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Miller PE, Huber K, Bohula EA, Krychtiuk KA, Pöss J, Roswell RO, Tavazzi G, Solomon MA, Kristensen SD, Morrow DA. Research Priorities in Critical Care Cardiology: JACC Expert Panel. J Am Coll Cardiol 2023; 82:2329-2337. [PMID: 38057075 PMCID: PMC10752230 DOI: 10.1016/j.jacc.2023.09.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 12/08/2023]
Abstract
Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology Medical University of Vienna, Vienna, Austria; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janine Pöss
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Robert O Roswell
- Northwell Health, Zucker School of Medicine, Hempstead, New York, USA
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Intensive Care Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | | | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Zuin M, Pinto DS, Nguyen T, Chatzizisis YS, Pasquetto G, Daggubati R, Bilato C, Rigatelli G. Trends in Cardiogenic Shock-Related Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019. Am J Cardiol 2023; 200:18-25. [PMID: 37271120 DOI: 10.1016/j.amjcard.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/28/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
Data on mortality trends in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) are scant. This study aimed to assess the trends in CS-AMI-related mortality in United States (US) subjects over the latest 21 years. Mortality data of US subjects with AMI listed as the underlying cause of death and CS as contributing cause were obtained from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) dataset from January 1999 to December 2019. CS-AMI-related age-adjusted mortality rates (AAMRs) per 100,000 US population were stratified by gender, race and ethnicity, geographic areas, and urbanicity. Nationwide annual trends were assessed as annual percent change (APC) and average APC with relative 95% confidence intervals (CIs). Between 1999 and 2019, CS-AMI was listed as the underlying cause of death in 209,642 patients, (AAMR of 3.01 per 100,000 people [95% CI 2.99 to 3.02]). AAMR from CS-AMI remained stable from 1999 to 2007 (APC -0.2%, [95% CI -2.0 to 0.5], p = 0.22) and then significantly increased (APC 3.1% [95% CI 2.6 to 3.6], p <0.0001), especially in male patients. Starting in 2009, the AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. The higher AAMRs were clustered in the South (average APC 4.5%, [95% CI 4.4 to 4.6]) of the country. In conclusion, CS-AMI-related mortality in US patients increased from 2009 to 2019. Targeted health policy measures are needed to address the rising burden of CS-AMI in US subjects.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardiology, West Vicenza Hospital, Arzignano, Italy.
| | - Duane S Pinto
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Thach Nguyen
- Cardiovascular Research, Methodist Hospital, Merrillville, Indiana; School of Medicine, Tan Tao University, Long An, Vietnam
| | - Yiannis S Chatzizisis
- Division of Cardiovascular Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | - Giampaolo Pasquetto
- Interventional Cardiology Unit, Department of Cardiology, AULSS 6 Ospedali Riuniti Padova Sud, Monselice, Italy
| | - Ramesh Daggubati
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Gianluca Rigatelli
- Interventional Cardiology Unit, Department of Cardiology, AULSS 6 Ospedali Riuniti Padova Sud, Monselice, Italy
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Henry TD, Yannopoulos D, van Diepen S. Extracorporeal Membrane Oxygenation for Cardiogenic Shock: When to Open the Parachute? Circulation 2023; 147:465-468. [PMID: 36745696 DOI: 10.1161/circulationaha.122.063190] [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] [Indexed: 02/08/2023]
Affiliation(s)
- Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, Heart and Vascular Institute at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Demetri Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis (D.Y.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
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4
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Improving Survival in Cardiogenic Shock-A Propensity Score-Matched Analysis of the Impact of an Institutional Allocation Protocol to Short-Term Mechanical Circulatory Support. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111931. [PMID: 36431066 PMCID: PMC9692664 DOI: 10.3390/life12111931] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for CS patients and presents outcome data before and after implementation. Data from 421 patients treated for CS with tMCS between 2018 and 2021 were analyzed. In 2019, we implemented a new SOP for allocating CS patients to tMCS modalities. The association between the time of SOP implementation and the 30-day and 1-year survival as well as hospital discharge was evaluated. Of the 421 patients included, 189 were treated before (pre-SOP group) and 232 after implementation of the new SOP (SOP group). Causes of CS included acute myocardial infarction (n = 80, 19.0%), acute-on-chronic heart failure in patients with dilated or chronic ischemic heart failure (n = 139, 33.0%), valvular cardiomyopathy (n = 14, 3.3%) and myocarditis (n = 5, 1.2%); 102 patients suffered from postcardiotomy CS (24.2%). The SOP group was further divided into an SOP-adherent (SOP-A) and a non-SOP-adherent group (SOP-NA). The hospital discharge rate was higher in the SOP group (41.7% vs. 29.7%), and treating patients according to the SOP was associated with an improved 30-day survival (56.9% vs. 38.9%, OR 2.21, 95% CI 1.01-4.80, p = 0.044). Patient allocation according to the presented SOP significantly improved 30-day survival.
