A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock

Prognosis of refractory cardiogenic shock in de-novo versus acute-on-chronic heart failure: Insights from the HYPO-ECMO trial

BACKGROUND

Acute-on-chronic heart failure (ACHF) currently represents the leading etiology of cardiogenic shock (CS). We aimed to assess the prognostic value of history of heart failure (HF) in patients with refractory CS as well as its effect on the benefit of moderate hypothermia (MH) (33-34 °C).

METHODS

Of the 334 patients included in the HYPO-ECMO trial, 321 (96 %) had available HF history information, among whom 65 (20 %) had prior HF. Inverse probability weighting (IPW) was used to compare ACHF patients and de-novo HF (DNHF) patients. Primary outcome was all-cause mortality at day 30. Main secondary outcomes were mortality and the composite of death, heart transplant, escalation to left ventricular assist device, or stroke up to day 180.

RESULTS

At 30 days, 26 patients (40.0 %) died in the ACHF group versus 122 patients (47.7 %) in the DNHF group (crude risk difference (RD), -7.7 % [-21.0 to 5.7] p = 0.26; IPW RD, -11.6 % [-24.8 to 1.6] p = 0.084). Mortality (IPW RD, -13.7 % [-27.1 to -0.2], p = 0.047) and the composite outcome (IPW RD, -19.5 % [-32.9 to -6.1], p = 0.004) were significantly lower at day 180 in the ACHF group. Patients randomized to MH tended to have a lower risk for the primary outcome (RD -10.9 %, [-23.1 to 1.2], p = 0.078) and a significant reduction in composite outcome (p < 0.05 at each timepoint) in the DNHF group but not in the ACHF group, despite the absence of a significant interaction (p > 0.05).

CONCLUSIONS

In VA-ECMO-treated CS, ACHF was associated with comparable 30-day survival but lower 180-day mortality and morbidity-mortality. In this exploratory post-hoc analysis, MH appeared to be associated with improved outcomes in DNHF patients only.

CLINICALTRIALS

gov Identifier: NCT02754193.

A CLINICAL PREDICTION MODEL FOR SHORT-TERM PROGNOSIS IN PATIENTS WITH NON-ACUTE MYOCARDIAL INFARCTION-RELATED CARDIOGENIC SHOCK

ABSTRACT

Background : While acute myocardial infarction (AMI) is widely recognized as the primary cause of cardiogenic shock (CS), non-AMI-related CS has been excluded from the majority of CS studies. Information on its prognostic factors remains largely understudied, and it is necessary to focus on these patients to identify the specific risk factors. In this study, we aimed to build and validate a predictive nomogram and risk classification system. Methods: 1298 patients and 548 patients with CS from the Medical Information Mart for Intensive Care IV and III databases were included in the study after excluding patients with AMI. Lasso and logistic regression analysis were used to identify statistically significant predictors, which were finally involved in the nomogram. The predictive performance of the nomogram was validated by calibration plots and was compared with other scoring systems by area under curve and decision curve analysis curves. Results: Age, heart rate, white blood cell count, albumin level, lactic acid level, GCS score, 24-h urine output, and vasopressor use were identified as the most critical factors for in-hospital death. Based on these results, a nomogram was established for predicting in-hospital mortality. The area under curve value of the nomogram was 0.806 in the training group and 0.814 and 0.730 in the internal and external validation sets, respectively, which were significantly higher than those of other commonly used intensive care unit scoring systems (Simplified Acute Physiology Score II, Acute Physiology Score III, and Sequential Organ Failure Assessment). In addition, the survival curve showed significant differences in the 30-day survival of the three risk subgroups divided by the nomogram. Conclusion: For non-AMI-associated CS, a predictive nomogram and risk classification system were developed and validated, and the nomogram demonstrated good performance in prognostic prediction and risk stratification.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

Vasoactive-Inotropic Score in Takotsubo syndrome induced cardiogenic shock

OBJECTIVE

To determine the prognostic value of the Vasoactive-Inotropic Score (VIS) in patients with Takotsubo syndrome (TTS) complicated by cardiogenic shock (CS).

