Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome

A Framework for Exception From Informed Consent in Trials Enrolling Patients With ST-Segment-Elevation Myocardial Infarction and Cardiogenic Shock

Cardiogenic shock (CS) is critical end-organ hypoperfusion attributable to reduced cardiac output. Acute ST-segment-elevation myocardial infarction with CS (AMI-CS) has high mortality. Clinical research is challenging in such patients as they often cannot provide consent, lack available legal representatives, and require initiation of therapy. Multiple trials have enrolled patients with AMI-CS outside the United States under deferred consent. Trials in the United States have enrolled patients with out-of-hospital cardiac arrest under exception from informed consent (EFIC). However, AMI-CS has a longer therapeutic window to initiate treatment than out-of-hospital cardiac arrest, and more patients or their representatives can engage in treatment decisions. We provide a rationale for how a trial enrolling patients with AMI-CS could qualify for conduct using EFIC by meeting each criterion specified in US human subject regulations. AMI-CS is a life-threatening situation, available treatments are unsatisfactory, and collection of valid evidence is necessary. Obtaining informed consent is often not feasible, and trial participation could benefit subjects. Only enrolling consented patients is impracticable and could reduce the study's generalizability. We propose a therapeutic window of 30 minutes within the study intervention must be initiated, with consent sought within 15 minutes, respecting any refusal or objection to enrollment, and otherwise enrollment under EFIC. A trial could enroll patients with AMI-CS under EFIC and can involve both patients and their representatives. Successful use of EFIC in trials of other interventions in patients with CS or enrolling patients with other acute cardiovascular conditions could increase the available evidence base to improve care.

Clinical efficacy and hemodynamic effects of levosimendan in cardiac surgery patients after surgery

OBJECTIVE

To investigate the therapeutic effect of levosimendan on hemodynamics in patients undergoing major cardiac surgery and presenting with acute postoperative heart failure.

METHODS

The subjects of the study were 160 patients with severe cardiac conditions who underwent surgery and had acute heart failure. Eighty cases each were assigned to the research and control groups using a random number table. Document the general patient data for each of the two groups; compare the clinical outcomes of the two groups. The hemodynamic states of the two groups were compared both before and after therapy. 48 h after surgery, echocardiography was performed in both groups to determine cardiac function. 48 h after surgery, N-terminal pro-brain B-type natriuretic peptide (NT-Pro-BNP) levels were compared between the two groups.

RESULTS

The overall effective rate was significantly higher in the research group (92.5%) compared to the control group (76.25%, P < 0.05). Post-treatment, the research group demonstrated a significant reduction in CVP (9.25 ± 2.11 cmH2O vs. 11.36 ± 3.08 cmH2O, P < 0.001), heart rate (100.30 ± 8.69 bpm vs. 105.74 ± 7.69 bpm, P < 0.001), and lactic acid levels (1.68 ± 0.59 mmol/L vs. 2.69 ± 0.55 mmol/L, P < 0.001). The research group also showed improvements in SBP (117.23 ± 8.74 mmHg vs. 113.25 ± 7.55 mmHg, P = 0.002) and urine output (4.21 ± 1.76 mL/kg/h vs. 3.65 ± 1.23 mL/kg/h, P = 0.021). Cardiac function indicators 48 h after surgery indicated a higher LVEF (55.21 ± 8.04% vs. 47.18 ± 6.60%, P < 0.001) and lower LVEDVi and LVESVi in the research group (P < 0.001 for both). NT-Pro-BNP levels were significantly lower in the research group (6010.19 ± 1208.52 pg/mL vs. 9663.21 ± 2391.34 pg/mL, P < 0.001). The incidence of complications was lower in the research group (5% vs. 22.5%, P = 0.001).

CONCLUSION

Cardiac surgery patients are prone to complications with acute heart failure after surgery. Treatment with levosimendan can significantly improve clinical efficacy and reduce complications. It can also effectively improve patients' cardiac function and promote hemodynamic stability.

