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Watanabe A, Miyamoto Y, Ueyama H, Gotanda H, Tsugawa Y, Kuno T. Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock. J Am Heart Assoc 2024; 13:e034645. [PMID: 38804220 DOI: 10.1161/jaha.123.034645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/04/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.
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Affiliation(s)
- Atsuyuki Watanabe
- Department of Medicine Mount Sinai Beth Israel Icahn School of Medicine at Mount Sinai New York NY
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology The University of Tokyo Tokyo Japan
| | - Hiroki Ueyama
- Division of Cardiology Emory University School of Medicine Atlanta GA
| | - Hiroshi Gotanda
- Division of General Internal Medicine Cedars-Sinai Medical Center Los Angeles CA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research David Geffen School of Medicine at The University of California, Los Angeles Los Angeles CA
- Department of Health Policy and Management UCLA Fielding School of Public Health, Los Angeles Los Angeles CA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center Albert Einstein College of Medicine New York NY
- Division of Cardiology, Jacobi Medical Center Albert Einstein College of Medicine New York NY
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Nair RM, Chawla S, Abdelghaffar B, Alkhalaieh F, Bansal A, Puri R, Yun J, Krishnaswamy A, Kapadia S, Menon V, Reed GW. Comparison of Contemporary Treatment Strategies in Patients With Cardiogenic Shock Due to Severe Aortic Stenosis. J Am Heart Assoc 2024; 13:e033601. [PMID: 38761069 DOI: 10.1161/jaha.123.033601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND The aims of this study were to understand the incidence and outcomes of patients with cardiogenic shock (CS) due to severe aortic stenosis (AS), and the impact of conventional treatment strategies in this population. METHODS AND RESULTS All patients admitted to the Cleveland Clinic cardiac intensive care unit between January 1, 2010 and December 31, 2021 with CS were retrospectively identified and categorized into those with CS in the setting of severe AS versus CS without AS. The impact of various treatment strategies on mortality was further assessed. We identified 2754 patients with CS during the study period, of whom 216 patients (8%) had CS in the setting of severe AS. Medical management was associated with the highest 30-day mortality when compared with either balloon aortic valve replacement or aortic valve replacement (surgical or transcatheter aortic valve replacement) (hazard ratio, 3.69 [95% CI, 2.04-6.66]; P<0.0001). Among patients who received transcatheter therapy, 30-day mortality was significantly higher in patients who received balloon aortic valvuloplasty versus transcatheter aortic valve replacement (26% versus 4%, P=0.02). Both surgical and transcatheter aortic valve replacement had considerably lower mortality than medical management and balloon aortic valvuloplasty at 30 days and 1 year (P<0.05 for both comparisons). CONCLUSIONS CS due to severe AS is associated with high in-hospital and 30-day mortality, worse compared with those with CS without AS. In suitable patients, urgent surgical aortic valvuloplasty or transcatheter aortic valve replacement is associated with favorable short- and long-term outcomes. Although balloon aortic valvuloplasty may be used to temporize patients with CS in the setting of severe AS, mortality is ≈50% if not followed by definitive aortic valve replacement within 90 days.
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Affiliation(s)
- Raunak M Nair
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Sanchit Chawla
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Bahaa Abdelghaffar
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Feras Alkhalaieh
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Agam Bansal
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Rishi Puri
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - James Yun
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Amar Krishnaswamy
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Samir Kapadia
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Venu Menon
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Grant W Reed
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
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Lamberti KK, Goffer EM, Edelman ER, Keller SP. Differential Effects of Pharmacologic and Mechanical Support on Right-Left Ventricular Coupling. J Cardiovasc Transl Res 2024:10.1007/s12265-024-10522-w. [PMID: 38767797 DOI: 10.1007/s12265-024-10522-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Percutaneous ventricular assist devices are increasingly relied on to maintain perfusion for cardiogenic shock patients. Optimal medical management strategies however remain uncertain from limited understanding of interventricular effects. This study analyzed the effects of pharmacologic and left-sided mechanical support on right ventricular function. METHODS A porcine model was developed to assess biventricular function during bolus pharmacologic administration before and after left-sided percutaneous ventricular assist and in cardiogenic shock. RESULTS The presence of mechanical support increased right ventricular load and stress with respect to the left ventricle. This shifted and exaggerated the relative effects of commonly used vasoactive agents. Furthermore, induction of cardiogenic shock led to differential pulmonary vascular and right ventricular responses. CONCLUSIONS Left ventricular ischemia and mechanical support altered interventricular coupling. Resulting impacts of pharmacologic agents indicate differential right heart responses and sensitivity to treatments and the need for further study to optimize biventricular function in shock patients.
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Affiliation(s)
- Kimberly K Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Efrat M Goffer
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Medicine (Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven P Keller
- Department of Medicine (Pulmonary and Critical Care Medicine), Johns Hopkins University, 1830 E. Monument Street 1830 Building; 5th Floor, Baltimore, MD, 21215, USA.