DESIGN

Retrospective cohort analysis.

SETTING

Multicenter registry (RETAKO) of patients diagnosed with TTS between 2003 and 2022.

PATIENTS OR PARTICIPANTS

A total of 1591 patients with TTS, of which 412 (26%) developed CS.

INTERVENTIONS

Patients were managed according to clinical criteria, with VIS calculated based on the maximum doses of inotropic and vasoactive drugs administered within the first 24 h of CS diagnosis.

MAIN VARIABLES OF INTEREST

30-day and 1-year mortality rates, VIS tertile classifications.

RESULTS

Of the patients who developed CS, 208 received inotropic support. Patients in the highest VIS tertile had significantly higher 30-day (HR 8.80, 95% CI 1.96-39.48; p = 0.005) and 1-year (HR 4.55, 95% CI 1.11-18.63; p < 0.035) mortality compared to the lowest tertile. High VIS was also linked to increased complications, including acute kidney injury, major bleeding, and the need for mechanical circulatory support. In-hospital mortality rates were 4% for the low tertile, 14% for the middle tertile, and 47% for the high tertile (p < 0.001).

CONCLUSIONS

VIS is associated with worse short- and long-term outcomes in TTS complicated by CS. Further research is needed to explore potential causal pathways, if any, and to optimize therapeutic strategies for these patients.

Factors Associated with Mortality Risk in Patients with Cardiogenic Shock Post-ST-Elevation Myocardial Infarction: Insights from a Regional Centre in Northwest Romania

Background and Objectives: ST elevation myocardial infarction (STEMI), particularly when complicated by cardiogenic shock (CS), is a critical condition associated with high mortality rates. Identifying predictors of in-hospital mortality can enhance patient management and outcomes. Materials and Methods: This observational, retrospective case-control study included STEMI patients, both complicated and uncomplicated by CS. Additionally, demographics, clinical characteristics, laboratory data and in-hospital mortality rates were analysed for STEMI patients with CS and those without CS. Results: This study included a total of 101 patients with STEMI, of whom 51 (50.5%) had STEMI without CS and 50 (49.5%) had STEMI with CS. No significant differences were observed in demographic characteristics or STEMI risk factors between the two groups. Emergency coronarography was performed in 90.1% of the patients, with successful thrombolysis achieved in 24.5%. Patients with CS exhibited a significantly higher mortality (52%) than those without CS (11.76%). Univariate analysis identified white blood cell counts, CK-MB, CK levels, elevated creatinine and uric acid levels and a reduced left ventricular ejection fraction (LVEF) as predictors of mortality. Logistic regression analysis revealed that LVEF and CK-MB were independent predictors of in-hospital mortality in patients with STEMI and CS. Each 1% increase in LVEF was associated with a reduced mortality risk (HR = 0.89; 95% CI 0.81-0.98; p = 0.018), while elevated CK-MB levels were linked to an increased mortality risk (HR = 1; 95% CI 1-1.01; p = 0.014). Conclusions: Reduced systolic function and elevated CK-MB levels are key predictors of in-hospital mortality and outcomes in STEMI patients with CS. These findings underscore the importance of early identification and support the development of targeted management strategies aimed at improving outcomes in this high-risk population.

The ketone body 3-hydroxybutyrate increases cardiac output and cardiac contractility in a porcine model of cardiogenic shock: a randomized, blinded, crossover trial

