A review of cardiogenic shock in acute myocardial infarction

Has the role of veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock following acute myocardial infarction been fully determined? A case report

Background

The persistent challenge of high mortality rates in acute myocardial infarction-induced cardiogenic shock endures notwithstanding advancements in the diagnosis and treatment of this disease over the past two decades. While recent studies present conflicting evidence on the efficacy of veno-arterial extracorporeal membrane oxygenation (VA ECMO), observational research supports the benefits of early VA ECMO initiation. However, the current lack of robust support from randomized clinical trials for VA ECMO use in this context highlights the ongoing uncertainty surrounding its effectiveness.

Case summary

A 52-year-old male with sudden, intense chest pain was diagnosed with cardiogenic shock due to non-ST-elevation acute myocardial infarction at a local hospital. Initial treatment included aspirin, clopidogrel, and noradrenaline. Upon transfer to our hospital, the patient's condition deteriorated, leading to acute respiratory distress and severe hypotension. Prior to emergent percutaneous coronary intervention, peripheral VA ECMO was initiated. Coronary angiography revealed left main coronary artery occlusion, and a successful intervention was performed. Post-intervention, the patient's haemodynamic parameters significantly improved, and after 7 days, ECMO was successfully discontinued. The patient was discharged in stable condition after 25 days, with favourable outcomes persisting at the 30-day mark. Continuous monitoring is planned during outpatient follow-up.

Discussion

The clinical case illustrates a successful treatment outcome achieved through teamwork by the heart team, supporting the efficacy of the VA ECMO pre-percutaneous coronary intervention approach. The careful selection of appropriate candidates and strategic initiation of VA ECMO may play a role in enhancing outcomes for individuals experiencing acute myocardial infarction complicated by challenging cardiogenic shock.

Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report

Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.

[Monitoring of emergency cardiovascular patients in the emergency department : Consensus paper of the DGK, DGINA and DGIIN]

Patients with potential or proven cardiovascular diseases represent a relevant proportion of the total spectrum in the emergency department. Their monitoring for cardiovascular surveillance until the diagnostics and acute treatment are initiated, often poses an interdisciplinary and interprofessional challenge, because resources are limited, nevertheless a high level of patient safety has to be ensured and the correct procedure has a major prognostic significance. This consensus paper provides an overview of the practical implementation, the modalities of monitoring and the application in a selection of cardiovascular diagnoses. The article provides specific comments on the clinical presentations of acute coronary syndrome, acute heart failure, cardiogenic shock, hypertensive emergency events, syncope, acute pulmonary embolism and cardiac arrhythmia. The level of evidence is generally low as no randomized trials are available on this topic. The recommendations are intended to supplement or establish local standards and to assist all physicians, nursing personnel and the patients to be treated in making decisions about monitoring in the emergency department.

The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality.

METHODS

STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE).

RESULTS

Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01).

CONCLUSIONS

CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.

Collagen matricryptin promotes cardiac function by mediating scar formation

AIMS

A peptide mimetic of a collagen-derived matricryptin (p1159) was shown to reduce left ventricular (LV) dilation and fibrosis after 7 days delivery in a mouse model of myocardial infarction (MI). This suggested p1159 long-term treatment post-MI could have beneficial effects and reduce/prevent adverse LV remodeling. This study aimed to test the potential of p1159 to reduce adverse cardiac remodeling in a chronic MI model and to elucidate p1159 mode-of-action.

MATERIALS AND METHODS

Using a permanent occlusion MI rodent model, animals received p1159 or vehicle solution up to 28 days. We assessed peptide treatment effects on scar composition and structure and on systolic function. To assess peptide effects on scar vascularization, a cohort of mice were injected with Griffonia simplicifolia isolectin-B4. To investigate p1159 mode-of-action, LV fibroblasts from naïve animals were treated with increasing doses of p1159.

