santa Maria University Hospital, CHULN, CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre, Freiburg University, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erwan Donal
- Service de Cardiologie, CCP CHU de Rennes, University of Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Giovanni Esposito
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland and University of Lausanne, Lausanne, Switzerland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Won-Keun Kim
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Konstantin A Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, German Centre for Cardiovascular Research (DZHK), Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Jerzy Pręgowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warszawa, Poland
| | - Giulio G Stefanini
- Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada and Université Laval, Quebec, QC, Canada
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany and University of Leipzig, Leipzig, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Flavien Vincent
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Schupp T, Forner J, Rusnak J, Weidner K, Egner-Walter S, Ruka M, Dudda J, Jawhar S, Brück LM, Dulatahu F, Bertsch T, Müller J, Behnes M, Akin I. Does Atrial Fibrillation Deteriorate the Prognosis in Patients With Septic or Cardiogenic Shock? Am J Cardiol 2023; 205:141-149. [PMID: 37598599 DOI: 10.1016/j.amjcard.2023.07.008] [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: 02/16/2023] [Revised: 05/16/2023] [Accepted: 07/05/2023] [Indexed: 08/22/2023]
Abstract
Atrial fibrillation (AF) is associated with increased risk of mortality in various clinical conditions. However, the prognostic role of preexisting and new-onset AF in critically ill patients, such as patients with septic or cardiogenic shock remains unclear. This study investigates the prognostic impact of preexisting and new-onset AF on 30-day all-cause mortality in patients with septic or cardiogenic shock. Consecutive patients with sepsis, or septic or cardiogenic shock were enrolled in 2 prospective, monocentric registries from 2019 to 2021. Statistical analyses included Kaplan-Meier, multivariable logistic, and Cox proportional regression analyses. In total, 644 patients were included (cardiogenic shock: n = 273; sepsis/septic shock: n = 361). The prevalence of AF was 41% (29% with preexisting AF, 12% with new-onset AF). Within the entire study cohort, neither preexisting AF (log-rank p = 0.542; hazard ratio [HR] 1.075, 95% confidence interval [CI] 0.848 to 1.363, p = 0.551) nor new-onset AF (log-rank p = 0.782, HR = 0.957, 95% CI 0.683 to 1.340, p = 0.797) were associated with 30-day all-cause mortality compared with non-AF. In patients with AF, ventricular rates >120 beats/min compared with ≤120 beats/min were shown to increase the risk of reaching the primary end point in AF patients with cardiogenic shock (log-rank p = 0.006, HR 1.886, 95% CI 1.164 to 3.057, p = 0.010). Furthermore, logistic regression analyses suggested increased age was the only predictor of new-onset AF (odds ratio 1.042, 95% CI 1.018 to 1.066, p = 0.001). In conclusion, neither the presence of preexisting AF nor the occurrence of new-onset AF was associated with the risk of 30-day all-cause mortality in consecutive patients admitted with cardiogenic shock.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Schanas Jawhar
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Lea Marie Brück
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Floriana Dulatahu
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Bad Neustadt an der Saale, Germany; Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany.
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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Zeymer U, Freund A, Hochadel M, Ostadal P, Belohlavek J, Rokyta R, Massberg S, Brunner S, Lüsebrink E, Flather M, Adlam D, Bogaerts K, Banning A, Sabaté M, Akin I, Jobs A, Schneider S, Desch S, Thiele H. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet 2023; 402:1338-1346. [PMID: 37643628 DOI: 10.1016/s0140-6736(23)01607-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock despite the lack of evidence from adequately powered randomised clinical trials. Three trials reported so far were underpowered to detect a survival benefit; we therefore conducted an individual patient-based meta-analysis to assess the effect of VA-ECMO on 30-day death rate. METHODS Randomised clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock were identified by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomisation was reported and trial investigators agreed to collaborate (ie, providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258). FINDINGS Four trials (n=567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR 0·93; 95% CI 0·66-1·29). Complication rates were higher with VA-ECMO for major bleeding (OR 2·44; 95% CI 1·55-3·84) and peripheral ischaemic vascular complications (OR 3·53; 95% CI 1·70-7·34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (pinteraction ≥0·079). INTERPRETATION VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted. FUNDING Foundation Institut für Herzinfarktforschung.
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Affiliation(s)
- Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany; Klinikum Ludwigshafen, Ludwigshafen, Germany.