Cardiogenic shock (CS) is characterized by reduced cardiac output (CO), reduced end-organ perfusion, and high mortality. Medical therapies have failed to improve survival. The ketone body 3-hydroxybutyrate (3-OHB) enhances cardiac function in heart failure and CS. We aimed to elucidate the cardiovascular and cardiometabolic effects of 3-OHB treatment during CS. In a randomized, assessor-blinded crossover design, we studied 16 female pigs (60 kg, 5 months of age). CS was induced by left main coronary artery microsphere injections. Predefined criteria for CS were a 30% reduction in CO or mixed venous saturation (SvO2). Intravenous 3-OHB infusion and a matching control solution were administered for 120 min in random order. Hemodynamic measurements were obtained by pulmonary artery catheterization and a left ventricular (LV) pressure-volume catheter. Myocardial mitochondrial function was assessed using high resolution respirometry. During CS, infusion with 3-OHB increased CO by 0.9 L/min (95%CI 0.4-1.3 L/min) compared with control infusion. SvO2 (P = 0.026) and heart rate (P < 0.001) increased. Stroke volume (P = 0.6) was not altered. LV contractile function as determined by LV end-systolic elastance improved during 3-OHB infusion compared with control infusion (P = 0.004). Systemic and pulmonary vascular resistance decreased, and diuresis increased. LV mitochondrial function was higher after 3-OHB infusion compared with control. We conclude that 3-OHB infusion enhances cardiac function by increasing contractility and reducing vascular resistance, while also preserving myocardial mitochondrial respiratory function in a large animal model of ischemic CS. These novel findings support the therapeutic potential of exogenous ketone supplementation in CS management.

The Role of a Cardiogenic Shock Team in Decision Making Surrounding Mechanical Circulatory Support

Cardiogenic shock (CS) confers high mortality rates and remains a challenge for cardiovascular specialists. The difficulty in treating CS lies in its complexity, phenotypic heterogeneity, and the need for expedient treatment. Emerging evidence suggests that cardiogenic shock teams (CS teams), consisting of multiple specialists working in tandem with set protocols and care pathways to offer standardized team-based care, may reduce mortality and morbidity in patients with CS. A key reason for improved outcomes may be the team's decisions surrounding the use of temporary mechanical support devices (tMCS). CS teams expedite the identification of patients who require tMCS and determine the most appropriate device based on patient factors, including shock phenotype. The CS team ensures that tMCS best practices are followed and assists in determining the timing of device escalation or de-escalation. This article will discuss the rationale and role of CS teams. The evidence behind CS teams and their impact on tMCS decision making will be reviewed. Recent trial evidence for the use of tMCS in CS secondary to acute myocardial infarction (AMI) will be examined. Considerations for creating and optimizing an AMI-CS team will be highlighted. Finally, we will examine the current use of CS teams, potential challenges, and future directions for establishing CS teams in Canada.

The current use of vasoactive agents in cardiogenic shock related to myocardial infarction and acute decompensated heart failure

Cardiogenic shock (CS) is a heterogeneous condition associated with exceptionally high mortality rates, despite significant advances in the field of cardiology. The primary causes of CS are myocardial infarction-related CS (AMI-CS) and acute decompensated heart failure-related CS (ADHF-CS). Management of CS is inherently complex, with the initial focus-irrespective of the underlying etiology-centered on preserving end-organ perfusion. Parenteral vasopressors and inotropes are the cornerstone of therapy to achieve this objective. However, data on the comparative efficacy of different vasoactive agents in CS remain limited, and no single agent has demonstrated clear superiority. Recent progress in the staging and phenotyping of CS has provided a framework for more tailored therapeutic approaches. This review offers a comprehensive and updated summary of current evidence on the use of vasopressors and inotropes in AMI-CS and ADHF-CS, including a discussion of specific scenarios, such as right ventricular CS (RV-CS).

Utilization of Palliative Care in Cardiogenic Shock Patients: A Retrospective Analysis of the National Inpatient Sample Database, 2020

Background: Cardiogenic shock (CS) is one of the leading causes of death in patients with myocardial infarction, myocarditis, and congestive heart failure. The utilization patterns of specialist palliative care (PC) consultation in these patients are currently unknown. Objectives: To determine the utilization of PC in patients with CS and the overall comorbidities of that population. Methods: Review of the 2020 National Inpatient Sample identified 6,471,165 hospitalizations of which 38,531 patients were hospitalized with CS via International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) code R57.0. Demographics and details of hospitalization were compared for patients who received PC evaluation (N = 8457) and those who did not (N = 30,074) as identified via ICD-10 CM code Z51.5. Results: Patients who received PC evaluation were older (≥65 years: 69.01% vs. 55.04%, p < 0.001), had shorter hospital stays (<14 days: 78.92% vs. 70.35% patients, p < 0.001), and higher in-hospital mortality (65.80% vs. 24.23%, p < 0.001) with higher Charlson Comorbidity Index (≥4, 55.22% vs. 48.09%, p < 0.001). Furthermore, the patients who received PC had significantly higher odds of death than those who did not (adjusted odds ratio = 6, p < 0.0001). Conclusion: Despite high mortality rates, specialist PC is not routinely involved in the care of those who die with CS, although does appear to be utilized among those most likely to die. This suggests preferential utilization of specialist PC for terminal patients; however, further research will be helpful to better understand current consult practices and increase PC utilization for this highly morbid population.