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, 21215, USA.
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4
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Chien SC, Wang CA, Liu HY, Lin CF, Huang CY, Chien LN. Comparison of the prognosis among in-hospital survivors of cardiogenic shock based on etiology: AMI and Non-AMI. Ann Intensive Care 2024; 14:74. [PMID: 38735891 PMCID: PMC11089020 DOI: 10.1186/s13613-024-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Current data on post-discharge mortality and rehospitalization is still insufficient among in-hospital survivors of cardiogenic shock (CS), including acute myocardial infarction (AMI) and non-AMI survivors. METHODS Patients with CS who survived after hospital discharge were selected from the Taiwan National Health Insurance Research Database. Each patient was followed up at 3-year intervals. Mortality and rehospitalization were analyzed using Kaplan-Meier curves and Cox regression models. RESULTS There were 16,582 eligible patients. Of these, 42.4% and 57.6% were AMI-CS and non-AMI-CS survivors, respectively. The overall mortality and rehospitalization rates were considerably high, with reports of 7.0% and 22.1% at 30 days, 24.5% and 58.2% at 1 year, and 38.9% and 73.0% at 3 years, respectively, among in-hospital CS survivors. Cardiovascular (CV) problems caused approximately 40% mortality and 60% rehospitalization. Overall, the non-AMI-CS group had a higher mortality burden than the AMI-CS group owing to older age and a higher prevalence of comorbidities. In multivariable models, the non-AMI-CS group exhibited a lower risk of all-cause mortality (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.60 to 0.78) and CV mortality (aHR 0.65, 95% CI 0.54 to 0.78) compared to the AMI-CS group. However, these risks diminished and even reversed after one year (aHR 1.13, 95% CI 1.03 to 1.25 for all-cause mortality; aHR 1.27, 95% CI 1.09 to 1.49 for CV mortality).This reversal was not observed in all-cause and CV rehospitalization. For rehospitalization, AMI-CS was associated with the risk of CV rehospitalization in the entire observation period (aHR:0.80, 95% CI:0.76-0.84). CONCLUSIONS In-hospital AMI-CS survivors had an increased risk of CV rehospitalization and 30-day mortality, whereas those with non-AMI-CS had a greater mortality risk after 1-year follow-up.
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Affiliation(s)
- Shih-Chieh Chien
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheng-An Wang
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Wan Fang Hospital, Taipei, Taiwan
| | - Hung-Yi Liu
- Health and Clinical Research Data Center, Office of Data Center, Taipei Medical University, Taipei, Taiwan
| | - Chao-Feng Lin
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan.
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5
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Vondran M, Kaminski A, Schemke S, Heringlake M. Shouldn't we first follow the guidelines before implementing alternative mechanical circulatory support modalities? JTCVS OPEN 2024; 18:87-89. [PMID: 38690423 PMCID: PMC11056468 DOI: 10.1016/j.xjon.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Maximillian Vondran
- Department of Cardiac and Vascular Surgery, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Alexander Kaminski
- Department of Cardiac and Vascular Surgery, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Simon Schemke
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
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Lamberti KK, Keller SP, Edelman ER. Dynamic load modulation predicts right heart tolerance of left ventricular cardiovascular assist in a porcine model of cardiogenic shock. Sci Transl Med 2024; 16:eadk4266. [PMID: 38354226 DOI: 10.1126/scitranslmed.adk4266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
Ventricular assist devices (VADs) offer mechanical support for patients with cardiogenic shock by unloading the impaired ventricle and increasing cardiac outflow and subsequent tissue perfusion. Their ability to adjust ventricular assistance allows for rapid and safe dynamic changes in cardiac load, which can be used with direct measures of chamber pressures to quantify cardiac pathophysiologic state, predict response to interventions, and unmask vulnerabilities such as limitations of left-sided support efficacy due to intolerance of the right heart. We defined hemodynamic metrics in five pigs with dynamic peripheral transvalvular VAD (pVAD) support to the left ventricle. Metrics were obtained across a spectrum of disease states, including left ventricular ischemia induced by titrated microembolization of a coronary artery and right ventricular strain induced by titrated microembolization of the pulmonary arteries. A sweep of different pVAD speeds confirmed mechanisms of right heart decompensation after left-sided support and revealed intolerance. In contrast to the systemic circulation, pulmonary vascular compliance dominated in the right heart and defined the ability of the right heart to adapt to left-sided pVAD unloading. We developed a clinically accessible metric to measure pulmonary vascular compliance at different pVAD speeds that could predict right heart efficiency and tolerance to left-sided pVAD support. Findings in swine were validated with retrospective hemodynamic data from eight patients on pVAD support. This methodology and metric could be used to track right heart tolerance, predict decompensation before right heart failure, and guide titration of device speed and the need for biventricular support.