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Petr Ostadal
- Department of Cardiology, Na Homolce Hospital, Department of Cardiology and University Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Belohlavek
- Department of Medicine II, General University Hospital and 1st Medical School, Charles University, Prague, Czech Republic
| | - Richard Rokyta
- Cardiology Department, University Hospital and Faculty of Medicine Pilsen, Charles University, Czech Republic
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Kris Bogaerts
- KU Leuven, Department of Public Health and Primary Care, I-BioStat, Leuven and UHasselt, Hasselt, Belgium
| | - Amerjeet Banning
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Manel Sabaté
- Consorci Institut D'Investigacions Biomediques August Pi I Sunyer, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Ibrahim Akin
- University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Jobs
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany.
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37
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Thiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, Lehmann R, Eitel I, Graf T, Seidler T, Schuster A, Skurk C, Duerschmied D, Clemmensen P, Hennersdorf M, Fichtlscherer S, Voigt I, Seyfarth M, John S, Ewen S, Linke A, Tigges E, Nordbeck P, Bruch L, Jung C, Franz J, Lauten P, Goslar T, Feistritzer HJ, Pöss J, Kirchhof E, Ouarrak T, Schneider S, Desch S, Freund A. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. N Engl J Med 2023; 389:1286-1297. [PMID: 37634145 DOI: 10.1056/nejmoa2307227] [Citation(s) in RCA: 194] [Impact Index Per Article: 194.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Extracorporeal life support (ECLS) is increasingly used in the treatment of infarct-related cardiogenic shock despite a lack of evidence regarding its effect on mortality. METHODS In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy. RESULTS A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P = 0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25). CONCLUSIONS In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone. (Funded by the Else Kröner Fresenius Foundation and others; ECLS-SHOCK ClinicalTrials.gov number, NCT03637205.).
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Affiliation(s)
- Holger Thiele
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Uwe Zeymer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ibrahim Akin
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Michael Behnes
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tienush Rassaf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Amir Abbas Mahabadi
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ralf Lehmann
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ingo Eitel
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tobias Graf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tim Seidler
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Andreas Schuster
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Carsten Skurk
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Daniel Duerschmied
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Peter Clemmensen
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Marcus Hennersdorf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Stephan Fichtlscherer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ingo Voigt
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Melchior Seyfarth
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Stefan John
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Sebastian Ewen
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Axel Linke
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Eike Tigges
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Peter Nordbeck
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Leonhard Bruch
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Christian Jung
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Jutta Franz
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Philipp Lauten
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tomaz Goslar
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Hans-Josef Feistritzer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Janine Pöss
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Eva Kirchhof
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Taoufik Ouarrak
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Steffen Schneider
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Steffen Desch
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Anne Freund
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
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Chen Z, Gao Y, Lin Y. Perspectives and Considerations of IABP in the Era of ECMO for Cardiogenic Shock. Adv Ther 2023; 40:4151-4165. [PMID: 37460921 DOI: 10.1007/s12325-023-02598-8] [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: 05/22/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
The development of mechanical circulatory support (MCS) has been rapid, and its use worldwide in patients with cardiogenic shock is increasingly widespread. However, current statistical data and clinical research do not demonstrate its significant improvement in the patient prognosis. This review focuses on the widely used intra-aortic balloon pumps (IABP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), analyzing and comparing their characteristics, efficacy, risk of complications, and the current exploration status of left ventricular mechanical unloading. Subsequently, we propose a rational approach to viewing the negative outcomes of current MCS, and look ahead to the future development trends of IABP.
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Affiliation(s)
- Zelin Chen
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yuping Gao
- Department of Cardiovascular Medicine, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, No. 99, Longcheng Street, Taiyuan, 030032, China.
| | - Yuanyuan Lin
- Department of Cardiovascular Medicine, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, No. 99, Longcheng Street, Taiyuan, 030032, China.