Enhancing Care in Cardiogenic Shock: Role of Palliative Care in Acute Cardiogenic Shock Through Destination Therapy

Despite advances in the management of cardiogenic shock (CS), morbidity and mortality in CS remain exceedingly high and one third of patients do not survive their admission. Palliative care (PC) is an interdisciplinary approach focussed on improving the quality of life of patients and families facing life-threatening illness. Rates of PC use in CS remain low, despite evidence suggesting decreased symptom burden and reduced use of health care in patients with heart failure and in critical care settings. PC should occur in tandem with mobilization of aggressive life-sustaining measures such as mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) in the care of patients presenting with CS. In this review, we describe the role of PC throughout the care continuum of patients with acute CS through to destination therapy with a left ventricular assist device. We explore the current use of PC in CS and challenges to goals-of-care discussions posed by MCS and ECMO, and highlight strategies on integrating PC in acute and chronic CS. Finally, we demonstrate the importance of incorporating PC early in management and challenge the traditional use of PC primarily as an end-of-life intervention.

Clinical Prediction Score for Successful Liberation from Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients

BACKGROUND

In cardiogenic shock (CS) patients requiring temporary mechanical circulatory support (tMCS), assessing cardiac recovery vs the need for heart replacement therapy is critical. We developed and validated a new clinical score aimed at predicting successful tMCS liberation.

METHODS

A cohort of 80 CS patients treated with Impella support between January 2018 and December 2020 was analyzed. Hemodynamic, echocardiographic, and laboratory data were collected at baseline, 24 hours, 48 hours, and 96 hours after device insertion. Patients were classified as successfully or unsuccessfully liberated from tMCS, based on recovery vs progression to death, left ventricular assist device implantation, or heart transplant. The W score, derived using independent predictors of successful liberation, was validated in 2 cohorts: 86 CS patients at our center and 23 patients from an external center.

RESULTS

Among the 80 patients (mean age 62.5 ± 11.8 years, 63.7% acute myocardial infarction CS), 47.5% achieved successful tMCS liberation. Independent predictors included left ventricular ejection fraction, N-terminal pro-brain natriuretic peptide, and inotropic score at 24 hours, along with creatinine and lactate at 96 hours (area under the curve [AUC] ≥ 0.7, P < 0.05). The W score, using a cutoff of ≥7, demonstrated good diagnostic accuracy (AUC 0.92, sensitivity 80%, specificity 85%, P < 0.001). In validation cohorts, a score ≥7 predicted successful liberation with AUCs of 0.80 (P < 0.001) and 0.72 (P < 0.015) at the internal and external centers, respectively.

CONCLUSIONS

The W score, based on key parameters at 24 and 96 hours post-tMCS, effectively supports clinicians in identifying CS patients likely to achieve successful tMCS liberation.

Transfer to Hub Hospitals and Outcomes in Cardiogenic Shock

BACKGROUND

There are limited large-scale data on the outcomes of patients with cardiogenic shock (CS) transferred to hub centers. This study aimed to compare the characteristics and outcomes of transferred patients with CS versus those who were not transferred.

METHODS

Adults (aged ≥18 years) with a primary or secondary diagnosis of CS were identified from the Nationwide Readmissions Database (2016-2020) and stratified by transfer status. Overlap propensity score weighting was performed to assess the association between transfer status and in-hospital mortality. Secondary outcomes, including length of hospital stay, hospitalization costs, and readmissions for cardiac and noncardiac etiologies, were assessed using multivariable regression.