KEY FINDINGS

Matricryptin p1159 significantly improved systolic function post-MI (2-fold greater EF compared to controls) by reducing left ventricular dilation and inducing the formation of a compliant and organized infarct scar, which promoted LV contractility and preserved the structural integrity of the heart. Specifically, infarcted scars from p1159-treated animals displayed collagen fibers aligned parallel to the epicardium, to resist circumferential stretching, with reduced levels of cross-linking, and improved tissue perfusion. In addition, we found that p1159 increases cardiac fibroblast migration by activating RhoA pathways via the membrane receptor integrin α4.

SIGNIFICANCE

Our data indicate p1159 treatment reduced adverse LV remodeling post-MI by modulating the deposition, arrangement, and perfusion of the fibrotic scar.

Unexpected Causes and Complications of ST-Segment Myocardial Infarction That Highlight the Importance and Limitations of Point-of-Care Ultrasound in the Emergency Department

Point-of-care transthoracic echocardiography is a valuable tool for Emergency Physicians evaluating a patient in shock. We describe a case report of ST-segment myocardial infarction complicated by cardiogenic shock and acute severe mitral valve regurgitation that was immediately identified by the Emergency Physician. However, subsequent testing revealed an unexpected unifying diagnosis. The diagnostic sequence in this case highlights the benefits and limitations of point-of-care ultrasound in the Emergency Department and reinforces its role to address discrete clinically relevant questions.

Impact of diabetes on outcomes of cardiogenic shock: A systematic review and meta-analysis

To provide synthesized evidence on the association of diabetes with clinical outcomes of patients with acute myocardial infarction (AMI) and associated cardiogenic shock (CS). We analyzed observational studies on patients with AMI and CS, identified through a systematic search using PubMed and Scopus databases. The main outcome was mortality and other outcomes of interest were risk of major bleeding, re-infarction, cerebrovascular adverse events, and need for revascularization. We conducted the meta-analysis with data from 15 studies. Compared to patients without diabetes, those with diabetes had an increased risk of in-hospital mortality (OR, 1.34; 95% CI, 1.17-1.54) and cerebrovascular complications (OR, 1.28; 95% CI, 1.11-1.48). We found similar risk of major bleeding (OR, 0.68; 95% CI, 0.43-1.09), re-infarction (OR, 0.98; 95% CI, 0.48-1.98) and need for re-vascularization (OR, 0.96; 95% CI, 0.75-1.22) as well as hospital stay lengths (in days) (WMD 0.00; 95% CI, -0.27-0.28; n = 4; I² = 99.7%) in the two groups of patients. Patients with diabetes, acute MI and associated cardiogenic shock have increased risks of mortality and adverse cerebrovascular events than those without diabetes.

Acute Thrombosis of the Left Main on the Tennis Court in a Young Patient – a Case Report

In acute coronary syndromes, timely revascularization of the obstructed artery is crucial. In young patients, acute myocardial infarction can have a very severe evolution and is frequently associated with cardiogenic shock. We present the case of a 36-year-old male patient, smoker with no other apparent risk factors for coronary artery disease, who suffered a cardiac arrest while playing tennis. Emergency coronary angiography revealed acute occlusion of the left anterior descendent artery, which was promptly revascularized. The patient had a good clinical evolution and was discharged after six days. The case underlines the importance of a well-functioning emergency system and STEMI network, able to provide life-saving therapy in a timely manner.

Factors Associated with the Prognosis of Patients with Acute Myocardial Infarction and Cardiogenic Shock