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Affiliation(s)
- Kimberly K Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Steven P Keller
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MA 21205, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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7
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Low CJW, Ling RR, Lau MPXL, Liu NSH, Tan M, Tan CS, Lim SL, Rochwerg B, Combes A, Brodie D, Shekar K, Price S, MacLaren G, Ramanathan K. Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med 2024; 50:209-221. [PMID: 38206381 DOI: 10.1007/s00134-023-07278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. METHODS We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. RESULTS We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66). CONCLUSION In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Michele Petrova Xin Ling Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel Sheng Hui Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Melissa Tan
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Shir Lynn Lim
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Pre-Hospital and Emergency Research Center, Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Alain Combes
- Service de Médecine Intensive-RéanimationInstitut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- UMRS 116, Institute of Cardio Metabolism and Nutrition, Sorbonne Universite INSERM, Paris, France
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Gold Coast, QLD, Australia
- University of Queensland, Gold Coast, QLD, Australia
- Bond University, Gold Coast, QLD, Australia
| | - Susanna Price
- Royal Brompton and Harefield Hospitals, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Bemtgen X, Kaier K, Rilinger J, Rottmann F, Supady A, von Zur Mühlen C, Westermann D, Wengenmayer T, Staudacher DL. Myocarditis mortality with and without COVID-19: insights from a national registry. Clin Res Cardiol 2024; 113:216-222. [PMID: 36565377 PMCID: PMC9789728 DOI: 10.1007/s00392-022-02141-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/07/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Myocarditis in context of a SARS-CoV-2 infection is vividly discussed in the literature. Real-world data however are sparse, and relevance of the myocarditis diagnosis to outcome in coronavirus disease (COVID-19) is unclear. PATIENTS AND METHODS Retrospective analysis of 75,304 patients hospitalized in Germany with myocarditis between 2007 and 2020 is reported by DESTATIS. Patients hospitalized between 01/2016 and 12/2019 served as reference cohort for the COVID-19 patients hospitalized in 2020. RESULTS A total of 75,304 patients were hospitalized between 2007 and 2020 (age 42.5 years, 30.1% female, hospital mortality 2.4%). In the reference cohort, 24,474 patients (age 42.8 years, 29.5% female, hospital mortality 2.2%) were registered. In 2020, annual myocarditis hospitalizations dropped by 19.6% compared to reference (4921 vs. 6119 annual hospitalization), of which 443/4921 (9.0%) were connected to COVID-19. In 2020, hospital mortality of myocarditis in non-COVID-19 patients increased significantly compared to reference (2.9% vs. 2.2%, p = 0.008, OR 1.31, 95% CI 1.08-1.60). In COVID-19 myocarditis, hospital mortality was even higher compared to reference (13.5% vs. 2.2%, p < 0.001, OR 6.93, 95% CI 5.18-9.18). CONCLUSION The burden of patients with myocarditis and COVID-19 in 2020 was low. Hospital mortality was more than sixfold higher in patients with myocarditis and COVID-19 compared to those with myocarditis but without COVID-19.
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Affiliation(s)
- Xavier Bemtgen
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Jonathan Rilinger
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix Rottmann
- Department of Medicine IV - Nephrology and Primary Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ergui I, Salama J, Hooda U, Ebner B, Dangl M, Vincent L, Sancassani R, Colombo R. In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019. Clin Cardiol 2024; 47:e24235. [PMID: 38366788 PMCID: PMC10873680 DOI: 10.1002/clc.24235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS). HYPOTHESIS Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients. METHODS The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05). RESULTS We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints. CONCLUSIONS These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.
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Affiliation(s)
- Ian Ergui
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Joshua Salama
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Urvashi Hooda
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Bertrand Ebner
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Michael Dangl
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Louis Vincent
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Rhea Sancassani
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
| | - Rosario Colombo
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
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10
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Bloom JE, Wong N, Nehme E, Dawson LP, Ball J, Anderson D, Cox S, Chan W, Kaye DM, Nehme Z, Stub D. Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:89-98. [PMID: 36808236 DOI: 10.1093/ehjqcco/qcad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023]
Abstract
AIMS The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). METHODS AND RESULTS This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. CONCLUSION This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shelley Cox
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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11
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Shah N, Orta G, Daryanani S, Amini K, Kesselman MM. Advanced Metrics and Early Predictors of Cardiogenic Shock. Cureus 2023; 15:e48100. [PMID: 38046754 PMCID: PMC10690069 DOI: 10.7759/cureus.48100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Cardiogenic shock (CS) can be defined as a range of illnesses that describes a state where cardiac output, which is the blood volume ejected from the left ventricle every minute that leads to tissue perfusion of nutrients, is insufficient in providing adequate oxygenation to the systemic circulation. The incidence of CS on admission has increased in recent years, with the six- and 12-month mortality rates remaining unchanged. The purpose of this literature review is to bring forth several parameters that have been utilized in the past 10 years to predict CS mortality. Further studies to implement these parameters in management algorithms, along with early screenings and advanced treatment options such as mechanical cardiac assist devices, can improve the mortality associated with CS. This literature-based review was conducted by evaluating current research focusing on the clinical presentation of CS and predictors of CS. PubMed served as the primary database for article retrieval due to access. Two searches were conducted: One for clinical presentations and advanced metrics for CS and another for early predictors for CS. Thirteen articles regarding clinical presentation and seven articles regarding early predictors were selected. Three tools/scores and five laboratory tests were identified that allowed clinicians to prognosticate outcomes in patients suffering from CS based on clinical and laboratory presentations. Examining these predictors will allow earlier intervention in the development of CS and potentially help lower the mortality rate of CS. The eventual creation of a scoring system that incorporates multiple metrics discussed in this review can provide the most accurate prognosis of CS, which can lead to more targeted interventions.
