Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Intra‐aortic balloon pump impacts the regional haemodynamics of patients with cardiogenic shock treated with femoro‐femoral veno‐arterial extracorporeal membrane oxygenation

Aims

To investigate the impact of intra‐aortic balloon pump (IABP) on the regional haemodynamics of patients with severe cardiogenic shock undergoing femoro‐femoral veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO).

Methods and results

From July 2017 to April 2018, a total of 39 adult patients with cardiogenic shock receiving both IABP and ECMO for circulatory support were enrolled consecutively in a university‐affiliated cardiac surgery intensive care unit. The blood flow rates (BFRs) of the bilateral femoral artery (IABP side: iFA, ECMO side: eFA) and carotid artery (left: LCA, right: RCA) and the velocity time integral (VTI) of aortic root were assessed by ultrasonography and compared when IABP was on and off. Seventeen of 39 (43.6%) patients survived to discharge, and 29 (74.4%) survived on ECMO. A total of 172 pairs of data (IABP on and off) were collected in this study, measured on the median of 2.0 (1.0, 4.5) days after patients received VA‐ECMO. The BFR on both sides of FA (iFA: 176.4 ± 104.5 vs. 152.2 ± 139.8 mL/min, P < 0.01; eFA: 299.3 ± 279.9 vs. 242.4 ± 258.8 mL/min, P < 0.01) and the aortic VTI (10.1 ± 4.4 vs. 8.5 ± 4.4 cm, P < 0.01) decreased significantly when turning the IABP off, while the BFR on both sides of CA remained unchanged (LCA: 555.7 ± 326.9 vs. 578.6 ± 328.0 mL/min, P = 0.27; RCA: 550.0 ± 331.1 vs. 533.0 ± 303.5 mL/min, P = 0.30). The LCA BFR dramatically increased after turning the IABP off (296.8 ± 129.7 vs. 401.4 ± 278.1 mL/min, P = 0.02) in patients with cardiac stunning (defined as pulse pressure ≤ 5 mmHg). However, there was no significant difference in LCA BFR between IABP‐On and IABD‐Off (359.6 ± 105.4 mL/min vs. 389.6 ± 139.3 mL/min, P = 0.31) in patients with cardiac stunning receiving a higher ECMO blood flow (> 3.5 L/min).

Conclusions

Concomitant IABP used in patients undergoing femoro‐femoral VA‐ECMO was associated with increased aortic VTI and BFR in bilateral FA. The change in CA BFR depended on cardiac function. A decreased LCA BFR was observed in patients with cardiac stunning when IABP was turned on, which might be compensated by a higher ECMO blood flow. Further study is needed to confirm the relationship between BFR and extremities and neurological complications.

Overview of mitral valve replacement versus mitral valve repair due to ischemic papillary muscle rupture: A meta-analysis inspired by a case report

BACKGROUND

Papillary muscle rupture (PMR) is an infrequent but catastrophic complication after myocardial infarction (MI). Surgical procedure is considered the optimal treatment, despite high risk. However, the gold standard technique is still a major dilemma. Therefore, a meta-analysis was carried out to assess and provide an overview comparing mitral valve replacement (MVR) and mitral valve repair (MVr) for PMR post-MI.

METHODS

A systematic literature search was performed. Data were extracted and verified using a standardized data extraction form. Meta-analysis was realized mainly using RevMan 5.4 software.

RESULTS

From four observational studies 1640 patients were identified; 81% underwent MVR and 19% MVr. Operative mortality results were significantly higher in MVR group than the MVr group. MVR was performed under emergency conditions and patients admitted in cardiogenic shock or who required the use of mechanical cardiac support underwent MVR. MVr had shorter time of hospitalization and similar incidence of postoperative complications than MVR. No significant differences existed between the two procedures regarding cardiopulmonary bypass time.

CONCLUSIONS

Mitral valve repair appears to be a viable alternative to MVR for post-MI PMR, given that it has lower operative mortality, shorter time of hospitalization and similar incidence of short-term postoperative complications than MVR. However, it needs to be pointed out that MVR was associated with the most critical clinical condition following PMR. There is uncertainty regarding the overall survival and improvement of the quality of life between the procedures. Nevertheless, further completed investigation is required.

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study

BACKGROUND

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant.

METHODS

We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups.

RESULTS

Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35).

CONCLUSION

This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Mechanical circulatory support in cardiogenic shock: a critical appraisal

INTRODUCTION

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD).

AREAS COVERED

Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

EXPERT OPINION

Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.

Neutrophil-Albumin Ratio as a Predictor of in-Hospital Mortality in Patients with Cardiogenic Shock