BACKGROUND Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) usually have high mortality. This study aimed to identify factors related to the short-term survival of patients with AMI and CS treated by percutaneous coronary intervention (PCI) under intra-aortic balloon pump (IABP) support. MATERIAL AND METHODS This retrospective study included consecutive patients with AMI and CS treated with PCI under IABP support. Clinical characteristics, including the infarct-related artery, lesion number, aspiration catheter usage, conventional or delayed stenting, and thrombolysis in myocardial infarction (TIMI) flow grade before and after PCI, were collected. Patients were followed up postoperatively for 30 days. Multivariate logistic regression was used to identify factors associated with the 30-day mortality. RESULTS There were marked differences between the nonsurvival group (n=49) and the survival group (n=92) in the no-reflow after surgery (49.0% vs 14.1%, P<0.001), postoperative TIMI grade 3 flow (65.3% vs 91.3%, P<0.001), and delayed stent implantation (18.4% vs 37.0%, P=0.022). Factors associated with 30-day mortality were postoperative TIMI grade 3 flow (odds ratio [OR]: 0.227; 95% confidence interval [CI]: 0.076-0.678; P=0.008), delayed stent implantation (OR: 0.371; 95% CI: 0.139-0.988; P=0.047), and intraoperative no-reflow (OR: 2.737; 95% CI: 1.084-6.911; P=0.033). CONCLUSIONS For patients with AMI complicated by CS treated with emergent PCI under IABP support, prevention of no-reflow during surgery by delayed stent implantation can reduce postoperative 30-day mortality in selected cases.

Association of Baseline Anemia with Mid-Term Clinical Outcomes in Patients Who Underwent Trans-Radial Primary Percutaneous Coronary Intervention

Radial access is recommended for primary percutaneous coronary intervention (PCI), because it has fewer bleeding complications than trans-femoral PCI. However, even if trans-radial PCI is chosen, patients with ST-elevation myocardial infarction (STEMI) presenting with anemia on admission might have poor clinical outcomes. The aim of this retrospective study was to investigate whether anemia on admission was associated with mid-term clinical outcomes in patients who underwent trans-radial primary PCI. The primary endpoint was a composite of all-cause death, recurrent acute myocardial infarction, and readmission for heart failure. A total of 288 consecutive patients with STEMI who underwent trans-radial primary PCI were divided into an anemia group (n = 79) and a non-anemia group (n = 209). The median follow-up duration was 301 days. The anemia group was significantly older than the non-anemia group (77.3 ± 11.9 versus 64.4 ± 12.7 years, respectively; P < 0.001). There were significantly more females in the anemia group than in the non-anemia group (36.7% versus 14.4%, respectively; P < 0.001). Kaplan-Meier analysis revealed that the composite outcome-free survival was significantly worse in the anemia group than in the non-anemia group (P < 0.001). Multivariate Cox hazard model analysis revealed that hemoglobin levels on admission were significantly associated with the composite outcome (per 1 g/dL increase: hazard ratio 0.76, 95% confidence interval 0.66-0.88, P < 0.001) after controlling for confounding factors. In conclusion, baseline anemia was significantly associated with poor clinical outcomes. Patients with STEMI presenting with anemia should be managed carefully, even if trans-radial primary PCI is chosen.

Assessing the Utility of End-Tidal Carbon Dioxide as a Marker for Fluid Responsiveness in Cardiogenic Shock

Background

Preventing end-organ failure in patients with shock requires rapid and easily accessible measurements of fluid responsiveness. Unlike septic shock, not all patients in cardiogenic shock are preload responsive. We conducted this study to determine the discriminant power of changes in end-tidal carbon dioxide (ETCO₂), systolic blood pressure (SBP), inferior vena cava (IVC) collapsibility index (IVC-CI), and venous to arterial carbon dioxide (Pv-aCO₂) gap after a fluid challenge and compared it to increases in cardiac output.

Methodology

In a prospective, quasi-experimental design, mechanically ventilated patients in cardiogenic shock were assessed for fluid responsiveness by comparing improvement in cardiac output (velocity time integral) with changes in ETCO₂, heart rate, SBP, Pv-aCO₂ gap, IVC-CI after a fluid challenge (a crystalloid bolus or passive leg raise).