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Li F, Li H, Luo R, Pei JB, Yu XY. Lyophilized recombinant human brain natriuretic peptide for chronic heart failure: Effects on cardiac function and inflammation. World J Clin Cases 2023; 11:6066-6072. [PMID: 37731575 PMCID: PMC10507552 DOI: 10.12998/wjcc.v11.i26.6066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/20/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Chronic heart failure (CHF) is a serious and prevalent condition characterized by impaired cardiac function and inflammation. Standard therapy for CHF has limitations, prompting the exploration of alternative treatments. Recombinant human brain natriuretic peptide (BNP) has emerged as a potential therapy, with evidence suggesting that it can improve cardiac function and reduce inflammation in patients with CHF. However, further research is required to determine the efficacy and safety of lyophilized recombinant human BNP in CHF patients and its impact on microinflammatory status. This study aimed to investigate the effects of lyophilized recombinant human BNP therapy on CHF patients' cardiac function and microinflammatory status. AIM To investigate the effects of freeze-dried recombinant human BNP therapy on cardiac function and microinflammatory status in patients with CHF. METHODS In total, 102 CHF patients admitted to our hospital from January 2021 to January 2022 were randomly assigned to control and observation groups (n = 51 patients/group). The control patients were treated with standard HF therapy for 3 d, whereas the observational patients were injected with the recombinant human BNP for 3 d. Clinical efficacy, inflammatory factor levels, myocardial damage, cardiac function before and after the treatment, and adverse reactions during treatment were compared between the two groups. RESULTS The overall clinical efficacy was higher in the observation group than in the control group. Compared with baseline, serum hypersensitive C-reactive protein, N-terminal proBNP, and troponin I level, and physical, emotional, social, and economic scores were lower in both groups after treatment, with greater reductions in levels and scores noted in the observation group than in the control group. The overall incidence of adverse reactions in the observation group was not significantly different compared with that in the control group (P > 0.05). CONCLUSION Freeze-dried recombinant human BNP therapy can improve heart function and enhance microinflammatory status, thereby improving overall quality of life without any obvious side effects. This therapy is safe and reliable.
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Affiliation(s)
- Feng Li
- Department of Cardiovascular Internal Medicine, People's Hospital of Jieshou, Jieshou 236500, Anhui Province, China
| | - Hao Li
- Department of Cardiovascular Internal Medicine, People's Hospital of Jieshou, Jieshou 236500, Anhui Province, China
| | - Rong Luo
- Department of Cardiovascular Internal Medicine, People's Hospital of Jieshou, Jieshou 236500, Anhui Province, China
| | - Jia-Bao Pei
- Department of Cardiovascular Internal Medicine, People's Hospital of Jieshou, Jieshou 236500, Anhui Province, China
| | - Xue-Ying Yu
- Department of Cardiovascular Internal Medicine, People's Hospital of Jieshou, Jieshou 236500, Anhui Province, China
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Schupp T, Behnes M, Rusnak J, Dudda J, Forner J, Ruka M, Egner-Walter S, Bertsch T, Müller J, Akin I. The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock. Coron Artery Dis 2023; 34:395-403. [PMID: 37139569 DOI: 10.1097/mca.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock. BACKGROUND Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available. METHODS All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses. RESULTS Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P = 0.019). CONCLUSION Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Bad Neustadt a. d. Saale
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
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Jentzer JC, Pöss J, Schaubroeck H, Morrow DA, Hollenberg SM, Mebazaa A. Advances in the Management of Cardiogenic Shock. Crit Care Med 2023; 51:1222-1233. [PMID: 37184336 DOI: 10.1097/ccm.0000000000005919] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVES To review a contemporary approach to the management of patients with cardiogenic shock (CS). DATA SOURCES We reviewed salient medical literature regarding CS. STUDY SELECTION We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials. DATA EXTRACTION We extracted salient study results and scientific statement recommendations regarding the management of CS. DATA SYNTHESIS Professional society recommendations were integrated with evaluated studies. CONCLUSIONS CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Janine Pöss
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Alexandre Mebazaa
- Department of Anesthesia & Critical Care, Université Paris Cité, APHP, Inserm MASCOT, FHU PROMICE, Paris, France