Trinitroglycerine-loaded chitosan nanoparticles attenuate renal ischemia-reperfusion injury by modulating oxidative stress

Renal ischemia-reperfusion (I/R) injury is a common clinical factor for acute kidney injury (AKI). A current study investigated the renoprotective effects of the trinitroglycerine (TNG) combination with chitosan nanoparticles (CNPs) on renal I/R-induced AKI. Rats were randomly assigned to five groups (n = 8/group): Sham, I/R, TNG (50 mg/kg) + I/R, CNPs (60 mg/kg) + I/R, and TNG-CNPs + I/R. Bilateral renal pedicles were occluded for 60 min to induce ischemia. TNG, CNPs, or TNG-CNPs were administered intraperitoneally 30 min before renal ischemia. After 24 h of reperfusion, blood samples were collected, and both kidneys were removed. The left kidney was used for oxidative stress analysis. The right kidney was preserved in 10% formalin for histopathological examination via H&E staining. After renal ischemia-reperfusion injury, there was an observed increase in plasma creatinine (Cr) and blood urea nitrogen (BUN), accompanied by a decrease in glomerular filtration rate (GFR) in rats. Total oxidative stress (TOS) levels were also significantly higher in the I/R group, whereas total antioxidative capacity (TAC) was reduced. Histopathological examination revealed damage in the kidneys of rats in the I/R group. Pretreatment with the TNG-CNP formulation before I/R increased plasma and tissue TAC levels in rats. It also corrected the renal histopathological changes and functional disorders induced by I/R injury, as evidenced by reduced Cr and BUN, increased GFR, and attenuated oxidative stress. The results suggest that the TNG-CNP combination provides renoprotective effects against I/R-induced AKI by improving antioxidant status and minimizing renal injury.

Effect of Levosimendan on Low Cardiac Output Syndrome After Pericardiectomy

Background

Low cardiac output syndrome (LCOS) after pericardiectomy is associated with high morbidity and mortality. This study aimed to assess the effect of levosimendan on postoperative LCOS in the patients with constrictive pericarditis.

Methods

Patients were retrospectively enrolled, and those receiving the treatment of levosimendan were assigned in the LEVO (+) group, and others were in the LEVO (-) group. Postoperative outcomes including durations of intubation, vasoactive agents using, ICU stay, hospital stay and mortality were compared between the two groups.

Results

A total of 32 patients were eligible for analysis, 19 of whom were in the LEVO (+) group, and 13 of whom were in the LEVO (-) group. The LEVO (+) group was associated with shorter postoperative duration of intubation (P < 0.001), vasopressor using (P = 0.006), ICU stay (P = 0.001) and hospital stay (P = 0.042), and less incidence of acute liver or kidney injury (P = 0.046). There were no significant differences in 30-day mortality and 1-year mortality between the LEVO (+) group and the LEVO (-) group. The prevalence of adverse events in the LEVO (+) group was acceptable.

Conclusion

Levosimendan could be administered in the patients with constrictive pericarditis developing LCOS after pericardiectomy to enhanced postoperative recovery.

Managing Arrhythmias in Cardiogenic Shock: Insights Into Milrinone and Dobutamine Therapy

Shock is a state of inadequate perfusion that affects vital organs. Cardiogenic shock (CS) predisposes patients to various arrhythmias. The adverse effect depends on intervention and pharmacogenomics. This narrative review sheds light on treatment strategies for arrhythmias caused by milrinone and dobutamine when managing CS. Dobutamine, through beta-1 agonism, and milrinone, by phosphodiesterase-3 inhibition, increase cardiac contractility by enhancing the availability of calcium to the myocardium. Dobutamine is also a beta-2 agonist, and milrinone is a phosphodiesterase-3 inhibitor; both result in peripheral vasodilation, leading to their use preferentially in patients with CS with normotensive blood pressure. To narrow down relevant literature, various electronic databases, including PubMed, Google Scholar, and Cochrane Library, were searched. The review revealed limited evidence favoring either milrinone or dobutamine as the preferred inotropic agent for managing CS, but it did reveal that though hospital stays using dobutamine were shorter, mortality from its induced arrhythmias led to an increase in all-cause mortality rates. Both proarrhythmic agents triggered ventricular and supraventricular tachyarrhythmias, some requiring cardioversion while others are non-sustained and managed medically or symptomatically. Though neither agent has a specific reversal agent, the effect of dobutamine was seen to be successfully aborted using intravenous ultrashort half-life beta-blockers (such as esmolol). The findings accentuated the critical need for a tailored approach to managing these iatrogenic arrhythmias, emphasizing clinical vigilance and individualized patient care.