Results

Out of 60 patients, with mean age 61.3 ± 14.8 years, mean acute physiology and chronic health evaluation (APACHE) score ­14.82 ± 7.49, and median ejection fraction (EF) 25% (25-35), 36.7% (22) had non ST-segment elevation myocardial infarction (NSTEMI) and 60% (36) were ST-segment elevation myocardial infarction (STEMI). ETCO₂ was the best predictor of fluid responsiveness; area under the curve (AUC) 0.705 (95% confidence interval (CI) 0.57-0.83), p=0.007, followed by reduction in Pv-aCO₂ gap; AUC 0.598 (95% CI; 0.45-0.74), p= 0.202. Changes in SBP, mean arterial pressure (MAP), IVC-CI weren’t significant; 0.431 (p=0.367), 0.437 (p=0.410), 0.569 (p=0.367) respectively. The discriminant value identified for ETCO₂ was more than equal to 2 mmHg, with sensitivity 58.6%, specificity 80.7%, positive predictive value 73.9% [95% CI; 56.5% to 86.1%], negative predictive value 69.7% [95% CI; 56.7% to 76.9%].

Conclusions

Change in ETCO₂ is a useful bedside test to predict fluid responsiveness in cardiogenic shock.

Acute Myocardial Infarction Complicated by Cardiogenic Shock: Analysis of the Position Statement From the European Society of Cardiology Acute Cardiovascular Care Association, With Perioperative Implications

Effective management of cardiogenic shock (CS) is hampered by a lack of evidence-based information. This is a high-mortality condition, without clear, evidence-based guidelines for perioperative management, specifically-a lack of target endpoints for treatment (e.g.: mean arterial pressure or oxygenation), utility of regional care systems or the benefits of palliative care. The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) recently published a position statement that aimed to offer contemporary guidance on the diagnosis and treatment of acute myocardial infarction (AMI) complicated by CS. Herein, we review this complex clinical topic and review the ACCA statement on AMI associated with CS, with a focus on relevance to perioperative management.

Do small hospitals have lower quality? Evidence from the English NHS

We investigate the extent to which small hospitals are associated with lower quality. We first take a patient perspective, and test if, controlling for casemix, patients admitted to small hospitals receive lower quality than those admitted to larger hospitals. We then investigate if differences in quality between large and small hospitals can be explained by hospital characteristics such as hospital type and staffing. We use a range of quality measures including hospital mortality rates (overall and for specific conditions), hospital acquired infection rates, waiting times for emergency patients, and patient perceptions of the care they receive. We find that small hospitals, with fewer than 400 beds, are generally not associated with lower quality before or after controlling for hospital characteristics. The only exception is heart attack mortality, which is generally higher in small hospitals.

Inotropic Agents and Vasopressors in the Treatment of Cardiogenic Shock

BACKGROUND

Worldwide, cardiogenic shock (CS) is the leading cause of death in patients admitted with an acute myocardial infarction (AMI). CS is characterised by reduced cardiac output secondary to systolic dysfunction which can lead to multi-organ failure. The mainstay of medical treatment in CS are inotropes and vasopressors to improve cardiac output. However, current clinical guidelines do not direct clinicians as to which agents to use and in what combinations. This article aims to review the current evidence on the management of CS with a major focus on the use of inotropes and vasopressors.

METHOD

A literature review was conducted analysing published literature from the following databases: PubMed, MedLine, Cochrane Library and Embase, as well as a manual search of articles that were deemed relevant. Relevant articles were identified by using keywords such as "cardiogenic shock".

RESULTS

Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias. Conversely, noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS. Compared to other inotropes, levosimendan appears to have a better safety profile and is associated with decreased mortality in CS, particularly when combined with a vasopressor. Our literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS.

Identifying cardiogenic shock in the emergency department

INTRODUCTION

Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early.

OBJECTIVE

This review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician.

DISCUSSION

The most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound.

CONCLUSIONS

The emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.

Extracorporeal Membrane Oxygenation in Cardiogenic Shock due to Acute Myocardial Infarction: A Systematic Review

Background

Cardiogenic shock is associated with high mortality, despite new strategies for reperfusion therapy. Short-term circulatory support devices may provide adequate support for appropriate myocardial and organ perfusion.