Intoduction: Cardiogenic shock (SK) is the most severe phase of the acute heart failure syndrome. One of the most widely studied inflammatory mediators in cardiogenic shock is neutrophils. Albumin has several functions, including in pressure regulation, plays a role as an antioxidant and anti-inflammatory agent. Several studies have shown the association of albumin levels with mortality in patients with cardiogenic shock. Purpose: This study aimed to evaluate the utilization of neutrophil-albumin ratio (NAR) in predicting in-hospital mortality in patients with cardiogenic shock (CS) Patients and methods: This study was an observational study with cross sectional design conducted at the Department of Cardiovascular, Harapan Kita Cardiovascular Hospital. The data were collected from the patient registry (January 2018 to April 2020). The study participants were all patients with cardiogenic shock admitted to our hospital. The endpoint was in-hospital mortality in CS patients. Predictors of hospital mortality were identified using multivariable logistic regression, followed by receiver operator characteristic (ROC) curve analysis and cut-off value for optimal NAR level. Results: A total of 130 patients hospitalized with CS were enrolled in this study, In-hospital mortality was found in 75 (57,7%) patients, among which 102 (78,5%) were male and 101 (77,7%) patients had acute coronary syndrome. There was a significant positive correlation between NAR levels and in-hospital mortality. The multivariate logistic regression showed that NAR was independently associated with increased risk of in-hospital mortality with odd ratio (OR) of 5,81, 95% confidence interval (CI) 2,303 - 14,692, P <0,001. NAR had a prognostic value in predicting in-hospital mortality of CS based on ROC curve analysis (AUC 0,802), with an optimal NAR cut-off value of 25. Conclusion: NAR is independently associated with in-hospital mortality in patients with CS Keywords: Neutropil-albumin ratio, cardiogenic Shock, mortality predictor

Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week

Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.

European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Machine Learning for Prediction of Outcomes in Cardiogenic Shock

Objective

The management of cardiogenic shock (CS) in the elderly remains a major clinical challenge. Existing clinical prediction models have not performed well in assessing the prognosis of elderly patients with CS. This study aims to build a predictive model, which could better predict the 30-day mortality of elderly patients with CS.

Methods

We extracted data from the Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III) as the training set and the data of validation sets were collected from the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. Three models, including the cox regression model, the Least Absolute Shrinkage and Selection Operator (LASSO) regression model, and the CoxBoost model, were established using the training set. Through the comparison of area under the receiver operating characteristic (ROC) curve (AUC), C index, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and median improvement in risk score, the best model was selected. Then for external validation, compared the best model with the simplified acute physiology score II (SAPSII) and the CardShock risk score.

Results

A total of 919 patients were included in the study, of which 804 patients were in the training set and 115 patients were in the verification set. Using the training set, we built three models: the cox regression model including 6 predictors, the LASSO regression model including 4 predictors, and the CoxBoost model including 16 predictors. Among them, the CoxBoost model had good discrimination [AUC: 0.730; C index: 0.6958 (0.6657, 0.7259)]. Compared with the CoxBoost model, the NRI, IDI, and median improvement in risk score of other models were all<0. In the validation set, the CoxBoost model was also well-discriminated [AUC: 0.770; C index: 0.7713 (0.6751, 0.8675)]. Compared with the CoxBoost model, the NRI, IDI, and median improvement in risk score of SAPS II and the CardShock risk score were all < 0. And we constructed a dynamic nomogram to visually display the model.

Conclusion

In conclusion, this study showed that in predicting the 30-day mortality of elderly CS patients, the CoxBoost model was superior to the Cox regression model, LASSO regression model, SAPS II, and the CardShock risk score.

Standard care versus individualized blood pressure targets among critically ill patients with shock: A multicenter feasibility and preliminary efficacy study

PURPOSE

Emerging evidence suggests that minimizing mean perfusion pressure (MPP) deficit during vasopressor therapy for shock can potentially reduce adverse kidney-related outcomes in ICU. We assessed feasibility and preliminary efficacy of individualizing MPP targets based on patients' own pre-illness basal-MPP among vasopressor-treated patients with shock.

MATERIAL AND METHODS

In this prospective before-and-after trial, 31 patients during the 'before'/observational phase and 31 patients during the 'after'/intervention phase were enrolled at two tertiary-level Australian ICUs. Feasibility endpoint was time-weighted average MPP-deficit during vasopressor therapy. Preliminary efficacy outcomes were new significant AKI, major adverse kidney events within 14 days (MAKE-14), and 90-day mortality.

RESULTS

Patients in the after group had lower MPP-deficit (median 18%, [interquartile range [IQR]: 11-23] vs. 4%, [IQR: 2-9], p < 0.001) and lower incidence of new significant AKI (8/31 [26%] vs. 1/31 [3%], p = 0.01) than the before group. The between-group differences in MAKE-14 (9/31 [29%] vs. 4/31 [13%], p = 0.12) and 90-day mortality (6/31 [19%] vs. 2/31 [6%], p = 0.13) were not statistically significant.

CONCLUSIONS

An individualized blood pressure target strategy during vasopressor therapy in ICU was feasible and appeared to be efficacious in this preliminary study. Testing this strategy in a larger randomized controlled trial is warranted.

STUDY REGISTRATION

ACTRN12617001459314.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Association Between the Acidemia, Lactic Acidosis, and Shock Severity With Outcomes in Patients With Cardiogenic Shock

Background

Lactic acidosis is associated with mortality in patients with cardiogenic shock (CS). Elevated lactate levels and systemic acidemia (low blood pH) have both been proposed as drivers of death. We, therefore, analyzed the association of both high lactate concentrations and low blood pH with 30‐day mortality in patients with CS.