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Affiliation(s)
- Nisarg Shah
- Cardiology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Gabriella Orta
- Cardiology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Sonia Daryanani
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Kayvan Amini
- Cardiology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Marc M Kesselman
- Rheumatology, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
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12
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Mukundan SV, Marbach JA. Live(r) and let die: redefining hypoxic hepatitis in cardiogenic shock. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:671-672. [PMID: 37542463 DOI: 10.1093/ehjacc/zuad091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Srini V Mukundan
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
| | - Jeffrey A Marbach
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA
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13
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Peters EJ, ten Berg S, Bogerd M, Timmermans MJC, Kraaijeveld AO, Bunge JJH, Teeuwen K, Lipsic E, Sjauw KD, van Geuns RJM, Dedic A, Dubois EA, Meuwissen M, Danse P, Verouden NJW, Bleeker G, Montero Cabezas JM, Ferreira IA, Engström AE, Lagrand WK, Otterspoor LC, Vlaar APJ, Henriques JPS. Characteristics, Treatment Strategies and Outcome in Cardiogenic Shock Complicating Acute Myocardial Infarction: A Contemporary Dutch Cohort. J Clin Med 2023; 12:5221. [PMID: 37629263 PMCID: PMC10455258 DOI: 10.3390/jcm12165221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high morbidity and mortality. Our study aimed to gain insights into patient characteristics, outcomes and treatment strategies in CS patients. Patients with CS who underwent percutaneous coronary intervention (PCI) between 2017 and 2021 were identified in a nationwide registry. Data on medical history, laboratory values, angiographic features and outcomes were retrospectively assessed. A total of 2328 patients with a mean age of 66 years and of whom 73% were male, were included. Mortality at 30 days was 39% for the entire cohort. Non-survivors presented with a lower mean blood pressure and increased heart rate, blood lactate and blood glucose levels (p-value for all <0.001). Also, an increased prevalence of diabetes, multivessel coronary artery disease and a prior coronary event were found. Of all patients, 24% received mechanical circulatory support, of which the majority was via intra-aortic balloon pumps (IABPs). Furthermore, 79% of patients were treated with at least one vasoactive agent, and multivessel PCI was performed in 28%. In conclusion, a large set of hemodynamic, biochemical and patient-related characteristics was identified to be associated with mortality. Interestingly, multivessel PCI and IABPs were frequently applied despite a lack of evidence.
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Affiliation(s)
- Elma J. Peters
- Heart Center, Department of Cardiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (E.J.P.)
| | - Sanne ten Berg
- Heart Center, Department of Cardiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (E.J.P.)
| | - Margriet Bogerd
- Heart Center, Department of Cardiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (E.J.P.)
| | | | - Adriaan O. Kraaijeveld
- Department of Cardiology, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands;
| | - Jeroen J. H. Bunge
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (J.J.H.B.)
- Department of Intensive Care Adults, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Koen Teeuwen
- Heart Center, Department of Interventional Cardiology, Catharina Hospital Eindhoven, 5623 EJ Eindhoven, The Netherlands;
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Krischan D. Sjauw
- Heart Center, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands
| | - Robert-Jan M. van Geuns
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Admir Dedic
- Department of Cardiology, Noordwest Clinics, 1815 JD Alkmaar, The Netherlands
| | - Eric A. Dubois
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (J.J.H.B.)
- Department of Intensive Care Adults, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Martijn Meuwissen
- Department of Cardiology, Amphia Hospital, 4818 CK Breda, The Netherlands
| | - Peter Danse
- Department of Cardiology, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands
| | - Niels J. W. Verouden
- Heart Center, Department of Cardiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (E.J.P.)
| | - Gabe Bleeker
- Department of Cardiology, Haga Hospital, 2545 AA The Hague, The Netherlands
| | | | | | - Annemarie E. Engström
- Department of Intensive Care, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.E.)
| | - Wim K. Lagrand
- Department of Intensive Care, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.E.)
| | - Luuk C. Otterspoor
- Department of Intensive Care Adults, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
- Department of Intensive Care, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.E.)
| | - José P. S. Henriques
- Heart Center, Department of Cardiology, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (E.J.P.)