Objectives

This review is aimed at evaluating the impact on survival when using venoarterial extracorporeal membrane oxygenation (V-A ECMO) in patients with cardiogenic shock due to acute myocardial infarction (AMI).

Methods

We performed a systematic review that included studies using V-A ECMO in patients with cardiogenic shock. Time on ECMO, side effects, and the number of deceased patients, transplanted or upgraded to durable assist devices were analysed. Literature search was done using PubMed/MEDLINE (inception (1969) to January 10, 2019), ProQuest (inception (January 14, 1988) to January 10, 2019), and clinicaltrials.gov (inception (September 12, 2005) to January 10, 2019), by 2 authors. This protocol is registered with PROSPERO (no. CRD42019123982).

Results

We included 9 studies with a total of 1,998 adult patients receiving V-A ECMO for AMI-induced cardiogenic shock. Survival rate varied from 30.0% to 79.2% at discharge and from 23.2% to 36.1% at 12 months. Time on ECMO varied between 1.96 and 6.0 days. Reported serious adverse events were gastrointestinal bleeding (3.6%) and peripheral complications (8.5%).

Conclusion

The use of V-A ECMO among patients with AMI-induced cardiogenic shock may provide survival benefits. However, V-A ECMO treatment effects are inconclusive because of limitations in cohort design and reporting.

Cellular Stress and General Pathological Processes

From the viewpoint of the general pathology, most of the human diseases are associated with a limited number of pathogenic processes such as inflammation, tumor growth, thrombosis, necrosis, fibrosis, atrophy, pathological hypertrophy, dysplasia and metaplasia. The phenomenon of chronic low-grade inflammation could be attributed to non-classical forms of inflammation, which include many neurodegenerative processes, pathological variants of insulin resistance, atherosclerosis, and other manifestations of the endothelial dysfunction. Individual and universal manifestations of cellular stress could be considered as a basic element of all these pathologies, which has both physiological and pathophysiological significance. The review examines the causes, main phenomena, developmental directions and outcomes of cellular stress using a phylogenetically conservative set of genes and their activation pathways, as well as tissue stress and its role in inflammatory and para-inflammatory processes. The main ways towards the realization of cellular stress and its functional blocks were outlined. The main stages of tissue stress and the classification of its typical manifestations, as well as its participation in the development of the classical and non-classical variants of the inflammatory process, were also described. The mechanisms of cellular and tissue stress are structured into the complex systems, which include networks that enable the exchange of information with multidirectional signaling pathways which together make these systems internally contradictory, and the result of their effects is often unpredictable. However, the possible solutions require new theoretical and methodological approaches, one of which includes the transition to integral criteria, which plausibly reflect the holistic image of these processes.

Application of pulse index continuous cardiac output system in elderly patients with acute myocardial infarction complicated by cardiogenic shock: A prospective randomized study

BACKGROUND

Cardiogenic shock (CS) secondary to acute myocardial infarction (AMI) complicates management of the condition, and often leads to poor prognosis. Prompt and accurate monitoring of cardiovascular and accompanying hemodynamic changes is crucial in achieving adequate management of the condition. Advances in technology has availed procedures such as pulse index continuous cardiac output (PiCCO), which can offer precise monitoring of cardiovascular functions and hemodynamic parameters. In this study, PiCCO is evaluated for its potential utility in improving management and clinical outcomes among elderly patients with AMI complicated by CS.

AIM

To assess whether use of the PiCCO system can improve clinical outcomes in elderly patients with AMI complicated by CS.

METHODS

Patients from emergency intensive care units (EICU) or coronary care units (CCU) were randomized to receive PiCCO monitoring or not. The APACHE II score, SOFA score, hs-TnI, NT-proBNP, PaO₂/FiO₂ ratio and lactate levels on day 1, 3 and 7 after treatment were compared. The infusion and urine volume at 0-24 h, 24-48 h and 48-72 h were recorded, as were the cardiac index (CI), extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) at similar time intervals.