Methods and Results

This was a 2‐center historical cohort study of unselected patients with CS with available data for admission lactate level or blood pH. CS severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock classification. All‐cause survival at 30 days was analyzed using Kaplan‐Meier curves and Cox proportional‐hazards analysis. There were 1814 patients with CS (mean age, 67.3 years; 68.5% men); 51.8% had myocardial infarction and 53.0% had cardiac arrest. The distribution of SCAI shock stages was B, 10.8%; C, 30.7%; D, 38.1%; and E, 18.7%. In both cohorts, higher lactate or lower pH predicted a higher risk of adjusted 30‐day mortality. Patients with a lactate ≥5 mmol/L or pH <7.2 were at increased risk of adjusted 30‐day mortality; patients with both lactate ≥5 mmol/L and pH <7.2 had the highest risk of adjusted 30‐day mortality. Patients in SCAI shock stages C, D, and E had higher 30‐day mortality in each SCAI shock stage if they had lactate ≥5 mmol/L or pH <7.2, particularly if they met both criteria.

Conclusions

Higher lactate and lower pH predict mortality in patients with cardiogenic shock beyond standard measures of shock severity. Severe lactic acidosis may serve as a risk modifier for the SCAI shock classification. Definitions of refractory or hemometabolic shock should include high lactate levels and low blood pH.

Impact of shock index before IABP implantation on recent prognosis of patients with cardiogenic shock complicating acute myocardial infarction

OBJECTIVE

To investigate the impact of shock index before Intra-Aortic Balloon Pump (IABP) implantation on recent prognosis of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) underwent primary percutaneous coronary intervention (PCI).

METHODS

A total of 103 patients with CS complicating AMI admitted in our hospital from June 2014 to May 2019 who underwent primary PCI with IABP support were enrolled in the study. We collected the data according to the medical records and collected their clinical manifestation and laboratory examination, as well as 28-day mortality, and also calculated the shock index (ratio of heart rate to systolic blood pressure) before IABP implantation.

RESULTS

Patients with higher SI at IABP insertion were associated with higher proportion of anterior infarction (81.5% vs. 61.2%, p = 0.022), previous history of PCI (24.1% vs. 8.16%, p = 0.030), culprit leision at left main (31.5% vs. 12.2%, p = 0.019), and final TIMI flow ≤ 2(55.5% vs. 26.5%, p = 0.003), invasive ventilation(40.7% vs. 20.4%, p = 0.026) as well as 28-day-mortality (81.5% vs. 61.2%, p = 0.022). SI at insertion may help predict recent outcome, with a cutoff value of 1.625, a sensitivity of 0.655 and a specificity of 0.708, and areas under the receiver-operating characteristic curve (AUCROC) was 0.713. On multiple analysis, SI, together with final TIMI flow, arterial pH and creatinine were independent predictive factors of recent prognosis among this population.

CONCLUSION

Among CS patients complicating AMI undergoing PCI with the support of IABP, higher SI before IABP implantation was associated with poorer prognosis, SI was an independent risk factor of 28-day mortality and may predict the 28-day outcome.

The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide.

RECENT FINDINGS

Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection.

SUMMARY

Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.

Mechanical circulatory support in patients with cardiogenic shock not secondary to cardiotomy: a network meta-analysis

To compare the efficacy and safety of different mechanical circulatory support (MCS) devices in CS. A total of 24 studies (7 randomized controlled trials-RCTs-and 17 non-RCTs) involving 11,117 patients were entered in a Bayesian network meta-analysis. The primary endpoint was 30-day mortality. Secondary endpoints were stroke and bleeding (requiring transfusion and/or intracranial and/or fatal). Compared with no MCS, extra-corporeal membrane oxygenation (ECMO) reduced 30-day mortality when used both alone (OR 0.37, 95% CrI 0.15-0.90) and together with the micro-axial pump Impella (OR 0.13, 95% CrI 0.02-0.80) or intra-aortic balloon pump (IABP) (OR 0.19, 95% CrI 0.05-0.63), although the relevant articles were affected by significant publication bias. Consistent results were obtained in a sensitivity analysis including only studies of CS due to myocardial infarction. After halving the weight of studies with a non-RCT design, only the benefit of ECMO + IABP on 30-day mortality was maintained (OR 0.22, 95% CI 0.057-0.76). The risk of bleeding was increased by TandemHeart (OR 13, 95% CrI 3.50-59), Impella (OR 5, 95% CrI 1.60-18), and IABP (OR 2.2, 95% CrI 1.10-4.4). No significant differences were found across MCS strategies regarding stroke. Although limited by important quality issues, the studies performed so far indicate that ECMO, especially if combined with Impella or IABP, reduces short-term mortality in CS. MCS increases the hazard of bleeding.

Influence of inflammation and cardiac hypertrophy on mechanical properties of human pericardium

Different devices for mechanical circulatory support (MCS) have been developed for the treatment of refractory cardiogenic shock. However, all of them are associated with direct blood contact, the need for anticoagulation and bleeding complications. To overcome these limitations the pericardial sac got into the focus as a promising implantation site for MCS. For this purpose, further knowledge about the mechanical properties of human pericardium is required. In this prospective, monocentric, experimental pilot study 56 samples of human pericardium were extracted postmortem from 13 critically ill patients. After preparation of test specimens uniaxial tensile tests were performed. The primary end points were load at fracture per sample width and strain at fracture. Acute inflammation was assessed by blood levels of C-reactive protein, white blood count and procalcitonin measured at several times during hospital stay. Inflammatory load was estimated by area under the inflammatory curves. Correlation and regression analysis were used to assess the relationship of primary end points to inflammation, comorbidities and postmortem time to preparation. Human pericardium showed a load at fracture per sample width of 1.95 [1.38–2.94] N/mm (median [inter quartile range]) and a strain at fracture of 89.29 [73.84–135.23] %. Markers of acute inflammation and cardiac hypertrophy did not correlate to load or strain at fracture. However, strain at fracture increased with higher body mass index and an increasing number of postmortem days. In contrast, higher patient age was associated with a lower strain at fracture. Inflammation and cardiac hypertrophy did not influence mechanical properties of human pericardium.