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14
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Araki T, Kondo T, Imaizumi T, Sumita Y, Nakai M, Tanaka A, Okumura T, Yang M, Butt JH, Petrie MC, Murohara T. Relationship between the volume of cases and in-hospital mortality in patients with cardiogenic shock receiving short-term mechanical circulatory support. Am Heart J 2023; 261:109-123. [PMID: 37031832 DOI: 10.1016/j.ahj.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND We examined the relationship between annual case volume at each hospital and outcome in cardiogenic shock (CS) patients receiving mechanical circulatory support (MCS) devices. METHODS This cross-sectional study used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients, 3 subcohorts were created; the intra-aortic balloon pump (IABP) alone (n = 48,643), the extracorporeal membrane oxygenation (ECMO) (n = 16,871), and the Impella cohorts (n = 696). RESULTS The median annual case volume was 13.5 (7.4-22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0-10.7) in the Impella cohort. The highest quintile for the volume of cases in the IABP alone and ECMO had the lowest in-hospital mortality (IABP alone, 25.1% in quintile 1 vs 15.2% in quintile 5; ECMO, 73.7% in quintile 1 in 67.4% in quintile 5). Adjusted ORs for in-hospital mortality decreased as case volume increased (IABP alone, 0.63 [0.58-0.68] in quintile 5; ECMO, 0.73 [0.65-0.82] in quintile 5, with the lowest quintile as reference) but did not decrease significantly in the Impella (0.90 [0.58-1.39] in tertile 3, with the lowest tertile as reference). In the continuous models with the case volume as a continuous variable, adjusted ORs for in-hospital mortality decreased to 28 IABP cases/year and 12 ECMO cases/year. They did not decrease or became almost flat above that. CONCLUSIONS Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline. Centralizing patients with refractory CS in a particular hospital might improve patient outcomes in each region.
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Affiliation(s)
- Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Eftychiou S, Kalakoutas A, Proudfoot A. The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review. JOURNAL OF INTENSIVE MEDICINE 2023; 3:89-103. [PMID: 37188124 PMCID: PMC10175707 DOI: 10.1016/j.jointm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.
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Affiliation(s)
| | - Antonis Kalakoutas
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0AG, UK
- Barts and the London School of Medicine and Dentistry, London E1 2AD, UK
| | - Alastair Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
- Queen Mary University of London, London EC1M 6BQ, UK
- Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin 13353, Germany
- Corresponding author: Alastair Proudfoot, Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
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16
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Ardito V, Sarucanian L, Rognoni C, Pieri M, Scandroglio AM, Tarricone R. Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses. J Cardiovasc Dev Dis 2023; 10:jcdd10040158. [PMID: 37103037 PMCID: PMC10142129 DOI: 10.3390/jcdd10040158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Lilit Sarucanian
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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17
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Polyzogopoulou E, Bezati S, Karamasis G, Boultadakis A, Parissis J. Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done. J Clin Med 2023; 12:2643. [PMID: 37048727 PMCID: PMC10095596 DOI: 10.3390/jcm12072643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
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.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sofia Bezati
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Grigoris Karamasis
- Second Department of Cardiology, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
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18
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Thiele H. [ECMO-CS trial-is this the end of ECMO?]. Med Klin Intensivmed Notfmed 2023; 118:156-159. [PMID: 36418473 DOI: 10.1007/s00063-022-00977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Holger Thiele
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
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19
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Prognosis in Patients With Cardiogenic Shock Who Received Temporary Mechanical Circulatory Support. JACC. ASIA 2023; 3:122-134. [PMID: 36873766 PMCID: PMC9982290 DOI: 10.1016/j.jacasi.2022.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
Abstract
Background Temporary mechanical circulatory support (MCS) is often used in patients with cardiogenic shock (CS), and the type of MCS may vary by cause of CS. Objectives This study sought to describe the causes of CS in patients receiving temporary MCS, the types of MCS used, and associated mortality. Methods This study used a nationwide Japanese database to identify patients receiving temporary MCS for CS between April 1, 2012, and March 31, 2020. Results Of 65,837 patients, the cause of CS was acute myocardial infarction (AMI) in 77.4%, heart failure (HF) in 10.9%, valvular disease in 2.7%, fulminant myocarditis (FM) in 2.5%, arrhythmia in 4.5%, and pulmonary embolism (PE) in 2.0% of cases. The most commonly used MCS was an intra-aortic balloon pump alone in AMI (79.2%) and in HF (79.0%) and in valvular disease (66.0%), extracorporeal membrane oxygenation with intra-aortic balloon pump in FM (56.2%) and arrhythmia (43.3%), and extracorporeal membrane oxygenation alone in PE (71.5%). Overall in-hospital mortality was 32.4%; 30.0% in AMI, 32.6% in HF, 33.1% in valvular disease, 34.2% in FM, 60.9% in arrhythmia, and 59.2% in PE. Overall in-hospital mortality increased from 30.4% in 2012 to 34.1% in 2019. After adjustment, valvular disease, FM, and PE had lower in-hospital mortality than AMI: valvular disease, OR: 0.56 (95% CI: 0.50-0.64); FM: OR: 0.58 (95% CI: 0.52-0.66); PE: OR: 0.49 (95% CI: 0.43-0.56); whereas HF had similar in-hospital mortality (OR: 0.99; 95% CI: 0.92-1.05) and arrhythmia had higher in-hospital mortality (OR: 1.14; 95% CI: 1.04-1.26). Conclusions In a Japanese national registry of patients with CS, different causes of CS were associated with different types of MCS and differences in survival.