RESULTS

Sixty patients with AMI complicated by CS were included in the study. The PiCCO group had a significantly lower APACHE II score, SOFA score, hs-TnI and NT-proBNP levels on day 1, 3 and 7 after treatment. The infusion and urine volume during 0-24 h in the PiCCO group were significantly greater, and this group also showed significantly higher ADL scores. Furthermore, the PiCCO group spent lesser days on vasoactive agents, mechanical ventilation, and had a reduced length of stay in EICU/CCU. Additionally, the CI was significantly higher at 48 h and 72 h in the PiCCO group compared with that at 24 h, and the EVLWI, ITBVI and GEDVI were significantly decreased at 48 h and 72 h.

CONCLUSION

Applying the PiCCO system could improve the clinical outcomes of elderly patients with AMI complicated by CS.

Non-arrhythmic causes of sudden death: A comprehensive review

Sudden cardiac death (SCD) is a major public health issue in the United States and worldwide. It is estimated to affect between 1 and 1.5 million patients worldwide annually, with the global burden expected to rise due to the concomitant rise in coronary artery disease in the developing world. Although arrhythmic causes of SCD such as ventricular tachycardia and ventricular fibrillation are common and well-studied, non-arrhythmic causes are also important, with diverse etiologies from ischemia-related structural heart disease to non-ischemic heart diseases, non-atherosclerotic coronary pathologies, and inflammatory states. Recent research has also found that risk factors and/or demographics predispose certain individuals to a higher risk of non-arrhythmia-related SCD. This review discusses the epidemiology, mechanisms, etiologies, and management of non-arrhythmic SCD.

Effect of morphine use on oral P2Y12 platelet inhibitors in acute myocardial infarction: Meta-analysis

BACKGROUND

Morphine is the recommended analgesic in acute myocardial infarction (AMI). This recommendation has come under scrutiny because of possible slow uptake of oral antiplatelet agents.

OBJECTIVE

We performed a meta-analysis of all available studies in AMI patients treated with prasugrel or ticagrelor (P2Y12 inhibitors) that reported use of morphine prior to loading the antiplatelet agents to critically assess the safety of co-administration of morphine and the newer P2Y12 inhibitors.

METHODS

Several sources were searched from inception to December 2017 with inclusion of eight studies, largely observational. Mean difference (MD) was calculated for continuous variables, and standardized mean difference (SMD) for platelet function was assessed by the various platelet assays, 2 h after the loading dose of oral P2Y12 inhibitors.

RESULTS

Higher platelet activity was noted among morphine group [SMD = 0.8, 95% confidence interval (CI) = 0.4-1.1, p < 0.01]. Morphine use caused higher odds of "high residual platelet reactivity" at 2 h (odds = 3.3, 95 %CI = 2.2-5.1, p < 0.01). Ticagrelor reached a lower plasma concentration in morphine group (MD = -481.8 ng/ml, 95% CI = -841.2 to -122.4 ng/ml, p < 0.01) with a higher vomiting rate (odds = 5.3, 95% CI = 2.5-11.1, p < 0.01). However, the composite of in-hospital mortality, stroke, and re-infarction was not significantly different between the groups (p = 0.83).

CONCLUSION

Co-administration of morphine with P2Y12 inhibitors possibly decreases their efficacy in platelet inhibition. However, this did not translate into higher adverse outcomes because of low event rates, inadequate for analysis. A large randomized study is needed to evaluate the narcotic-P2Y12 interaction.