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Damluji AA, Tehrani B, Sinha SS, Samsky MD, Henry TD, Thiele H, West NEJ, Senatore FF, Truesdell AG, Dangas GD, Smilowitz NR, Amin AP, deVore AD, Moazami N, Cigarroa JE, Rao SV, Krucoff MW, Morrow DA, Gilchrist IC. Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:2003-2019. [PMID: 36265932 PMCID: PMC10312149 DOI: 10.1016/j.jcin.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 01/09/2023]
Abstract
In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Behnam Tehrani
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Marc D Samsky
- New York University School of Medicine, New York, New York, USA
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, Christ Hospital, Cincinnati, Ohio, USA
| | - Holger Thiele
- Heart Center Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | - Fortunato F Senatore
- Division of Cardiology and Nephrology, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Alexander G Truesdell
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - George D Dangas
- Division of Cardiology, Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | | | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Adam D deVore
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nader Moazami
- New York University School of Medicine, New York, New York, USA
| | | | - Sunil V Rao
- New York University School of Medicine, New York, New York, USA
| | | | - David A Morrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey Medical Center, Hershey, Pennsylvania, USA
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Gilchrist IC. Time to lift the fog of iatrogenic complications in mechanical support. Catheter Cardiovasc Interv 2022; 99:1712-1713. [PMID: 35476281 DOI: 10.1002/ccd.30199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Ian C Gilchrist
- Division of Cardiology, Penn State Heart and Vascular Institute, Hershey Medical Center, Penn State University College of Medicine, Hershey, Pennsylvania, USA
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Hernandez-Montfort J, Miranda D, Randhawa VK, Sleiman J, de Armas YS, Lewis A, Taimeh Z, Alvarez P, Cremer P, Perez-Villa B, Navas V, Hakemi E, Velez M, Hernandez-Mejia L, Sheffield C, Brozzi N, Cubeddu R, Navia J, Estep JD. Hemodynamic-based Assessment and Management of Cardiogenic Shock. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock (CS) remains a deadly disease entity challenging patients, caregivers, and communities across the globe. CS can rapidly lead to the development of hypoperfusion and end-organ dysfunction, transforming a predictable hemodynamic event into a potential high-resource, intense, hemometabolic clinical catastrophe. Based on the scalable heterogeneity from a cellular level to healthcare systems in the hemodynamic-based management of patients experiencing CS, we present considerations towards systematic hemodynamic-based transitions in which distinct clinical entities share the common path of early identification and rapid transitions through an adaptive longitudinal situational awareness model of care that influences specific management considerations. Future studies are needed to best understand optimal management of drugs and devices along with engagement of health systems of care for patients with CS.
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Affiliation(s)
| | - Diana Miranda
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jose Sleiman
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Yelenis Seijo de Armas
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Antonio Lewis
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paulino Alvarez
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paul Cremer
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Bernardo Perez-Villa
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Viviana Navas
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Emad Hakemi
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Mauricio Velez
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Luis Hernandez-Mejia
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Cedric Sheffield
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Nicolas Brozzi
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Robert Cubeddu
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Jose Navia
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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8
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Proudfoot AG, Kalakoutas A, Meade S, Griffiths MJD, Basir M, Burzotta F, Chih S, Fan E, Haft J, Ibrahim N, Kruit N, Lim HS, Morrow DA, Nakata J, Price S, Rosner C, Roswell R, Samaan MA, Samsky MD, Thiele H, Truesdell AG, van Diepen S, Voeltz MD, Irving PM. Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach. Circ Heart Fail 2021; 14:e008635. [PMID: 34807723 PMCID: PMC8692411 DOI: 10.1161/circheartfailure.121.008635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
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Affiliation(s)
- Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
- Department of Anaesthesiology & Intensive Care, German Heart Centre Berlin, Germany
- Queen Mary University of London, London, UK
- Corresponding author: Alastair Proudfoot, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, Mobile: 07779011194,
| | | | - Susanna Meade
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Mark JD Griffiths
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mir Basir
- Department of Cardiology, Henry Ford Health System, Detroit, MI USA
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine and Division of Respirology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Natalie Kruit
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Hoong Sern Lim
- Department of Cardiology, University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - David A. Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Mark A Samaan
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Marc D. Samsky
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Peter M Irving
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King’s College London, UK
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Samsky MD, Morrow DA, Proudfoot AG, Hochman JS, Thiele H, Rao SV. Cardiogenic Shock After Acute Myocardial Infarction: A Review. JAMA 2021; 326:1840-1850. [PMID: 34751704 PMCID: PMC9661446 DOI: 10.1001/jama.2021.18323] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction. OBSERVATIONS Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization-only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction. CONCLUSIONS AND RELEVANCE Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.