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Key Words
- AMI, acute myocardial infarction
- CS, cardiogenic shock
- ECMO, extracorporeal membrane oxygenation
- FM, fulminant myocarditis
- HF, heart failure
- IABP, intra-aortic balloon pump
- ICD-10, International Classification of Diseases-10th Revision
- MCS, mechanical circulatory support
- OR, odds ratio
- PE, pulmonary embolism
- cardiogenic shock
- extracorporeal membrane oxygenation
- intra-aortic balloon pump
- mechanical circulatory support
- pVAD, percutaneous ventricular assist device
- percutaneous ventricular assist device
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20
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Meertens MM, Tichelbäcker T, Macherey-Meyer S, Heyne S, Braumann S, Nießen SF, Baldus S, Adler C, Lee S. Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction. Front Cardiovasc Med 2023; 9:1104357. [PMID: 36741852 PMCID: PMC9889933 DOI: 10.3389/fcvm.2022.1104357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
Background Incidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps' (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS. Objective The objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI. Methods A systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality. Results Twelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30-0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16-0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35-2.08, P = 0.72). Conclusion In this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only.
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21
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Rottmann FA, Breiden AK, Bemtgen X, Welte T, Supady A, Wengenmayer T, Staudacher DL. Levosimendan in acute heart failure with severely reduced kidney function, a propensity score matched registry study. Front Cardiovasc Med 2022; 9:1027727. [PMID: 36337866 PMCID: PMC9631470 DOI: 10.3389/fcvm.2022.1027727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/06/2022] [Indexed: 11/14/2022] Open
Abstract
Background Patients with heart failure frequently present with kidney dysfunction. Kidney function is relevant, as prognosis declines with reduced kidney function and potentially beneficial drugs like levosimendan are contraindicated for missing safety data. Materials and methods A single-center retrospective registry study was conducted including all patients receiving levosimendan on a medical intensive care unit between January 2010 and December 2019. Exclusion criteria were a follow-up less than 24 h or missing glomerular filtration rate (eGFR) before administration of levosimendan. The first course of treatment was evaluated. Patients were stratified by eGFR before drug administration and the primary endpoint was a composite of supraventricular-, ventricular tachycardia and death within 7 days after administration of levosimendan. An internal control group was created by propensity score matching. Results A total of 794 patients receiving levosimendan were screened and 368 unique patients were included. Patients were predominantly male (73.6%) and median age was 63 years. Patients were divided by eGFR into three groups: >60 ml/min/1.73 m2 (n = 110), 60–30 ml/min/1.73 m2 (n = 130), and <30 ml/min/1.73 m2 (n = 128). ICU survival was significantly lower in patients with lower eGFR (69.1, 57.7, and 50.8%, respectively, p = 0.016) and patients with lower eGFR were significantly older and had significantly more comorbidities. The primary combined endpoint was reached in 61.8, 63.1, and 69.5% of subjects, respectively (p = 0.396). A multivariate logistic regression model suggested only age (p < 0.020), extracorporeal membrane oxygenation (p < 0.001) or renal replacement therapy (p = 0.028) during day 1–7 independently predict the primary endpoint while kidney function did not (p = 0.835). A propensity score matching of patients with eGFR < 30 and >30 ml/min/1.73 m2 based on these predictors of outcome confirmed the primary endpoint (p = 0.886). Conclusion The combined endpoint of supraventricular-, ventricular tachycardia and death within 7 days was reached at a similar rate in patients independently of kidney function. Prospective randomized trials are warranted to clarify if levosimendan can be used safely in severely reduced kidney function.