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Schupp T, Rusnak J, Forner J, Weidner K, Ruka M, Egner-Walter S, Dudda J, Bertsch T, Kittel M, Behnes M, Akin I. Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock. J Pers Med 2023; 13:1348. [PMID: 37763116 PMCID: PMC10532680 DOI: 10.3390/jpm13091348] [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: 08/08/2023] [Revised: 08/16/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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Schupp T, Rusnak J, Weidner K, Ruka M, Egner-Walter S, Dudda J, Forner J, Bertsch T, Mashayekhi K, Ayoub M, Akin M, Kittel M, Behnes M, Akin I. Prognostic Value of the AST/ALT Ratio versus Bilirubin in Patients with Cardiogenic Shock. J Clin Med 2023; 12:5275. [PMID: 37629321 PMCID: PMC10455678 DOI: 10.3390/jcm12165275] [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: 07/05/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
This study investigates the prognostic value of the aspartate-to-alanine aminotransferase ratio (i.e., AST/ALT ratio) and bilirubin in patients with cardiogenic shock (CS). Despite ongoing improvements regarding the treatment of CS patients, invasive care unit (ICU) mortality in CS patients remains unacceptably high. Limited data regarding the prognostic value of the AST/ALT ratio and bilirubin in patients suffering from CS is available. The authors hypothesize the measurement of liver enzymes during the course of CS may be an easy and feasible method to assess right-heart dysfunction and prognosis in patients with CS. Consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from the day of disease onset (day 1), days 2, 3, 4 and 8. The prognostic value of the AST/ALT ratio and bilirubin was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses. A total of 157 CS patients were included, with an overall rate of all-cause mortality at 30 days of 51%. The median AST/ALT ratio on day 1 was 1.4, and the median bilirubin was 0.63 mg/dL. No association of the baseline AST/ALT ratio (HR = 1.005; 95% CI 0.649-1.558; p = 0.981) and bilirubin (HR = 1.320; 95% CI 0.834-2.090; p = 0.236) with the risk of 30-day all-cause mortality was found. In contrast, the AST/ALT ratio on day 4 was associated with the risk of 30-day all-cause mortality (HR = 2.826; 95% CI 1.227-6.510; p = 0.015), which was still evident after the multivariable adjustment (HR = 2.830; 95% CI 1.054-7.690; p = 0.039). The AST/ALT ratio during the course of ICU hospitalization from day 4-but not the baseline AST/ALT ratio and bilirubin-was associated with an increased risk of 30-day all-cause mortality in CS patients.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, 77933 Lahr, Germany
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum, 32545 Bad Oeynhausen, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (T.S.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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Forner J, Schupp T, Weidner K, Ruka M, Egner-Walter S, Behnes M, Akin M, Ayoub M, Mashayekhi K, Akin I, Rusnak J. Effect of Cardiovascular Risk Factors on 30-Day All-Cause Mortality in Cardiogenic Shock. J Clin Med 2023; 12:4870. [PMID: 37510985 PMCID: PMC10381971 DOI: 10.3390/jcm12144870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Although previous studies investigated the influence of cardiovascular risk (CVR) factors in patients with acute coronary syndrome, data concerning the effect of CVR factors on the prognosis of patients with cardiogenic shock (CS) is scarce. Consecutive patients with CS were prospectively included from 2019 to 2021. The prognosis of patients with "low CVR" (i.e., 0-1 CVR factors) was compared to patients with "high CVR" (i.e., 2-4 CVR factors) according to presence or absence of arterial hypertension, diabetes mellitus, hyperlipidaemia or smoking. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier and Cox proportional regression analyses. 273 consecutive patients with CS were included. 28% presented with low CVR and 72% with high CVR. Within the entire study cohort, the risk of 30-day all-cause mortality did not differ between patients with high and low CVR (55% vs. 57%; log rank p = 0.727; HR = 0.942; 95% CI 0.663-1.338; p = 0.738). Even after multivariable adjustment, high CVR was not associated with an elevated risk of 30-day all-cause mortality (HR = 1.039; 95% CI 0.648-1.667; p = 0.873). The presence of arterial hypertension (55% vs. 58%; log rank p = 0.564; HR = 0.906; 95% CI 0.638-1.287; p = 0.582), diabetes mellitus (60% vs. 52%; log rank p = 0.215; HR = 1.213; 95% CI 0.881-1.671; p = 0.237) and a history of smoking (56% vs. 56%; log rank p = 0.725; HR = 0.945; 95% CI 0.679-1.315; p = 0.737) did not significantly influence short-term prognosis.. Only the absence of hyperlipidaemia significantly decreased the risk of all-cause mortality (65% vs. 51%; log rank p = 0.038; HR = 0.718; 95% CI 0.516-0.998; p = 0.049), which was no longer observed after multivariable adjustment (HR = 0.801; 95% CI 0.536-1.195; p = 0.277). In conclusion, neither the overall CVR nor individual CVR factors were associated with the risk of 30-day all-cause mortality in patients with CS.
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Affiliation(s)
- Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center, University of Bochum, 32545 Bad Oeynhausen, Germany;
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, 77933 Lahr, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (J.F.)