RESULTS

Of 314 098 patients with CS (27% with acute myocardial infarction-related CS and 73% with nonacute myocardial infarction-related CS), 30 630 (9.8%) were transferred. In the unweighted population, compared with nontransferred patients, transferred patients were on average younger (65 versus 68 years), had higher comorbidities, and were more likely to be cared for at large teaching hospitals. During the hospitalization, they had higher rates of renal failure, pulmonary artery catheter use, and mechanical circulatory support use. In-hospital mortality was lower in transferred patients-39.1% versus 47.1%; unadjusted odds ratio (OR), 0.71 (95% CI, 0.70-0.73); adjusted OR, 0.73 ([95% CI, 0.71-0.76]; P<0.001). This was consistent across subgroups of CS cause, age, sex, hospital location, mechanical circulatory support use, and presence of cardiac arrest. The transferred cohort had lower costs and length of stay, but more frequent all-cause (adjusted OR, 1.21 [95% CI, 1.16-1.27]), cardiac (adjusted OR, 1.16 [95% CI, 1.11-1.22]), heart failure (adjusted OR, 1.14 [95% CI, 1.08-1.21]), and noncardiac readmissions (adjusted OR, 1.68 [95% CI, 1.21-2.33]) at 30 days postdischarge compared with the nontransferred cohort.

CONCLUSIONS

Despite higher comorbidity, organ failure, and use of cardiac/noncardiac procedures, patients with CS who were transferred to hub centers had lower in-hospital mortality, hospitalization costs, and length of stay.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

Protocol-Driven Best Practices and Cardiogenic Shock Survival in Asian Patients

BACKGROUND

Cardiogenic shock carries high mortality. This study investigated the relationship between protocol-advocated best practices and outcomes.

METHODS

Patients with cardiogenic shock supported by Impella CP in an Asian tertiary cardiac center were evaluated for 30-day post percutaneous ventricular assist device (PVAD) survival after adopting a standardized protocol emphasizing early mechanical circulatory support (shock-to-PVAD time ≤180 minutes), pulmonary artery catheterization for invasive hemodynamics, and safe vascular access.

RESULTS

Of 109 consecutive patients (mean age 58.5±11.2, 80.7% male, 67% acute myocardial infarction, 33% acute decompensated heart failure), 45 (41.3%), 33 (30.3%), and 31 (28.4%) were in SCAI Shock Stages C, D, and E, respectively. A suggestive trend of improving 30-day survival was observed (56.8%, 63.9%, and 72.2% in successive one thirds, P1, P2, and P3 of patients), paralleling a similar trend in achievement of best practices. Patients achieving all 3 best practices significantly increased from 35.1% (P1) to 52.8% (P3) (P=0.026). Median shock-to-PVAD time reduced from 5 [interquartile range: 2-23] hours (P1) to 1.5 [1-5] hours (P3) (P for trend=0.014), whereas pulmonary artery catheterization utilization (80.6-86.1%) and device-related major vascular complications (5.6-8.4%) remained relatively stable. Achieving more best practices was significantly associated with better 30-day survival, with patients achieving all 3, 2, and ≤1 best practices had 30-day survival rates of 75.0%, 63.6%, and 35.7%, respectively (P=0.043). In multivariate Cox regression analysis, shock-to-PVAD time >180 minutes remained an independent predictor of mortality (P=0.031).

CONCLUSIONS

Achievement of protocol-advocated best practices, especially early shock recognition and prompt PVAD support in appropriate patients, was associated with improved outcomes with PVAD use in cardiogenic shock. Future studies are suggested to confirm the benefits of a protocolized approach and evaluate the value of individual best practices.