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

[Initial diagnosis and treatment of shock]

BACKGROUND

Structured procedures have been established internationally for the initial clinical care of patients with traumatic injuries. Comparable concepts have not yet been applied to the initial clinical care of life-threatening nontraumatic emergencies. In 2022, a working group of the German Society for Acute and Emergency Medicine (DGINA) presented the Advanced Critical Illness Life Support (ACiLS) concept for the care of nontraumatic emergencies and offers corresponding training courses.

OBJECTIVE

To present systematic clinical first aid for patients with the leading symptom of shock according to the ACiLS concept.

RESULT

The (PR_E-)AUD2IT basic algorithm used in the ACiLS concept divides the initial care of a critically ill patient into the elements of preparation, resources, initial care, medical history, examination, differential diagnosis, diagnostics, interpretation and to do, interrupted by three team time-out elements for structured communication. The use of this concept is demonstrated here using the example of shock.

CONCLUSION

The ACiLS concept has the potential to improve the quality of initial care of nontraumatic emergencies in emergency department shock rooms and intensive care units. Further evaluations in practice and training capacities are essential.

Low-dose dobutamine in acute myocardial infarction with intermediate to high risk of cardiogenic shock development (the DOBERMANN-D trial): study protocol for a double-blinded, placebo-controlled, single-center, randomized clinical trial

BACKGROUND

Cardiogenic shock (CS) occurs in 5-10% of patients with acute myocardial infarction (AMI), and the condition is associated with a 30-day mortality rate of up to 50%. Most of the AMI patients are in SCAI SHOCK stage B upon hospital arrival, but some of these patients will progression through the stages to overt shock (SCAI C-E). Around one third of patients who develop CS are not in shock at the time of hospital admission. Pro-B-type natriuretic peptide (proband) is a biomarker closely related to CS development. The aim of this study is to investigate the potential for preventing progression of hemodynamic instability by early inotropic support with low-dose dobutamine infusion administrated after revascularization in AMI patients with intermediate to high risk of in-hospital CS development.

METHODS

This investigator-initiated, double-blinded, placebo-controlled, randomized, single-center, clinical trial will include 100 AMI patients (≥ 18 years) without CS at hospital admission and at intermediate-high risk of in-hospital CS development (ORBI risk score ≥ 10). Patients will be randomized in a 1:1 ratio to a 24 h intravenous (IV) infusion of dobutamine (5 μg/kg/min) or placebo (NaCl) administrated after acute percutaneous coronary intervention (PCI) (< 24 h from symptom onset). Blood samples are drawn at time points from study inclusion (before infusion, 12, 24, 36, and 48 h). The primary outcome is peak plasma proBNP within 48 h after infusion as a surrogate-measure for the hemodynamic status. Hemodynamic function will be assessed pulse rate, blood pressure, and lactate within 48 h after infusion and by transthoracic echocardiography (TTE) performed after 24-48 h and at follow-up after 3 months. Markers of cardiac injury (troponin T and creatine kinase MB (CK-MB)) will be assessed.

DISCUSSION

Early inotropic support with low-dose dobutamine infusion in patients with AMI, treated with acute PCI, and at intermediate-high risk of in-hospital CS may serve as an intervention promoting hemodynamic stability and facilitating patient recovery. The effect will be assessed using proBNP as a surrogate marker of CS development, hemodynamic measurements, and TTE within the initial 48 h and repeated at a 3-month follow-up.