Fulminant Myocarditis Following SARS-CoV-2 Infection

A 60-year-old woman with a past medical history of asthma presented with fulminant myocarditis 9 days after testing positive for SARS-CoV-2 and 16 days after developing symptoms consistent with COVID-19. Her hospital course was complicated by the need for veno-arterial extracorporeal membrane oxygenation, ventricular arrhythmias, and pseudomonas bacteremia. She ultimately recovered and was discharged to home with normal left ventricular systolic function. Thereafter, she developed symptomatic ventricular tachycardia, for which she received an implantable cardioverter-defibrillator and antiarrhythmic drug therapy.

The clinical efficacy of integrated care in combination with vasopressin for cardiogenic shock induced by acute myocardial infarction: A randomized controlled study protocol

BACKGROUND

Cardiogenic shock (CS) is the most serious complication of acute myocardial infarction (AMI) with high mortality, and the conventional nursing mode can not meet the clinical needs. Studies have shown that integrated care model has advantages for critical and chronic diseases. However, there is no clinical study to evaluate the clinical efficacy of this nursing model on cardiogenic shock induced by acute myocardial infarction (CS-AMI).

METHODS

This is a prospective randomized controlled trial to study the clinical efficacy of integrated care combined with vasopressin in the treatment of CS-AMI. Participants will be randomized in a 1:1 ratio to receive integrated care combined with vasopressin in the treatment group and conventional care combined with vasopressin in the control group. The patients will be followed up for 3 months after systematic treatment. Observation indicators include: length of hospital stay, quality of life score, blood pressure level, and nursing satisfaction score. Finally, SPASS 20.0 software will be used for statistical analysis of the data.

DISCUSSION

This study will evaluate the clinical efficacy of integrated nursing combined with vasopressin in the treatment of CS-AMI. The results of this study will provide a reference for selecting appropriate nursing programs for CS-AMI patients.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/K8CN4.

Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal?

Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.

Percutaneous Coronary Intervention Volume and Cardiac Surgery Availability Effect on Acute Coronary Syndrome-Related Cardiogenic Shock

OBJECTIVES

This study sought to assess the association between cardiac surgery availability and percutaneous coronary intervention (PCI) volume with clinical outcomes of cardiogenic shock (CS) complicating acute coronary syndrome (ACS).

BACKGROUND

CS remains a grave complication of ACS with high mortality rates despite timely reperfusion and improved heart failure therapies.

METHODS

The study analyzed data from consecutive patients with CS complicating ACS who underwent PCI and were prospectively enrolled in the VCOR (Victorian Cardiac Outcomes Registry) from 26 hospitals in Victoria. We compared patients treated at cardiac surgical centers (CSCs) versus non-CSCs as well as the annual CS PCI volume (stratified into tiers of <10, 10-25, and >25 cases) for in-hospital major adverse cardiac and cerebrovascular events (MACCE) and long-term mortality.

RESULTS

Of 1,179 patients with CS, the mean age of patients was 65 years; males comprised 74%, and 22% had diabetes mellitus. Cardiac arrest occurred in 38% of patients, while 90% presented with ST-segment elevation myocardial infarction and 26% received intra-aortic balloon pump support. Overall, in-hospital and long-term mortality were 42% and 51%, respectively. There was no difference among patients treated non-CSCs compared with a CSCs for in-hospital MACCE and mortality (both P > 0.05). Similarly, there was no association between tiers of annual CS PCI volume with in-hospital MACCE and mortality (both P > 0.05).

CONCLUSIONS

Comparable short- and long-term mortality rates among patients with ACS complicated by CS treated by PCI irrespective of cardiac surgery availability and CS PCI volume support the emergent treatment of these gravely ill patients at their presenting PCI-capable hospital.

Hospital-Level Disparities in the Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction

There are limited contemporary data evaluating the relation between hospital characteristics and outcomes of patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). As such, we used the National Inpatient Sample database (2000 to 2017), to identify adult admissions with primary diagnosis of AMI and concomitant CA. Interhospital transfers were excluded, and hospitals were classified based on location and teaching status (rural, urban nonteaching, and urban teaching) and bed size (small, medium, and large). Among 494,083 AMI-CA admissions, 9.3% received care at rural hospitals, 43.4% at urban nonteaching hospitals, and 47.3% at urban teaching hospitals. Compared with urban nonteaching and teaching hospitals, AMI-CA admissions at rural hospitals received lower rates of cardiac and noncardiac procedures. Admissions to urban teaching hospitals had higher rates of acute organ failure, concomitant cardiogenic shock, and cardiac and noncardiac procedures. When hospitals were stratified by bed size, 9.8% of AMI-CA admissions were admitted to small capacity hospitals, 26.0% to medium capacity, and 64.2% to large capacity hospitals. The use of cardiac and noncardiac procedures was lower in small hospitals with higher rates of use in medium and large hospitals. In-hospital mortality was higher in urban nonteaching (adjusted odds ratio [OR] 1.17; 95% confidence interval [CI]1.14 to 1.20; p <0.001) and urban teaching hospitals (adjusted OR 1.36; 95% CI 1.32 to 1.39; p <0.001) compared with rural hospitals. Compared with small hospitals, medium (adjusted OR 1.11; 95% CI 1.08 to 1.14; p <0.001) and large hospitals (adjusted OR 1.22; 95% CI 1.19 to 1.25; p <0.001) were associated with higher in-hospital mortality. In conclusion, AMI-CA admissions to large and urban hospitals had higher in-hospital mortality compared with small and rural hospitals potentially owing to greater acuity.