Charting the Course for Careers in Interventional Heart Failure: Training, Challenges, and Future Directions

Interventional heart failure (IHF) has emerged as a critical subspecialty due to the increasing complexity of heart failure (HF) treatment now spanning both pharmacological and nonpharmacological device-based therapies. Although initially existing at the intersection of interventional cardiology and advanced HF, IHF has expanded to encompass multiple domains of cardiology including cardiogenic shock (CS), transcatheter valve therapies, relief of increased left atrial pressures, and coronary intervention in low ejection fraction and after heart transplant. Although rapidly growing, training pathways remain elusive, and existing training pathways are not well equipped to deliver necessary training components and encourage growth in the field. Those with a career in IHF can be divided into 3 main phenotypes. Those who are not formally interventional trained, but might implant pressure sensors, perform endomyocardial biopsies, and place nonlarge bore devices. Those who have formal interventional cardiology training might focus on coronary interventions, shock calls, and large-bore devices. Those with structural training might focus on transcatheter valve therapies and structural procedures in HF. There are several possible training pathways for IHF and we propose 5 focuses for training. Finally, we describe areas of interest and growth for careers in IHF. The field of IHF has been misunderstood as one of "jack of all trades" but actually represents the trend of increasing specialization for careers within cardiology due to the increasing complexity of therapeutic options within cardiovascular disease. By addressing current training challenges, the field is poised to make significant strides. Trainees entering this specialty will have the opportunity to be at the forefront of cardiovascular care, contributing to innovative treatments and improving outcomes for patients with complex HF.

Levosimendan in Patients with Cardiogenic Shock Refractory to Dobutamine Weaning

BACKGROUND

This study examines the effects of levosimendan in patients refractory to dobutamine weaning.

METHODS

This retrospective study included patients with cardiogenic shock refractory to dobutamine weaning failure admitted between 2010 and 2022. Patients treated with another type of dobutamine alone were compared with those treated with levosimendan in combination with dobutamine. Successful inotrope withdrawal was defined as survival without catecholamine support, transplant, or definitive ventricular assist device at 30 days. Secondary outcomes included all-cause mortality at 30 and 90 days.

RESULTS

Among 349 patients with cardiogenic shock and failure to withdraw from dobutamine, levosimendan was administered in combination with dobutamine in 114 patients, and another type of dobutamine alone was administered in 235 patients. At 30 days, successful inotrope withdrawal occurred in 46 (43.4%) patients taking levosimendan plus dobutamine versus 24 (10.5%) patients in the dobutamine-only group (weighted odds ratio [OR] 4.99, 95% confidence interval [CI] 2.65-9.38; p < 0.001), with similar results at 90 days (weighted OR 6.16, 95% CI 3.22-11.78; p < 0.001). Levosimendan + dobutamine was associated with lower 30-day mortality (weighted OR 0.47, 95% CI 0.26-0.84; p = 0.01), with no difference at 90 days (weighted OR 0.67, 95% CI 0.39-1.14; p = 0.14).

CONCLUSION

Adding levosimendan to dobutamine may improve inotrope withdrawal success and reduce 30-day mortality in patients with initial weaning failure.

A case of destination therapy for post-fulminant myocarditis with myelodysplastic syndrome

We encountered a 64-year-old woman who experienced fulminant myocarditis and underwent treatment with veno-arterial extracorporeal membrane oxygenation and Impella CP support. Subsequently, she underwent a device upgrade to Impella 5.5 and received continuous hemodiafiltration for 3 months. During mechanical circulatory support, she developed refractory anemia and thrombocytopenia, leading to a diagnosis of myelodysplastic syndrome. Following the removal of the devices, she no longer required blood transfusions. She received HeartMate 3 left ventricular assist device implantation as a destination therapy indication despite the presence of myelodysplastic syndrome. She was successfully managed by aspirin-free antithrombotic therapy without any hemocompatibility-related adverse events for 4 months after index discharge on foot. We present a patient with a unique and rare presentation, wherein HeartMate 3 was implanted and successfully managed without aspirin to prevent bleeding complications associated with myelodysplastic syndrome.