TRIAL REGISTRATION

The Regional Ethics Committee : H-21045751. EudraCT: 2021-002028-19.

CLINICALTRIALS

gov: NCT05350592, Registration date: 2022-03-08. WHO Universal Trial Number: U1111-1277-8523.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed.

SUMMARY

Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

In-Hospital Mortality in Patients With Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation With Concomitant Use of Impella vs. Intra-Aortic Balloon Pump - A Retrospective Cohort Study Using a Japanese Claims-Based Database

BACKGROUND

Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking.

METHODS AND RESULTS

Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001).

CONCLUSIONS

Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

Management of cardiogenic shock: a narrative review

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors

Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity. Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock, although its contribution has declined over the past two decades, compared with other causes. Despite some advances in cardiogenic shock management, this clinical syndrome is still burdened by an extremely high mortality. Its management is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished. With these aims, medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role. The purpose of this article is to review current evidence on the use of these medications in patients with cardiogenic shock and discuss specific clinical settings with indications to their use.

A novel interpretative tool for early prediction of low cardiac output syndrome after valve surgery: online machine learning models

OBJECTIVE

Low cardiac output syndrome (LCOS) is a severe complication after valve surgery, with no uniform standard for early identification. We developed interpretative machine learning (ML) models for predicting LCOS risk preoperatively and 0.5 h postoperatively for intervention in advance.

METHODS

A total of 2218 patients undergoing valve surgery from June 2019 to Dec 2021 were finally enrolled to construct preoperative and postoperative models. Logistic regression, support vector machine (SVM), random forest classifier, extreme gradient boosting, and deep neural network were executed for model construction, and the performance of models was evaluated by area under the curve (AUC) of the receiver operating characteristic and calibration curves. Our models were interpreted through SHapley Additive exPlanations, and presented as an online tool to improve clinical operability.

RESULTS

The SVM algorithm was chosen for modeling due to better AUC and calibration capability. The AUCs of the preoperative and postoperative models were 0.786 (95% CI 0.729-0.843) and 0.863 (95% CI 0.824-0.902), and the Brier scores were 0.123 and 0.107. Our models have higher timeliness and interpretability, and wider coverage than the vasoactive-inotropic score, and the AUC of the postoperative model was significantly higher. Our preoperative and postoperative models are available online at http://njfh-yxb.com.cn:2022/lcos.

CONCLUSIONS

The first interpretable ML tool with two prediction periods for online early prediction of LCOS risk after valve surgery was successfully built in this study, in which the SVM model has the best performance, reserving enough time for early precise intervention in critical care.

Vasoactive Inotropic Score compared to the sequential organ failure assessment cardiovascular score in intensive care

BACKGROUND

The cardiovascular component of the sequential organ failure assessment (cvSOFA) score may be outdated because of changes in intensive care. Vasoactive Inotropic Score (VIS) represents the weighted sum of vasoactive and inotropic drugs. We investigated the association of VIS with mortality in the general intensive care unit (ICU) population and studied whether replacing cvSOFA with a VIS-based score improves the accuracy of the SOFA score as a predictor of mortality.

METHODS

We studied the association of VIS during the first 24 h after ICU admission with 30-day mortality in a retrospective study on adult medical and non-cardiac emergency surgical patients admitted to Kuopio University Hospital ICU, Finland, in 2013-2019. We determined the area under the receiver operating characteristic curve (AUROC) for the original SOFA and for SOFAVISmax , where cvSOFA was replaced with maximum VIS (VISmax ) categories.

RESULTS

Of 8079 patients, 1107 (13%) died within 30 days. Mortality increased with increasing VISmax . AUROC was 0.813 (95% confidence interval [CI], 0.800-0.825) for original SOFA and 0.822 (95% CI: 0.810-0.834) for SOFAVISmax , p < .001.