Percutaneous repositioning of Impella RP: the Snare–Manoeuvre–Prolapse technique—a case report

Background

Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability.

Case summary

A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had ‘fallen back’ into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare.

Discussion

The snare–manoeuvre–prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics.

Development and External Validation of a Nomogram for Predicting Acute Kidney Injury in Cardiogenic Shock Patients in Intensive Care Unit

Background

The aim of this study was to construct and external validate a nomogram for predicting cardiogenic shock acute kidney injury (CS-AKI) in patients in intensive care unit (ICU).

Methods

All patients diagnosed with CS from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in this study. Least absolute shrinkage and selection operator (LASSO) regression and recursive feature elimination for support vector machine (SVM-RFE) were used to determine the overlapping clinical features associated with CS-AKI. The predictive nomogram was established based on the significant clinical parameters and externally verified in this study.

Results

LASSO regression and SVM-RFE demonstrated that Charlson Comorbidity Index (CCI), usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI in the training cohort. The predictive nomogram based on the eight parameters showed good predictive performance as calculated by C-index were 0.823 (95% confidence index, 95% CI 0.798-0.849), 0.819 (95% CI 0.769-0.849), and 0.733 (95% CI 0.704-0.763) in the training set, in the internal validation set and in the external validation sets, respectively. Moreover, the nomogram exhibited not only encouraging calibration ability but also great clinical utility in the training set and in the validation sets.

Conclusion

CCI, usage of mechanical ventilation, SOFA score, white blood cell, albumin, eGFR, anion gap, and positive fluid balance were closely associated with CS-AKI. The predictive nomogram for CS-AKI manifested well-predictive ability for the identification of ICU patients with CS-AKI.

Direct Cardiac Compression Devices to Augment Heart Biomechanics and Function

The treatment of end-stage heart failure has evolved substantially with advances in medical treatment, cardiac transplantation, and mechanical circulatory support (MCS) devices such as left ventricular assist devices and total artificial hearts. However, current MCS devices are inherently blood contacting and can lead to potential complications including pump thrombosis, hemorrhage, stroke, and hemolysis. Attempts to address these issues and avoid blood contact led to the concept of compressing the failing heart from the epicardial surface and the design of direct cardiac compression (DCC) devices. We review the fundamental concepts related to DCC, present the foundational devices and recent devices in the research and commercialization stages, and discuss the milestones required for clinical translation and adoption of this technology. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Age stratified sex-related differences in incidence, management, and outcomes of cardiogenic shock

BACKGROUND

There is a lack of data on age-stratified sex differences in the incidence, treatment, and outcomes of cardiogenic shock (CS). We sought to study these differences from a contemporary database.

METHODS

Patients admitted with CS (2004-2018) were identified from the United States National Inpatient Sample. We compared CS (acute myocardial infarction-related cardiogenic shock [AMI-CS] and non-acute myocardial infarction-related cardiogenic shock [Non-AMI-CS]) incidence, management, and outcomes in males and females, stratified into four age groups (20-44, 45-64, 65-84, and ≥85 years of age). Propensity score matching (PSM) was used for adjustment.

RESULTS

A total of 1,506,281 weighted hospitalizations for CS were included (AMI-CS, 39%; Non-AMI-CS, 61%). Across all age groups, females had a lower incidence of CS compared with males. After PSM and among the AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 45-64 (28.5% vs. 26.3%) and 65-84 years (39.3% vs. 37.9%) (p < 0.01, for all). Among the Non-AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 20-44 (33.5% vs. 30.5%), 45-64 (35.1% vs. 31.9%), and 65-84 years (41.7% vs. 40.3%) (p < 0.01, for all). Similar age-dependent differences in the management of CS were also observed between females and males.

CONCLUSIONS

Females have a lower incidence of CS regardless of age. Significant disparities in the management and outcomes of CS were observed based on sex. However, these disparities varied by age and etiology of CS (AMI-CS vs. Non-AMI-CS) with pronounced disparity among females in the age range of 45-84 years.

Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic Shock

Background

Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in‐hospital mortality. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra‐aortic balloon pumping (IABP) use during VA‐ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA‐ECMO plus IABP treatment compared with VA‐ECMO alone.

Methods and Results

From the nationwide Japanese administrative case‐mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)–DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA‐ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA‐ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA‐ECMO alone). We compared in‐hospital, 7‐day, and 30‐day mortality between the VA‐ECMO plus IABP versus the VA‐ECMO alone support. Patients managed with VA‐ECMO plus IABP demonstrated significantly lower in‐hospital, 7‐day, and 30‐day mortality than those managed with VA‐ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38–0.59], 0.41 [95% CI, 0.33–0.51], and 0.30 [95% CI, 0.25–0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment‐weighting models.