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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45
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Arrigo M, Blet A, Morley-Smith A, Aissaoui N, Baran DA, Bayes-Genis A, Chioncel O, Desch S, Karakas M, Moller JE, Poess J, Price S, Zeymer U, Mebazaa A. Current and future trial design in refractory cardiogenic shock. Eur J Heart Fail 2023; 25:609-615. [PMID: 36987926 DOI: 10.1002/ejhf.2838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/23/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich Triemli, Zurich, Switzerland
| | - Alice Blet
- Department of Anesthesia and Intensive Care, Croix-Rousse Hospital, North Hospital Group, Hospices Civils de Lyon and CRCL, UMRS Inserm 1052/CNRS 5286, University Claude Bernard Lyon 1, Centre Léon Bérard, Lyon, France
| | - Andrew Morley-Smith
- Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris, Hôpital Cochin, AP-HP and Université de Paris, After-ROSC Network, INSERM U970, Paris, France
| | - David A Baran
- Section of Heart Failure, Transplant and MCS, Cleveland Clinic Heart Vascular and Thoracic Institute, Weston, FL, USA
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autonoma, Barcelona, Spain
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu", and University of Medicine Carol Davila, Bucharest, Romania
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Mahir Karakas
- Department of Intensive Care Medicine, University Medical Center, Hamburg Eppendorf, Hamburg, Germany
| | - Jacob Eifer Moller
- Department of Cardiology, Heart Center, Copenhagen University Hospital Rigshospitalet and Department of Cardiology, Odense University Hospital, Denmark
| | - Janine Poess
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Susanna Price
- Royal Brompton & Harefield Hospitals, National Heart & Lung Institute, Imperial College, London, UK
| | - Uwe Zeymer
- Klinikum Ludwigshafen und Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, St. Louis and Lariboisière University Hospitals and INSERM UMR-S 942, MASCOT, Université de Paris, Paris, France
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46
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Milne B, Dalzell J, Kunst G. Management of cardiogenic shock after acute coronary syndromes. BJA Educ 2023; 23:172-181. [PMID: 37124173 PMCID: PMC10140595 DOI: 10.1016/j.bjae.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023] Open
Affiliation(s)
- B. Milne
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - G. Kunst
- King's College Hospital NHS Foundation Trust, London, UK
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47
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Hamzaoui O, Boissier F. Hemodynamic monitoring in cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:104-113. [PMID: 37188114 PMCID: PMC10175734 DOI: 10.1016/j.jointm.2022.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by acute end-organ hypoperfusion due to inadequate cardiac output that can result in multiorgan failure, which may lead to death. The diminished cardiac output in CS leads to systemic hypoperfusion and maladaptive cycles of ischemia, inflammation, vasoconstriction, and volume overload. Obviously, the optimal management of CS needs to be readjusted in view of the predominant dysfunction, which may be guided by hemodynamic monitoring. Hemodynamic monitoring enables (1) characterization of the type of cardiac dysfunction and the degree of its severity, (2) very early detection of associated vasoplegia, (3) detection and monitoring of organ dysfunction and tissue oxygenation, and (4) guidance of the introduction and optimization of inotropes and vasopressors as well as the timing of mechanical support. It is now well documented that early recognition, classification, and precise phenotyping via early hemodynamic monitoring (e.g., echocardiography, invasive arterial pressure, and the evaluation of organ dysfunction and parameters derived from central venous catheterization) improve patient outcomes. In more severe disease, advanced hemodynamic monitoring with pulmonary artery catheterization and the use of transpulmonary thermodilution devices is useful to facilitate the right timing of the indication, weaning from mechanical cardiac support, and guidance on inotropic treatments, thus helping to reduce mortality. In this review, we detail the different parameters relevant to each monitoring approach and the way they can be used to support optimal management of these patients.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine Intensive Réanimation, Hôpital Robert Debré, Université de Reims, Reims 51092, France
- Unité HERVI, Hémostase et Remodelage Vasculaire Post-Ischémie, EA 3801, Reims 51092, France
| | - Florence Boissier
- Médecine Intensive Réanimation, Hôpital Universitaire de Poitiers, Poitiers 90577, France
- INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers 90577, France
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48
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Eftychiou S, Kalakoutas A, Proudfoot A. The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review. JOURNAL OF INTENSIVE MEDICINE 2023; 3:89-103. [PMID: 37188124 PMCID: PMC10175707 DOI: 10.1016/j.jointm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.