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Affiliation(s)
- Felix Arne Rottmann
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Medicine IV – Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
- *Correspondence: Felix Arne Rottmann,
| | - Ann Katrin Breiden
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Welte
- Department of Medicine IV – Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
- Friedrich Miescher Institute for Biomedical Research, Basel, Switzerland
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Leander Staudacher
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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22
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Zeng P, Yang C, Chen J, Fan Z, Cai W, Huang Y, Xiang Z, Yang J, Zhang J, Yang J. Comparison of the Efficacy of ECMO With or Without IABP in Patients With Cardiogenic Shock: A Meta-Analysis. Front Cardiovasc Med 2022; 9:917610. [PMID: 35872892 PMCID: PMC9300857 DOI: 10.3389/fcvm.2022.917610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Studies on extracorporeal membrane oxygenation (ECMO) with and without an intra-aortic balloon pump (IABP) for cardiogenic shock (CS) have been published, but there have been no meta-analyses that compare the efficacy of these two cardiac support methods. This meta-analysis evaluated the outcomes of these two different treatment measures. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials databases were searched until March 2022. Studies that were related to ECMO with or without IABP in patients with CS were screened. Quality assessments were evaluated with the methodological index for nonrandomized studies (MINORS). The primary outcome was in-hospital survival, while the secondary outcomes included duration of ECMO, duration of ICU stay, infection/sepsis, and bleeding. Revman 5.3 and STATA software were used for this meta-analysis. Results In total, nine manuscripts with 2,573 patients were included in the systematic review. CS patients who received ECMO in combination with IABP had significantly improved in-hospital survival compared with ECMO alone (OR = 1.58, 95% CI = 1.26–1.98, P < 0.0001). However, there were no significant differences in the duration of ECMO (MD = 0.36, 95% CI = −0.12–0.84, P = 0.14), duration of ICU stay (MD = −1.95, 95% CI = −4.05–0.15, P = 0.07), incidence of infection/sepsis (OR = 1.0, 95% CI = 0.58–1.72, P = 1.0), or bleeding (OR = 1.28, 95% CI = 0.48–3.45, P = 0.62) between the two groups of patients with CS. Conclusion ECMO combined with IABP can improve in-hospital survival more effectively than ECMO alone in patients with CS.
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Affiliation(s)
- Ping Zeng
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Chaojun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Chen
- Hubei Key Laboratory of Cardiology, Department of Cardiology, Cardiovascular Research Institute, Renmin Hospital, Wuhan University, Wuhan, China
| | - Zhixing Fan
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Wanyin Cai
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Yifan Huang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Zujin Xiang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Zhang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jian Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
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23
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Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS. Basic mechanisms in cardiogenic shock: part 2 - biomarkers and treatment options. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:366-374. [PMID: 35218355 DOI: 10.1093/ehjacc/zuac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/02/2022] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, all other widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Within Part 2 of this two-part educational review on basic mechanisms in cardiogenic shock, we aimed to highlight the current status of translating our understanding of the pathophysiology of cardiogenic shock into clinical practice. We summarize the current status of biomarker research in risk stratification and therapy guidance. In addition, we summarized the current status of translating the findings from bench-, bedside, and biomarker studies into treatment options. Several large randomized controlled trials (RCTs) are underway, providing a huge opportunity to study contemporary cardiogenic shock patients. Finally, we call for translational, homogenous, biomarker-based, international RCTs testing novel treatment approaches to improve the outcome of our patients.
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Affiliation(s)
- Konstantin A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Duke Clinical Research Institute, 300 W Morgan Street, 27701 Durham, NC, USA
| | - Christiaan Vrints
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Core Facilities, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Kurt Huber
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Unit, Wilhelminenhospital, Montleartstraße 37, 1160 Vienna, Austria
- Medical School, Sigmund Freud University, Freudplatz 1, 1020 Vienna, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
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24
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Aortic Valve Insufficiency as a Late Complication After Impella Device Implantation. JACC Cardiovasc Interv 2022; 15:e91-e93. [PMID: 35367172 DOI: 10.1016/j.jcin.2022.01.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 11/22/2022]
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25
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Atti V, Narayanan MA, Patel B, Balla S, Siddique A, Lundgren S, Velagapudi P. A Comprehensive Review of Mechanical Circulatory Support Devices. Heart Int 2022; 16:37-48. [PMID: 36275352 PMCID: PMC9524665 DOI: 10.17925/hi.2022.16.1.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/07/2021] [Indexed: 08/08/2023] Open
Abstract
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.
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Affiliation(s)
- Varunsiri Atti
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | | | - Brijesh Patel
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | - Sudarshan Balla
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott Lundgren
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Poonam Velagapudi
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, NE, USA
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26
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Baran DA, Jaiswal A, Hennig F, Potapov E. Temporary Mechanical Circulatory Support: Devices, Outcomes and Future Directions. J Heart Lung Transplant 2022; 41:678-691. [DOI: 10.1016/j.healun.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
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27
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Werdan K, Ferrari MW, Prondzinsky R, Ruß M. [Cardiogenic shock complicating myocardial infarction]. Herz 2022; 47:85-100. [PMID: 35015088 DOI: 10.1007/s00059-021-05088-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/30/2022]
Abstract
Cardiogenic shock as a complication of myocardial infarction (5-10%) increases the mortality of uncomplicated myocardial infarction from less than 10% to 40%. This is due to the development of multiple organ dysfunction syndrome triggered by the extensive shock-induced impairment of organ perfusion. Therefore, guideline-based treatment should not only be restricted to reopening of the occluded coronary artery and management of complications of the infarction: important for survival are also guideline-driven optimization of organ perfusion by inotropic and vasoactive substances and, with well-defined indications, by temporary mechanical circulatory support but not by intra-aortic counterpulsation. Equally important, however, are shock-specific intensive care measures to prevent or attenuate organ dysfunction, such as lung protective ventilation in cases where ventilation is obligatory.