Conclusions

This large‐scale, nationwide study demonstrated that the combination of VA‐ECMO plus IABP support was associated with significantly lower mortality compared with VA‐ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.

Role of Cardiac Imaging Modalities in the Evaluation of COVID-19-Related Cardiomyopathy

Cardiac involvement has been described during the course of SARS-CoV-2 disease (COVID-19), with different manifestations. Several series have reported only increased cardiac troponin without ventricular dysfunction, others the acute development of left or right ventricular dysfunction, and others myocarditis. Ventricular dysfunction can be of varying degrees and may recover completely in some cases. Generally, conventional echocardiography is used as a first approach to evaluate cardiac dysfunction in patients with COVID-19, but, in some cases, this approach may be silent and more advanced cardiac imaging techniques, such as myocardial strain imaging or cardiac magnetic resonance, are necessary to document alterations in cardiac structure or function. In this review we sought to discuss the information provided by different cardiac imaging techniques in patients with COVID-19, both in the acute phase of the disease and after discharge from hospital, and their diagnostic and prognostic role. We also aimed at verifying whether a specific form of cardiac disease due to the SARS-CoV-2 can be identified.

Perioperative temporary mechanical circulatory support with Impella in cardiac surgery patients

BACKGROUND

The benefits of perioperative mechanical circulatory support (MCS) in cardiac surgery patients are still uncertain. This study aims to review early outcomes of perioperative temporary MCS using the Impella device in cardiac surgery patients.

METHODS

Retrospective, single-center analysis in cardiac surgery patients presenting with cardiogenic shock (CS) in whom Impella was used for perioperative temporary MCS, either as single device therapy or as left ventricular (LV) venting strategy for concomitant extracorporeal membrane oxygenation (ECPELLA). Study outcomes were 30-day mortality and occurrence of complication composite outcome.

RESULTS

Between 2016 and 2019, a total of 33 consecutive patients were supported with Impella (single-device therapy in 19 [57.6%] patients and ECPELLA in 14 [42.4%] patients). The 30-day mortality of Impella-alone and ECPELLA groups was 15.8% and 50.0% (P=0.03). The 30-day mortality according to pre-, intra-, and postoperative implantation was 12.5%, 60.0%, and 28.6% (P=0.04), and it was significantly lower in those patients in whom a left ventricular assist device was implanted in comparison to all other surgical procedures (P<0.01). The complication composite outcome occurred more frequently after axillary implantation compared to femoral Impella (P=0.05) due to higher stroke rates (P=0.03). Bleeding requiring surgical re-exploration was more frequent in the ECPELLA than in the Impella-alone group (1 [3.0%] vs. 5 [15.1%]; P=0.03).

CONCLUSIONS

Temporary MCS with Impella is associated with high complication and mortality rates. However, preoperative use of Impella as single-device temporary MCS is associated with lower mortality rates and is a reasonable alternative as a bridge-to-decision strategy for acutely decompensated patients.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Advocacy and Legislation for Regionalization Practices in the Treatment of Cardiogenic Shock: The Time Is Now

Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.

Ventricular Unloading Using the ImpellaTM Device in Cardiogenic Shock

Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.

End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry

AIMS

Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs.

METHODS AND RESULTS

The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13 422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died.

CONCLUSIONS

In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.

Incidence, Clinical Characteristics and Short-Term Prognosis in Patients With Cardiogenic Shock and Various Left Ventricular Ejection Fractions After Acute Myocardial Infarction

The 2016 European Society of Cardiology Guidelines introduced a new term, mid-range left ventricular ejection fraction (mrEF) heart failure, however, the clinical characteristics and short-term outcomes in cardiogenic shock patients with mrEF after acute myocardial infarction remain unclear. This retrospective study analyzed the baseline characteristics, management, and outcomes according to the left ventricular ejection fraction (LVEF), reduced LVEF (rEF) ≤40%, mrEF 41% to 49%, and preserved LVEF (pEF) ≥50% in patients with acute myocardial infarction complicated by cardiogenic shock. The primary end point was 30-day all-cause mortality and the secondary end point was the composite events of major adverse cardiovascular events (MACEs). In 218 patients, 71 (32.6%) were patients with mrEF. Compared with those with pEF, patients with mrEF had some similar clinical characteristics to that of rEF. The 30-day all-cause mortality in patients with rEF, mrEF, and pEF were 72.7%, 56.3%, and 32.0%, respectively (p = 0.001). The 30-day MACE were 90.9%, 69.0%, and 60.2%, respectively (p = 0.001). After multivariable adjustment, patients with mrEF and rEF had comparable 30-day all-cause mortality (hazard ratio [HR] = 0.81, 95% confidence interval [CI] 0.50 to 1.33, p = 0.404), and pEF was associated with decreased risk of 30-day all-cause mortality compared with rEF (HR = 0.41, 95% CI 0.24 to 0.71, p = 0.001). In contrast, the risk of 30-day MACE in mrEF and pEF were lower than that of rEF (HR = 0.62, 95% CI 0.40 to 0.96, p = 0.031 and HR = 0.53, 95% CI 0.34 to 0.80, p = 0.003, respectively). In conclusion, 1/3 of patients with acute myocardial infarction complicated by cardiogenic shock were mrEF. The clinical characteristics and short-term mortality in patients with mrEF were inclined to that of rEF and the occurrence of early left ventricular systolic dysfunction is of prognostic significance.