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Affiliation(s)
| | - Antonis Kalakoutas
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0AG, UK
- Barts and the London School of Medicine and Dentistry, London E1 2AD, UK
| | - Alastair Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
- Queen Mary University of London, London EC1M 6BQ, UK
- Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin 13353, Germany
- Corresponding author: Alastair Proudfoot, Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
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49
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Parlow S, Santo PD, Sterling LH, Goodliffe L, Motazedian P, Prosperi-Porta G, Morgan B, Koopman Z, Jung RG, Lepage-Ratte MF, Robinson L, Feagan H, Simard T, Wells GA, Kyeremanteng K, Ainsworth C, Amin F, Marbach JA, Fernando SM, Labinaz M, Belley-Cote EP, Hibbert B, Mathew R. Inotrope versus Placebo Therapy in Cardiogenic Shock: Rationale and Study Design of the CAPITAL DOREMI2 Trial. Am Heart J 2023; 262:83-89. [PMID: 37094667 DOI: 10.1016/j.ahj.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a state of end-organ hypoperfusion related to cardiac dysfunction. Current guidelines recommend consideration of inotrope therapy in patients with CS, however no robust data support their use. The purpose of the CAPITAL DOREMI2 trial is to examine the efficacy and safety of inotrope therapy against placebo in the initial resuscitation of patients with CS. METHODS AND DESIGN This is a multi-center, double-blind, randomized, placebo-controlled trial comparing single-agent inotrope therapy to placebo in patients with CS. A total of 346 participants with Society for Cardiovascular Angiography and Interventions class C or D CS will be randomized in a 1:1 fashion to inotrope or placebo therapy, which will be administered over a 12-hour period. After this period, participants will continue open-label therapies at the discretion of the treating team. The primary outcome is a composite of all-cause in-hospital death, and, as measured during the 12-hour intervention period, any of: sustained hypotension or high dose vasopressor requirements, lactate greater than 3.5 mmol/L at 6 hours or thereafter, need for mechanical circulatory support, arrhythmia leading to emergent electrical cardioversion, and resuscitated cardiac arrest. All participants will be followed for the duration of their hospitalization, and secondary outcomes will be assessed at the time of discharge. IMPLICATION This trial will be the first to establish the safety and efficacy of inotrope therapy against placebo in a population of patients with CS and has the potential to alter the standard care provided to this group of patients.
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Affiliation(s)
- Simon Parlow
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Lee H Sterling
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Laura Goodliffe
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Pouya Motazedian
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graeme Prosperi-Porta
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Baylie Morgan
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Zandra Koopman
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Richard G Jung
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Melissa Fay Lepage-Ratte
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Robinson
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hannah Feagan
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Trevor Simard
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Faizan Amin
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Emilie P Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rebecca Mathew
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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50
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Schupp T, Behnes M, Rusnak J, Ruka M, Dudda J, Forner J, Egner-Walter S, Barre M, Abumayyaleh M, Bertsch T, Müller J, Akin I. Does Albumin Predict the Risk of Mortality in Patients with Cardiogenic Shock? Int J Mol Sci 2023; 24:ijms24087375. [PMID: 37108536 PMCID: PMC10138505 DOI: 10.3390/ijms24087375] [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: 02/04/2023] [Revised: 04/02/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
This study investigates the prognostic impact of albumin levels in patients with cardiogenic shock (CS). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Limited data regarding the prognostic value of albumin in patients with CS is available. All consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from the day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. The prognostic impact of albumin was tested for 30-day all-cause mortality. Moreover, the prognostic performance of albumin decline during ICU treatment was examined. Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, multivariable mixed analysis of variance (ANOVA), C-Statistics, and Cox proportional regression analyses. In total, 230 CS patients were included, with an overall all-cause mortality at 30 days of 54%. The median albumin on day 1 was 30.0 g/L. Albumin on day 1 was able to discriminate between 30-day survivors and non-survivors (area under the curve (AUC) 0.607; 0.535-0.680; p = 0.005). CS patients with albumin < 30.0 g/L were associated with an increased risk of 30-day all-cause mortality (63% vs. 46%; log-rank p = 0.016; HR = 1.517; 95% CI 1.063-2.164; p = 0.021), which was demonstrated even after multivariable adjustment. Moreover, a decrease of albumin levels by ≥20% from day 1 to day 3 was accompanied by a higher risk of 30-days all-cause mortality (56% vs. 39%; log-rank p = 0.036; HR = 1.645; 95% CI 1.014-2.669; p = 0.044). Especially when combined with lactate, creatinine, and cardiac troponin I, reliable discrimination of 30-day all-cause mortality was observed, including albumin in CS risk stratification models (AUC = 0.745; 95% CI 0.677-0.814; p = 0.001). In conclusion, low baseline albumin levels as well as a decay of albumin levels during the course of ICU treatment, deteriorate prognostic outcomes in CS patients. The additional assessment of albumin levels may further improve risk stratification in CS patients.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Max Barre
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Mohammad Abumayyaleh
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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