Outcomes of Acute Myocardial Infarction in Heart Transplant Recipients

Heart transplantation (HT) recipients represent a growing patient population. Although mechanisms might differ, coronary artery disease is an important cause of morbidity in this group. Limited data are available on the outcomes of acute myocardial infarction (AMI) in HT in comparison to general population (non-HT). The study population was extracted from the National Readmissions Data 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification codes for AMI and HT. The study outcomes included in-hospital all-cause mortality, length of hospital stay (LOS), cardiogenic shock, acute kidney injury, the likelihood of receiving invasive left-sided cardiac catheterization with and/or without percutaneous coronary intervention (PCI) and 30-day readmission rates. A total of 259,794 discharges with a principal diagnosis of AMI were identified, in which 789 had a history of HT. In comparison to non-HT, HT group was associated with longer LOS (5.9 vs 4.9 days, p <0.01), more cardiogenic shock (8.8% vs 6.4%, p <0.01), more acute kidney injury (26.2% vs 17.6%, p <0.01), less catheterization (59.7% vs 75.1%, p <0.01), less use of PCI (35.2% vs 50.0%, p <0.01), and higher 30-day readmission rate (21.3% vs 14.4%, p <0.01). However, there was no statistically significant difference in all-cause mortality (6.8% vs 5.4%, p = 0.07). In conclusion, compared with non-HT, HT with AMI was associated with longer LOS, more in-hospital morbidity, lower likelihood of receiving invasive treatment (including PCI), and higher 30-day readmission rates. There was no significant difference in all-cause mortality.

Current Status of Inotropes in Heart Failure

Inotropes are medications that improve the contractility of the heart and are used in patients with low cardiac output or evidence of end-organ dysfunction. Since their initial discovery, inotropes have held promise in alleviating symptoms and potentially increasing longevity in such patients. Decades of intensive study have further elucidated the benefits and risks of using inotropes. In this article, the authors discuss the history of inotropes, their indications, mechanism of action, and current guidelines pertaining to their use in heart failure. The authors provide insight into their appropriate use and related shortcomings and the practical aspects of inotrope use.

Percutaneous biventricular Impella support in therapy-refractory cardiogenic shock

INTRODUCTION

Percutaneous mechanical circulatory support systems have increasingly been adopted as a bail out strategy in patients with cardiogenic shock. Since studies showed mostly mixed results, however, the use of support systems remains a case by case decision.

CASE

Here, we report on a case of therapy-refractory cardiogenic shock due to acute myocardial infarction treated with percutaneous right and left ventricular assist devices (Impella RP and CP).

CONCLUSION

Due to myocardial stunning, even patients with fulminant cardiogenic shock have the potential for full recovery. In the present case, we demonstrate the feasibility of biventricular Impella support in therapy-refractory cardiogenic shock facilitating bridge to recovery.

Monitoring Acute Myocardial Infarction Complicated with Cardiogenic Shock — from the Emergency Room to Coronary Care Units

Cardiogenic shock remains the leading cause of death in patients hospitalized for acute myocardial infarction, despite many advances encountered in the last years in reperfusion, mechanical, and pharmacological therapies addressed to stabilization of the hemodynamic condition of these critical patients. Such patients require immediate initiation of the most effective therapy, as well as a continuous monitoring in the Coronary Care Unit. Novel biomarkers have been shown to improve diagnosis and risk stratification in patients with cardiogenic shock, and their proper use may be especially important for the identification of the critical condition, leading to prompt therapeutic interventions. The aim of this review was to evaluate the current literature data on complex biomarker assessment and monitoring of patients with acute myocardial infarction complicated with cardiogenic shock in the Coronary Care Unit.

Left Heart Decompression in Acute Complicated Myocardial Infarction During Extracorporeal Membrane Oxygenation

Acute myocardial infarction (AMI) can progress to cardiogenic shock and mechanical complications. When extracorporeal membrane oxygenation (ECMO) is applied to a patient with AMI with cardiogenic shock and mechanical complications, left ventricular (LV) decompression is an important recovery factor because LV dilation increases myocardial wall stress and oxygen consumption. The authors present the case of a 72-year-old man with AMI and LV dilation who developed cardiogenic shock and papillary muscle rupture and who was treated successfully by ECMO with a left atrial venting.