CONCLUSION

Mortality increased consistently with increasing VISmax . Replacing cvSOFA with VISmax improved the predictive accuracy of the SOFA score.

Improved mortality and haemodynamics with milrinone in cardiogenic shock due to acute decompensated heart failure

AIMS

Studies in cardiogenic shock (CS) often have a heterogeneous population of patients, including those with acute myocardial infarction and acute decompensated heart failure (ADHF-CS). The therapeutic profile of milrinone may benefit patients with ADHF-CS. We compared the outcomes and haemodynamic trends in ADHF-CS receiving either milrinone or dobutamine.

METHODS AND RESULTS

Patients presenting with ADHF-CS (from 2014 to 2020) treated with a single inodilator (milrinone or dobutamine) were included in this study. Clinical characteristics, outcomes, and haemodynamic parameters were collected. The primary endpoint was 30 day mortality, with censoring at the time of transplant or left ventricular assist device implantation. A total of 573 patients were included, of which 366 (63.9%) received milrinone and 207 (36.1%) received dobutamine. Patients receiving milrinone were younger, had better kidney function, and lower lactate at admission. In addition, patients receiving milrinone received mechanical ventilation or vasopressors less frequently, whereas a pulmonary artery catheter was more frequently used. Milrinone use was associated with a lower adjusted risk of 30 day mortality (hazard ratio = 0.52, 95% confidence interval 0.35-0.77). After propensity-matching, the use of milrinone remained associated with a lower mortality (hazard ratio = 0.51, 95% confidence interval 0.27-0.96). These findings were associated with improved pulmonary artery compliance, stroke volume, and right ventricular stroke work index.

CONCLUSIONS

The use of milrinone compared with dobutamine in patients with ADHF-CS is associated with lower 30 day mortality and improved haemodynamics. These findings warrant further study in future randomized controlled trials.

Levosimendan: current and possible areas of clinical application: A review

Levosimendan belongs to the class of calcium sensitizers, which exhibits its positive inotropic effects by increasing the affinity of troponin from the myocardium to calcium without additional myocardial oxygen demand, what favorably distinguishes it from catecholamines and their negative effects (myocardial ischemia, arrhythmias, vasoconstriction, hyperglycemia). In 2000, the drug was first used for the short-term treatment of decompensated chronic heart failure. After more than 20 years, the clinical use of levosimendan has covered a wide area among patients with pathology of the cardiovascular system and its use has gone far beyond the primary indications. To date, the drug has been studied in more than 200 randomized trials in patients with various clinical profiles: acute decompensation of chronic heart failure, progressive heart failure, acute myocardial infarction, cardiogenic shock, therapy of low cardiac output syndrome in cardiac surgery, perioperative use in pediatric cardiac surgery, septic shock, pulmonary hypertension, right ventricular failure, Takotsubo cardiomyopathy, patients with mechanical circulatory support devices. This review highlights the pharmacological features of the drug and key randomized clinical trials on the use of levosimendan in various categories of patients, in addition to officially recommended indications. The article also provides a brief overview of current and planned randomized trials.

The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review

Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.

Therapeutic Development of Levosimendan in Acute and Advanced Heart Failure: A Systematic Review

Levosimendan (LS) has been progressively used for the treatment of patients developing acute as well as chronic or advanced cardiac dysfunction. It has proven to be a better inotropic agent than its counterparts in terms of its ability to increase the cardiac output in an acutely or chronically decompensated heart without an increase in the myocardial oxygen demand. The purpose of this systematic review, which was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020, was to determine the efficacy and advantages of utilizing LS in patients with both acute and chronic heart failure. We collected and reviewed articles, including clinical trials, literature reviews, randomized and non-randomized control trials, case-control and cohort studies, and systematic reviews and meta-analyses published between January 1, 2012, and November 27, 2022. The databases that were used to collect these articles included Pubmed, Pubmed Central, Cochrane Library, and Google Scholar. After applying appropriate filters, a total of 143 reports were identified from these four databases. They were further screened and subjected to quality assessment tools which finally yielded 21 studies that were included in this systematic review. This review provides strong evidence that the pharmacological properties and different mechanisms of action of LS give it an upper hand over other inotropic agents for its successful administration in patients with either acute or advanced cardiac failure, which consists of left as well as right ventricular failure, either individually or in combination.

Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done

Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.

Inotropes, vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis

PURPOSE

To compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction.

SOURCE

We conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality.

PRINCIPAL FINDINGS

We included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis.

CONCLUSION

The results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding.

STUDY REGISTRATION

Center for Open Science ( https://osf.io/ky2gr ); registered 10 November 2020.

Machine Learning Model for Predicting Risk of In-Hospital Mortality after Surgery in Congenital Heart Disease Patients

Background

A machine learning model was developed to estimate the in-hospital mortality risk after congenital heart disease (CHD) surgery in pediatric patient.

Methods

Patients with CHD who underwent surgery were included in the study. A Extreme Gradient Boosting (XGBoost) model was constructed based onsurgical risk stratification and preoperative variables to predict the risk of in-hospital mortality. We compared the predictive value of the XGBoost model with Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) and Society of Thoracic Surgery-European Association for Cardiothoracic Surgery (STS-EACTS) categories.

Results

A total of 24,685 patients underwent CHD surgery and 595 (2.4%) died in hospital. The area under curve (AUC) of the STS-EACTS and RACHS-1 risk stratification scores were 0.748 [95% Confidence Interval (CI): 0.707-0.789, p < 0.001] and 0.677 (95% CI: 0.627-0.728, p < 0.001), respectively. Our XGBoost model yielded the best AUC (0.887, 95% CI: 0.866-0.907, p < 0.001), and sensitivity and specificity were 0.785 and 0.824, respectively. The top 10 variables that contribute most to the predictive performance of the machine learning model were saturation of pulse oxygen categories, risk categories, age, preoperative mechanical ventilation, atrial shunt, pulmonary insufficiency, ventricular shunt, left atrial dimension, a history of cardiac surgery, numbers of defects.

Conclusions

The XGBoost model was more accurate than RACHS-1 and STS-EACTS in predicting in-hospital mortality after CHD surgery in China.

Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning

Background

This study aimed to develop machine learning models to predict Low Cardiac Output Syndrome (LCOS) in patients following cardiac surgery using machine learning algorithms.

Methods

The clinical data of cardiac surgery patients in Nanjing First Hospital between June 2019 and November 2020 were retrospectively extracted from the electronic medical records. Six conventional machine learning algorithms, including logistic regression, support vector machine, decision tree, random forest, extreme gradient boosting and light gradient boosting machine, were employed to construct the LCOS predictive models with all predictive features (full models) and selected predictive features (reduced models). The discrimination of these models was evaluated by the area under the receiver operating characteristic curve (AUC) and the calibration of the models was assessed by the calibration curve. Shapley Additive explanation (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) were used to interpret the predictive models.

Results

Data from 1,585 patients [982 (62.0%) were male, aged 18 to 88, 212 (13.4%) with LCOS] were employed to train and validate the LCOS models. Among the full models, the RF model (AUC: 0.909, 95% CI: 0.875–0.943; Sensitivity: 0.849, 95% CI: 0.724–0.933; Specificity: 0.835, 95% CI: 0.796–0.869) and the XGB model (AUC: 0.897, 95% CI: 0.859–0.935; Sensitivity: 0.830, 95% CI: 0.702–0.919; Specificity: 0.809, 95% CI: 0.768–0.845) exhibited well predictive power for LCOS. Eleven predictive features including left ventricular ejection fraction (LVEF), first post-operative blood lactate (Lac), left ventricular diastolic diameter (LVDd), cumulative time of mean artery blood pressure (MABP) lower than 65 mmHg (MABP &lt; 65 time), hypertension history, platelets level (PLT), age, blood creatinine (Cr), total area under curve above threshold central venous pressure (CVP) 12 mmHg and 16 mmHg, and blood loss during operation were used to build the reduced models. Among the reduced models, RF model (AUC: 0.895, 95% CI: 0.857–0.933; Sensitivity: 0.830, 95% CI: 0.702–0.919; Specificity: 0.806, 95% CI: 0.765–0.843) revealed the best performance. SHAP and LIME plot showed that LVEF, Lac, LVDd and MABP &lt; 65 time significantly contributed to the prediction model.