Norepinephrine use in cardiogenic shock patients is associated with increased 30 day mortality

Aims

Norepinephrine is recommended as a first‐line vasopressor agent in the haemodynamic stabilization of cardiogenic shock. The survival benefit of norepinephrine therapy has not been demonstrated in clinical practice, however. This study aimed to explore the relationship between norepinephrine use and outcomes in cardiogenic shock patients in real‐world conditions.

Methods and results

We conducted a retrospective cohort study based on the Medical Information Mart for Intensive Care III (MIMIC‐III) database. Cardiogenic shock patients were enrolled and categorized into a norepinephrine group or a non‐norepinephrine group. Propensity score matching (PSM) was used to control for confounders. Cox proportional‐hazards models and multivariable logistic regression were used to investigate the relationship between norepinephrine treatment and mortality. A total of 927 eligible patients were included: 552 patients in the norepinephrine group and 375 patients in the non‐norepinephrine group. After PSM, 222 cases from each group were matched using a 1:1 matching algorithm. Thirty day mortality for patients treated with norepinephrine was significantly higher than for those in the non‐norepinephrine group (41% vs. 30%, OR 1.61, 95% CI 1.09–2.39, P = 0.017; HR 1.50, 95% CI 1.09–2.06, P = 0.013). In the multivariable analysis, there was no significant difference between norepinephrine therapy and long‐term (90 day, 180 day, or 1 year) mortality (90 day (OR 1.19, 95% CI 0.82–1.74, P = 0.363), 180 day (OR 1.17, 95% CI 0.80–1.70, P = 0.418), 1 year (OR 1.14, 95% CI 0.79–1.66, P = 0.477). Patients in the norepinephrine group required more mechanical ventilation (84% vs. 67%, OR 2.67, 95% CI 1.70–4.25, P < 0.001) and experienced longer ICU stays (median 7 vs. 4 days, OR 7.92, 95% CI 1.40–44.83, P = 0.020) than non‐norepinephrine group.

Conclusions

Cardiogenic shock patients treated with norepinephrine were associated with significantly increased short‐term mortality, while no significant difference was found on long‐term survival rates. Future trials are needed to validate and explore this association.

European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Rates and impact of vascular complications in mechanical circulatory support

BACKGROUND

Mechanical circulatory support (MCS) devices are increasingly used for hemodynamic support in cardiogenic shock or high-risk percutaneous coronary interventions. Vascular complications remain a major source of morbidity and mortality despite technological advances with percutaneous techniques. Little is known about the rates and predictors of vascular complications with large-bore access MCS in the contemporary era.

METHODS

The study cohort was derived from National Inpatient Sample using data from 2015 to 2019 for cardiac hospitalizations with the use of: intra-aortic balloon pump (IABP) Impella, and/or extracorporeal membrane oxygenation (ECMO). The rates of vascular complications and in-hospital outcomes were analyzed using multivariable logistic regression.

RESULTS

Of 221,700 hospitalizations with MCS use, the majority had only IABP (68%). The rates of vascular complications were greatest with ECMO (15.8%) when compared with IABP (3.0%) and Impella (5.6%). Among patients with vascular complications, in-hospital mortality was higher with ECMO (56.3%) when compared with IABP (26.2%) and Impella (33.8%). Peripheral arterial disease (PAD) was the strongest predictor of vascular complications, with 10 times higher odds when present (adjusted odds ratio [aOR] 10.96, p < 0.001). In risk-adjusted models, when compared with IABP, the use of Impella (aOR: 1.73, p < 0.001), ECMO (aOR: 5.35, p < 0.001), or a combination of MCS devices (aOR: 3.47, p < 0.001) was associated with higher odds of vascular complications.

CONCLUSIONS

In contemporary practice, the use of MCS is associated with significant vascular complications and in-hospital mortality. Predictors of vascular complications include larger arteriotomy size, female gender, and peripheral arterial disease. Vascular access management remains essential to prevent major complications.

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity

Background

Echocardiographic findings vary with shock severity, as defined by the Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Left ventricular stroke work index (LVSWI) measured by transthoracic echocardiography (TTE) can predict mortality in the cardiac intensive care unit (CICU). We sought to determine whether LVSWI could refine mortality risk stratification by the SCAI shock classification in the CICU.

Methods

We included consecutive CICU patients from 2007 to 2015 with TTE data available to calculate the LVSWI, specifically the mean arterial pressure, stroke volume index and medial mitral E/e’ ratio. In-hospital mortality as a function of LVSWI was evaluated across the SCAI shock stages using logistic regression, before and after multivariable adjustment.

Results

We included 3635 unique CICU patients, with a mean age of 68.1 ± 14.5 years (36.5% females); 61.1% of patients had an acute coronary syndrome. The LVSWI progressively decreased with increasing shock severity, as defined by increasing SCAI shock stage. A total of 203 (5.6%) patients died during hospitalization, with higher in-hospital mortality among patients with lower LVSWI (adjusted OR 0.66 per 10 J/m2 higher) or higher SCAI shock stage (adjusted OR 1.24 per each higher stage). A LVSWI <33 J/m2 was associated with higher adjusted in-hospital mortality, particularly among patients with shock (SCAI stages C, D and E).