Impella support for refractory cardiogenic shock accompanied by diabetic ketoacidosis: a case report

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are strongly recommended in patients with heart failure, regardless of the presence of diabetes mellitus. A 74 year-old woman with a reduced left ventricular ejection fraction and diabetes mellitus (the types were unknown), receiving insulin and SGLT2 inhibitor, was hospitalized for altered consciousness with systemic hypotension. Upon admission, she was diagnosed with cardiogenic shock due to diabetic ketoacidosis. Intensive fluid resuscitation under Impella CP support successively improved her metabolic acidosis, preventing worsening pulmonary congestion by mechanically unloading the heart. After hemodynamic stabilization, she was diagnosed with type 1 diabetes mellitus for the first time. She was discharged on day 54 and was followed for 6 months without any recurrences. We must remain vigilant regarding the risk of diabetic ketoacidosis in patients using SGLT2 inhibitors, particularly those on insulin therapy or with diabetes mellitus of unknown types. Impella device shows promise as a circulatory support system in alleviating the left ventricle's workload and averting exacerbated pulmonary congestion, especially in cases where patients necessitate aggressive fluid replacement therapy, such as in the treatment of diabetic ketoacidosis concurrent with compromised cardiac function.

Higher vasoactive usage despite hemodynamic goals is associated with higher mortality in acute myocardial infarction-related cardiogenic shock

Background

Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI) with high mortality. Few studies have examined the selection and subsequent choice of vasoactive agents in CS. This study investigates the impact of vasoactive drug use and in-hospital outcomes among AMI-CS.

Materials and methods

A total of 309 patients who underwent pulmonary artery catheterization between 2006 and 2021 were categorized by the number of vasoactive drugs used (0-1, 2, or >2). Clinical and 24 h hemodynamic data were analyzed. Primary outcomes explored the correlation between vasoactive use and in-hospital mortality. Secondary analyses assessed hemodynamic changes and estimated mortality probabilities at different intervals using logistic regression.

Results

In total, 57 patients received 0-1, 76 received 2, and 176 received >2 vasoactive drugs. The median age was 61 years; most were men (82%), and 82.8% had ST-segment elevation myocardial infarction. End-organ function showed progressive deterioration with escalating vasoactive use. Survival analysis revealed an increased mortality in the >2 vasoactive group [HRadj = 4.62 (2.07-10.32)], achieving ≥5/6 hemodynamic goals that did not mitigate mortality [HRadj = 7.18 (1.59-32.39)]. Subgroup analyses within patients who reached different hemodynamic goals reiterated adverse outcomes associated with >2 vasoactives (P < 0.05). Further analysis showed that vasopressin was associated with the highest mortality in a time-dependent fashion [HRDay1, 8.77 (6.04-12.75) → HRDay30, 1.23 (0.8-1.87)], and levosimendan had similar behavior [HRDay1, 2.67 (1.82-3.91) → HRDay30, 0.66 (0.42-1.03)].

Conclusions

A significant association between the number of vasoactives and in-hospital mortality was found in AMI-CS, which requires future long-term studies to explore the role of vasoactive drug therapies and early temporary mechanical circulatory support.

Anticoagulation with Nafamostat Mesilate During Impella Support: A Case Report

Achieving an optimal balance between thrombosis prevention and bleeding risk during temporary mechanical circulatory support remains a significant clinical challenge. Effective anticoagulation management that ensures device functionality while minimizing major bleeding events should have the potential to improve short-term outcomes. Here, we report the successful use of nafamostat mesilate (NM) as an anticoagulant during Impella support in two male patients with advanced heart failure and cardiogenic shock. NM therapy resulted in improved thrombocytopenia without the occurrence of major bleeding or thrombotic events. However, NM-related hyponatremia was observed, highlighting the need for careful monitoring during its administration and further cumulative evidence to validate optimal NM therapy during temporary mechanical circulatory supports.

Inotropes and mortality in patients with cardiogenic shock: an instrumental variable analysis from the SWEDEHEART registry

BACKGROUND

The use of inotropic agents in treating cardiogenic shock (CS) remains controversial. This study investigates the effect of inotropes on 30-day mortality in CS patients using data from the SWEDEHEART registry (The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies).