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Affiliation(s)
- Marc D Samsky
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
- Clinic For Anesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Free University Berlin and Humboldt University Berlin, Germany
- Department of Anaesthesiology & Intensive Care, German Heart Centre Berlin, Germany
| | - Judith S Hochman
- Cardiovascular Clinical Research Center, Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sunil V Rao
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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10
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Baran DA. A deceptively simple problem: the case of cardiogenic shock. Eur J Heart Fail 2021; 23:1952-1954. [PMID: 34333813 DOI: 10.1002/ejhf.2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/11/2022] Open
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11
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Kaso ER, Pan JA, Salerno M, Kadl A, Aldridge C, Haskal ZJ, Kennedy JLW, Mazimba S, Mihalek AD, Teman NR, Giri J, Aronow HD, Sharma AM. Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism: a Meta-Analysis and Call to Action. J Cardiovasc Transl Res 2021; 15:258-267. [PMID: 34282541 PMCID: PMC8288068 DOI: 10.1007/s12265-021-10158-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 01/08/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63–2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment.
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Affiliation(s)
- Elona Rrapo Kaso
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Jonathan A Pan
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Michael Salerno
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Chad Aldridge
- Department of Therapy Services, University of Virginia, Charlottesville, VA, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sula Mazimba
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jay Giri
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Herbert D Aronow
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya M Sharma
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.
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Tyler JM, Brown C, Jentzer JC, Baran DA, van Diepen S, Kapur NK, Garberich RF, Garcia S, Sharkey SW, Henry TD. Variability in reporting of key outcome predictors in acute myocardial infarction cardiogenic shock trials. Catheter Cardiovasc Interv 2021; 99:19-26. [PMID: 33871159 DOI: 10.1002/ccd.29710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 04/02/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Among acute myocardial infarction patients with cardiogenic shock (AMICS), a number of key variables predict mortality, including cardiac arrest (CA) and shock classification as proposed by Society for Cardiovascular Angiography and Intervention (SCAI). Given this prognostic importance, we examined the frequency of reporting of high risk variables in published randomized controlled trials (RCTs) of AMICS patients. METHODS We identified 15 RCTs enrolling 2,500 AMICS patients and then reviewed rates of CA, baseline neurologic status, right heart catheterization data, lactate levels, inotrope and vasopressor requirement, hypothermia, mechanical ventilation, left ventricular ejection fraction (LVEF), mechanical circulatory support, and specific cause of death based on the primary manuscript and Data in S1. RESULTS A total of 2,500 AMICS patients have been enrolled in 15 clinical trials over 21 years with only four trials enrolling >80 patients. The reporting frequency and range for key prognostic factors was: neurologic status (0% reported), hypothermia (28% reported, prevalence 33-75%), specific cause of death (33% reported), cardiac index and wedge pressure (47% reported, range 1.6-2.3 L min-1 m-2 and 15-24 mmHg), lactate (60% reported, range 4-7.7 mmol/L), LVEF (73% reported, range 25-45%), CA (80% reported, prevalence 0-92%), MCS (80% reported, prevalence 13-100%), and mechanical ventilation (93% reported, prevalence 35-100%). This variability was reflected in the 30-day mortality which ranged from 20-73%. CONCLUSIONS In a comprehensive review of seminal RCTs in AMICS, important predictors of outcome were frequently not reported. Future efforts to standardize CS trial data collection and reporting may allow for better assessment of novel therapies for AMICS.
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Affiliation(s)
- Jeffrey M Tyler
- Interventional Cardiolgy at Scripps Clinic, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Christopher Brown
- Interventional Cardiolgy at Scripps Clinic, Cedars Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jacob Colin Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Baran
- Advanced Heart Failure Center, Sentara Heart Hospital, Norfolk, Virginia, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
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van Diepen S, Morrow DA. Potential growth in cardiogenic shock research though an international registry collaboration: the merits and challenges of a Hub-of-Spokes model. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:3-5. [PMID: 33580781 DOI: 10.1093/ehjacc/zuaa038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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