Conclusions

The LVSWI by TTE noninvasively characterizes the severity of shock, including both systolic and diastolic parameters, and can identify low-risk and high-risk patients at each level of clinical shock severity.

Lactate Clearance as a Surrogate for Mortality in Cardiogenic Shock: Insights From the DOREMI Trial

Background

Recent studies have shown improved outcomes in cardiogenic shock through protocols directed toward early identification and initiation of mechanical circulatory support. However, objective therapeutic targets—based on clinical and/or laboratory data—to guide real‐time clinical decision making are lacking. Lactate clearance has been suggested as a potential treatment target because of its independent association with mortality.

Methods and Results

In a post hoc analysis of the DOREMI (Dobutamine Compared to Milrinone in the Treatment of Cardiogenic Shock) trial—a randomized, double‐blind, controlled trial comparing milrinone to dobutamine in the treatment of cardiogenic shock—we used prospectively collected lactate data to evaluate lactate clearance as a surrogate marker for in‐hospital mortality. In total, 82 (57.7%) patients survived to hospital discharge (survivors). In multivariate logistic regression analysis, complete lactate clearance, percentage lactate clearance, and percentage lactate clearance per hour were independently associated with survival beginning as early as 8 hours after enrollment. Complete lactate clearance was the strongest predictor of survival at all time points, with odds ratios ranging between 2.46 (95% CI, 1.09–5.55; P=0.03) at 8 hours to 5.44 (95% CI, 2.14–13.8; P<0.01) at 24 hours.

Conclusions

Complete lactate clearance is a strong and independent predictor of in‐hospital survival in patients with cardiogenic shock. Together with previously published data, these results further support the validity of lactate clearance as an appropriate surrogate for mortality and as a potential therapeutic target in future cardiogenic shock trials.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03207165.

A Comprehensive Review of Mechanical Circulatory Support Devices

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Transcatheter aortic valve replacement in a patient with critical bicuspid aortic stenosis and cardiogenic shock: case report

Background

Cardiogenic shock (CS) is associated with significant morbidity and mortality (27–51%). Little is known about the feasibility and safety of emergency transcatheter aortic valve replacement (TAVR) for critical aortic stenosis (AS) in acute myocardial infarction (AMI) with CS.

Case summary

A 57-year-old male with history of tobacco dependence and diabetes mellitus presented with acute posterior ST-segment elevation myocardial infarction and CS. The patient initially underwent successful primary percutaneous intervention to an anomalous circumflex artery coming off the right cusp. It was noted to have advanced CS out of proportion to his coronary anatomy. Echocardiographic assessment noted critical AS. Heart team decided to perform percutaneous aortic balloon valvuloplasty under support of extracorporeal membrane oxygenation. Percutaneous aortic balloon valvuloplasty was performed and was complicated by severe aortic regurgitation (AR). A balloon-expandable transcatheter heart valve was then placed with resolution of AR and stabilization of the patient. Then, the patient was subsequently decannulated within a week then was able to go home after 47 days (32 days intensive care unit). His course was notable for a minor stroke due to initial period of hypotension and CS. He was extubated and remained hospitalized for several weeks participating in rehabilitation. Follow-up echo showed a well-seated and functioning transcatheter heart valve. His left ventricular systolic function improved from 21% to 45%.

Conclusion

Emergency TAVR is feasible and can be performed in a patient with AMI and CS. Early initiation of mechanical support allowed the patient to receive definitive treatment. The multidisciplinary heart team is essential and reflected in the ultimate outcome of our patient.

Withdrawal of Temporary Mechanical Circulatory Support in Patients With Capacity

CONTEXT

Little is known about the real-time decision-making process of patients with capacity to choose withdrawal of temporary mechanical circulatory support (MCS).

OBJECTIVES

To assess how withdrawal of temporary MCS occurs when patients possess the capacity to make this decision themselves.

METHODS

This retrospective case series included adults supported by CentriMag Acute Circulatory Support or Veno-Arterial Extracorporeal Membrane Oxygenation from February 2, 2007 to May 27, 2020 at a tertiary academic medical center who possessed capacity to participate in end-of-life discussions. Authors performed chart review to determine times between "initiation of temporary MCS," "determination of 'bridge to nowhere,'" "patient expressing desire to withdraw," "agreement to withdraw," "withdrawal," and "death," as well as reasons for withdrawal and the role of ethics, psychiatry, and palliative care.

RESULTS

A total of 796 individuals were included. MCS was withdrawn in 178 (22.4%) of cases. Six of these 178 patients (3.4%) possessed the capacity to decide to withdraw MCS. Time between "patient expressing desire to withdraw" and "agreement to withdraw" ranged from 0 to 3 days; time between "agreement to withdraw" and "withdrawal" ranged from 0 to 6 days. Common reasons for withdrawal include perceived decline in quality of life or low probability of recovery. Ethics and psychiatry were consulted in 3 of 6 cases and palliative care in 5 of 6 cases.

CONCLUSION

While it is rare for patients on MCS to request withdrawal, such cases provide insight into reasons for withdrawal and the important roles of multidisciplinary teams in helping patients and families through end-of-life decision-making.