Shock Index More Sensitive Than Cardiogenic Shock in ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

BACKGROUND

Cardiogenic shock (CS) is a strong predictor of mortality in patients with ST-elevation myocardial infarction (STEMI), but there is evidence that shock index (SI), taking into account both blood pressure and heart rate, is a more sensitive and powerful predictor. We investigated the independent impact of SI and CS on 30-day and 1-year mortality in patients with STEMI, treated by primary percutaneous coronary intervention (PCI).Methods and Results:In 7,412 consecutive patients with STEMI treated with primary PCI, the predictive value of either SI or CS on 1-year mortality was assessed. Best cut-off value of SI, determined using receiver operating characteristic (ROC) curve, was 0.7, with an ROC AUC of 0.66 (95% CI: 0.65-0.67), compared with an ROC AUC of 0.60 (95% CI: 0.59-0.61) for CS (P<0.001). At admission, 387 patients (5.2%) had CS and 1,567 patients (21.1%) had SI ≥0.7. The adjusted hazard ratio of mortality in patients with SI ≥0.7 and in CS patients was, respectively, 3.3 (95% CI: 2.4-4.6) and 3.1 (95% CI: 2.1-4.6) after 30 days, and 2.3 (95% CI: 1.8-2.9) and 3.1 (95% CI: 2.2-4.2) after 1 year.

CONCLUSIONS

SI identifies more patients with increased risk of mortality, and seems to be a more sensitive prognostic predictor than CS in patients with STEMI treated by primary PCI.

Prognostic value of computed tomography pulmonary angiography indices in patients with cancer-related pulmonary embolism: Data from a multicenter cohort study

OBJECTIVE

To analyze the prognostic value of pulmonary artery obstruction versus right-ventricle (RV) dysfunction radiologic indices in cancer-related pulmonary embolism (PE).

METHODS

We enrolled 303 consecutive patients with paraneoplastic PE, evaluated by computed tomography pulmonary angiography (CTPA) between 2013 and 2014. The primary outcome measure was serious complications at 15days. Multivariate analyses were conducted by using binary logistic and robust regressions. Radiological features such as the Qanadli index (QI) and RV dysfunction signs were analyzed with Spearman's partial rank correlations.

RESULTS

RV diameter was the only radiological variable associated with an adverse outcome. Subjects with enlarged RV (diameter>45mm) had more 15-day complications (58% versus 40%, p=0.001). The QI correlated with the RV diameter (r=0.28, p<0.001), left ventricle diameter (r=-0.19, p<0.001), right ventricular-to-left ventricular diameter ratio (r=0.39, p<0.001), pulmonary artery diameter (r=0.22, p<0.001), and pulmonary artery/ascending aorta ratio (r=0.27, p<0.001). A QI≥50% was only associated with 15-day complications in subjects with enlarged RV, inverted intraventricular septum, or chronic cardiopulmonary diseases. The central or peripheral PE location did not affect the correlations among radiological variables and was not associated with clinical outcomes.

CONCLUSIONS

Right ventricular dysfunction signs in CTPA are more useful than QI in predicting cancer-related PE outcome.

IABP: history-evolution-pathophysiology-indications: what we need to know

Treatment with the intraaortic balloon pump (IABP) is the most common form of mechanical support for the failing heart. Augmentation of diastolic pressure during balloon inflation contributes to the coronary circulation and the presystolic deflation of the balloon reduces the resistance to systolic output. Consequently, the myocardial work is reduced. The overall effect of the IABP therapy is an increase in the myocardial oxygen supply/demand ratio and thus in endocardial viability.

This is an overall synopsis of what we need to know regarding IABP. Furthermore, this review article attempts to systematically delineate the pathophysiology linked with the hemodynamic consequences of IABP therapy. The authors also look at the future of the use of the balloon pump and conclude that the positive multi-systemic hemodynamic regulation during IABP treatment should further justify its use.