Conclusion

In this study, we successfully developed several machine learning models to predict LCOS after surgery, which may avail to risk stratification, early detection and management of LCOS after cardiac surgery.

Intensive Care Management of the Cardiogenic Shock Patient

Optimal management of patients with cardiogenic shock requires a detailed and systematic assessment of all organ systems, balancing the risks and benefits of any investigation and intervention, while avoiding the complications of critical illness. Overall prognosis depends upon a number of factors, including that of the underlying cardiac disease and its potential reversibility, the severity of shock, the involvement of other organ systems, the age of the patient and comorbidities. As with all intensive care patients, the mainstay of management is supportive, up to and including implementation and management of a number of devices, including acute mechanical circulatory support. The assessment and management of these most critically ill patients therefore demands in-depth knowledge and skill relating to cardiac intensive care, extending well beyond standard intensive care or cardiology practice.

Levosimendan Administration May Provide More Benefit for Survival in Patients with Non-Ischemic Cardiomyopathy Experiencing Acute Decompensated Heart Failure

Background: Acute decompensated heart failure (ADHF) is a life-threatening condition with a high mortality rate. Levosimendan is an effective inotropic agent used to maintain cardiac output and a long-lasting effect. However, only few studies have compared the clinical outcomes, after levosimendan therapy, among etiologies of ADHF. Methods: Between July 2014 and December 2019, 184 patients received levosimendan therapy for ADHF at our hospital. A total of 143 patients had ischemic cardiomyopathy (ICM), and 41 patients had non-ICM (NICM). Data on comorbidities, echocardiographic findings, laboratory findings, use of mechanical devices, consumption of other inotropic or vasopressor agents, frequency of HF hospitalization, cardiovascular (CV) mortality, and all-cause mortality were compared between the ICM and NICM groups. Results: Patients with ICM were older with higher prevalence of diabetes mellitus when compared to patients with NICM. Patients with NICM had a poorer left ventricular ejection fraction (LVEF) and higher left ventricular end-systolic volume when compared to patients with ICM. At the 30 day follow-up period, a lower CV mortality (ICM vs. NICM: 20.9% vs. 5.1%; log-rank p = 0.033) and lower all-cause mortality (ICM vs. NICM: 28.7% vs. 9.8%; log-rank p = 0.018) was observed in the NICM patients. A significantly lower all-cause mortality was noted at 180 day (ICM vs. NICM: 39.2% vs. 22.0%; log-rank p = 0.043) and 1 year (ICM vs. NICM: 41.3% vs. 24.4%; log-rank p = 0.046) follow up in the NICM subgroup. NICM (hazard ratio (HR): 0.303, 95% confidence interval (CI): 0.108–0.845; p = 0.023) and ECMO use (HR: 2.550, 95% CI: 1.385–4.693; p = 0.003) were significant predictors of 30 day all-cause mortality. Conclusions: In our study on levosimendan use for ADHF patients, better clinical outcomes were noted in the NICM population when compared to the ICM population. In the patients with cardiogenic shock or ventilator use, significantly lower incidence of 30 day mortality presented in the NICM population when compared with the ICM population.

Drug Treatment of Heart Failure in Children: Gaps and Opportunities

Medical therapy for pediatric heart failure is based on a detailed mechanistic understanding of the underlying causes, which are diverse and unlike those encountered in most adult patients. Diuresis and improved perfusion are the immediate goals of care in the child with acute decompensated heart failure. Conversion to maintenance oral therapy for heart failure is based on the results of landmark studies in adults, as well as recent pediatric clinical trials and heart failure guidelines. There will continue to be an important role for newer drugs, some of which are in active trials in adults, and some of which are already approved for use in children. The need to plan for clinical trials in children during drug development for heart failure is emphasized.

Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety

The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a "should be considered" recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.

Effect of levosimendan on renal function in background of left ventricular dysfunction: a meta-analysis of randomized trials

OBJECTIVE

Levosimendan, an inotrope, is widely used in the management of heart failure (HF) and cardiac surgery, but it remains uncertain whether levosimendan can improve renal function in patients with left ventricular dysfunction (LVD).

METHODS

PubMed, Embase, and Cochrane CENTRAL from the inception to June 2020 were systematically screened for randomized controlled trials (RCTs) to investigate whether levosimendan offers kidney-related advantages in cardiovascular patients with LVD. We pooled the effects using a random-effect model.

RESULTS

Twenty-eight studies enrolling 5069 patients were included. Levosimendan reduced the sCr (SMD -0.28, 95% CI (-0.48, -0.09), P = 0.005, I² = 52.5%, high quality) and the risk of ARF (relative risk 0.75, 95%CI (0.60, 0.95), P = 0.017, I² = 11.3%, moderate-quality) in patients with LVD compared with control group. The reduction of sCr was more pronounced in patients with a relatively higher baseline sCr level. For secondary outcomes, levosimendan therapy was associated with the improvement of GFR (SMD 0.32, 95%CI (-0.05, 0.68), P = 0.092, I² = 55.1%, low-quality) and urine output (SMD 0.42, 95%CI (0.06, 0.79), P = 0.024, I² = 50.0%, very low-quality), but there was no significant reduction in BUN (SMD -0.14, 95%CI (-0.97, 0.70), P = 0.774, I² = 77.9%, very low-quality).

CONCLUSIONS

Levosimendan might improve renal function of patients with LVD.

Endogenous Cardiotonics: Search And Problems

Medicinal preparations currently used for the treatment of patients with chronic cardiac failure involve those that reduce the heart load (vasodilators, diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors). Cardiotonic drugs with the cAMP-dependent mechanism are unsuitable for long-term administration due to the intensification of metabolic processes and an increase in the oxygen demand of the myocardium and all tissues of the body. For many years, digoxin has remained the only preparation enhancing the efficiency of myocardial performance. The detection of digoxin and ouabain in intact animals has initiated a search for other compounds with cardiotonic activity. The review summarizes current data on the effect exerted on the heart performance by endogenous compounds, from simple, such as NO and CO, to steroids, fatty acids, polypeptides, and proteins. Controversial questions and problems with the introduction of scientific achievements into clinical practice are discussed. The results obtained by the authors and their colleagues after many years of studies on the cardiotropic properties of serum lipoproteins are also reported. The experimentally established cardiotonic activity of apoprotein A-1, which is accompanied by a decrease in the relative consumption of oxygen, maybe of great interest.

Pharmacological Conditioning of the Heart: An Update on Experimental Developments and Clinical Implications

The aim of pharmacological conditioning is to protect the heart against myocardial ischemia-reperfusion (I/R) injury and its consequences. There is extensive literature that reports a multitude of different cardioprotective signaling molecules and mechanisms in diverse experimental protocols. Several pharmacological agents have been evaluated in terms of myocardial I/R injury. While results from experimental studies are immensely encouraging, translation into the clinical setting remains unsatisfactory. This narrative review wants to focus on two aspects: (1) give a comprehensive update on new developments of pharmacological conditioning in the experimental setting concentrating on recent literature of the last two years and (2) briefly summarize clinical evidence of these cardioprotective substances in the perioperative setting highlighting their clinical implications. By directly opposing each pharmacological agent regarding its recent experimental knowledge and most important available clinical data, a clear overview is given demonstrating the remaining gap between basic research and clinical practice. Finally, future perspectives are given on how we might overcome the limited translatability in the field of pharmacological conditioning.