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Affiliation(s)
- Karl Werdan
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Gruber-Str. 40, 06120, Halle (Saale), Deutschland. .,, Ginsterweg 25, 06120, Halle (Saale), Deutschland.
| | - Markus Wolfgang Ferrari
- Klinik für Innere Medizin I, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Deutschland
| | - Roland Prondzinsky
- Klinik für Innere Medizin I, Carl-von-Basedow-Klinikum Saalekreis gGmbH, Bereich Merseburg, Merseburg, Deutschland
| | - Martin Ruß
- Internisten am Marktplatz, Traunstein/Belegkardiologie Traunstein, Traunstein, Deutschland
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28
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Michels G, Bauersachs J, Böttiger BW, Busch HJ, Dirks B, Frey N, Lott C, Rott N, Schöls W, Schulze PC, Thiele H. Leitlinien des European Resuscitation Council (ERC) zur kardiopulmonalen Reanimation 2021: Update und Kommentar. Anaesthesist 2022; 71:129-140. [DOI: 10.1007/s00101-021-01084-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Heringlake M, Berggreen AE, Paarmann H. Still a place for aortic counterpulsation in cardiac surgery and patients with cardiogenic shock? Crit Care 2021; 25:309. [PMID: 34461956 PMCID: PMC8407061 DOI: 10.1186/s13054-021-03673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany.
| | - Astrid Ellen Berggreen
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Hauke Paarmann
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
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30
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Parlow S, Di Santo P, Mathew R, Jung RG, Simard T, Gillmore T, Mao B, Abdel-Razek O, Ramirez FD, Marbach JA, Dick A, Glover C, Russo JJ, Froeschl M, Labinaz M, Fernando SM, Hibbert B. The association between mean arterial pressure and outcomes in patients with cardiogenic shock: insights from the DOREMI trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:712-720. [PMID: 34382063 DOI: 10.1093/ehjacc/zuab052] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/18/2021] [Accepted: 06/26/2021] [Indexed: 11/14/2022]
Abstract
AIMS Cardiogenic shock (CS) is a state of low cardiac output resulting in end-organ hypoperfusion. Despite high in-hospital mortality rates, little evidence exists regarding the optimal mean arterial pressure (MAP) target in CS. We therefore evaluated the relationship between achieved MAP and clinical outcomes in patients with CS. METHODS AND RESULTS We performed a post hoc analysis of the CAPITAL DOREMI trial: a randomized, double-blind trial comparing dobutamine to milrinone in patients with CS. We divided patients into a high MAP group (average MAP ≥ 70 mmHg over the 36 h following randomization), and a low MAP group (average MAP < 70 mmHg). Our primary outcome included in-hospital all-cause mortality, resuscitated cardiac arrest, need for cardiac transplantation or mechanical circulatory support, non-fatal myocardial infarction, transient ischaemic attack or stroke, or initiation of renal replacement therapy. In total, 71 (37.0%) patients achieved an average MAP < 70 mmHg, and 121 (63.0%) achieved an average MAP ≥ 70 mmHg. The primary outcome occurred in 48 (67.6%) patients in the low MAP group and 51 (42.2%) patients in the high MAP group [adjusted relative risk (aRR) 0.70; 95% confidence interval (CI) 0.53-0.92; P = 0.01]. All-cause mortality occurred in 41 (57.8%) and 35 (28.9%) patients in the low and high MAP groups, respectively (aRR 0.56; 95% CI 0.40-0.79; P < 0.01). There were no significant differences in any secondary outcomes between each group. CONCLUSIONS In patients with CS treated with inotrope therapy, low MAP is associated with worse clinical outcomes. Randomized data evaluating optimal MAP targets in CS is needed to guide medical therapy.
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Affiliation(s)
- Simon Parlow
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Pietro Di Santo
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Room 101, Ottawa, Ontario, K1G 5Z3, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Richard G Jung
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada.,Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada
| | - Trevor Simard
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada.,Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, 200 First St. SW, Rochester, Minnesota, 55905, USA
| | - Taylor Gillmore
- Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada
| | - Brennan Mao
- Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada
| | - Omar Abdel-Razek
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - F Daniel Ramirez
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Jeffrey A Marbach
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, 02111, USA
| | - Alexander Dick
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Christopher Glover
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Juan J Russo
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Michael Froeschl
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Marino Labinaz
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada
| | - Shannon M Fernando
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.,Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada
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31
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Lang CN, Zotzmann V, Schmid B, Kaier K, Bode C, Wengenmayer T, Staudacher DL. Utilization of transfusions and coagulation products in cardiogenic shock with and without mechanical circulatory support. J Crit Care 2021; 65:62-64. [PMID: 34090149 DOI: 10.1016/j.jcrc.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Corinna N Lang
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany.
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
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