METHODS AND RESULTS

Data were sourced from the national SWEDEHEART registry for all CS patients in Sweden from 2000 to 2022. The primary endpoint was 30-day all-cause mortality. We employed multilevel Cox proportional-hazards regression with instrumental variable and inverse probability weighting propensity score to adjust for confounders. The treatment-preference instrument was the quintile of preference for inotrope use at the treating hospital. A total of 16 214 patients (60.5% men, 39.5% women) were included; 23.5% had diabetes, 10.2% had a previous myocardial infarction (MI), and 13.8% had previous heart failure (HF). The median age was 70 years [interquartile range (IQR); 19], with 66.4% over 70. Acute coronary syndrome (ACS) caused CS in 82.9%. Inotropes were administered to 43.8% of patients, while 56.2% did not receive them. There were 7875 (48.1%) deaths. Patients treated with inotropes were, on average, 2 years younger and more likely to have ACS, while those not treated had more previous MI and were less likely to undergo percutaneous coronary intervention (PCI). The number of CS cases decreased by 12% per year (Ptrend < 0.001), and inotrope use increased by 5% per year (Ptrend < 0.001). Unadjusted mortality in CS rose by 2% per calendar year (Ptrend < 0.001). Inotropes were associated with higher mortality [adjusted hazard ratio (HR) 1.72; 95% CI 1.26-2.35; P = 0.001], with significant interactions between inotrope treatment, age, and diagnosis (Pinteraction < 0.001 and Pinteraction = 0.018).

CONCLUSION

In this observational study, inotropes were linked to higher mortality in CS patients, particularly those younger than 70. While CS cases decreased, inotrope use and mortality increased in Sweden.

Clinician Perspectives of Barriers and Enablers to Quality Cardiogenic Shock Care: A Focus Group Study

BACKGROUND & AIM

Cardiogenic shock is a medical emergency that is associated with high mortality rates. It is a resource-intensive and costly condition that is complicated by comorbidities and clinical deterioration. However, the barriers and enablers to quality cardiogenic shock care are relatively unknown from the perspective of Australian clinicians. This study aimed to i) To explore clinicians' perspectives on the barriers to delivering these best practice care and optimal outcomes for patients with cardiogenic shock; and ii) To understand priorities to overcome these barriers, with the intent of using the findings to inform the development and implementation of a clinical trial for cardiogenic shock management-ESCAPE-CS: Evaluation of a Standardised ClinicAl Pathway to improve Equity and outcomes in Cardiogenic Shock (ESCAPE-CS).

METHOD

A qualitative focus group study was conducted via videoconference with experienced clinicians, and audio-recorded and transcribed verbatim. Data were analysed using thematic analysis in NVivo.

RESULTS

Five focus groups were conducted, including 19 participants (11 male and eight female), comprising seven intensive care unit physicians, seven nurse consultants/educators, three cardiologists, and two emergency department physicians working in metropolitan and rural, regional, or remote health settings. Five themes were identified: CONCLUSIONS: This study provided critical insights into the barriers and possible enablers to delivering best practice care and optimal outcomes for patients with cardiogenic shock. There is scope for an improved model of care in cardiogenic shock management to address inequalities emerging from multifactorial complexities.

Guideline-directed medical therapy implementation during hospitalization for cardiogenic shock

AIMS

Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry.

METHODS

We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30 day, 6 month and 12 month patient outcomes were collected by retrospective chart review.

RESULTS

Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64 years [interquartile range (IQR) 56, 70], 72% (n = 133) were male, 22% (n = 40) were Black and 7% (n = 12) were Hispanic. Forty-one per cent of patients (n = 76) presented with shock related to acute myocardial infarction (AMI), while 59% (n = 109) had HF-related CS (HF-CS). The median length of hospital stay was 12 days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n = 144), 58% (n = 107) and 55% (n = 101), respectively. Utilization of three-drug GDMT was 33.0% (n = 61). Ten per cent of CS survivors with HFrEF (n = 19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P < 0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6 month and 1 year survival (P < 0.01): On average, 6 month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1 year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5).

CONCLUSIONS

Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.

Clinical characteristics and predictive biomarkers of intensive care unit-acquired weakness in patients with cardiogenic shock requiring mechanical circulatory support

Intensive care unit-acquired weakness (ICU-AW) is recognized as newly-acquired bilateral muscle weakness, which is a complication of critical illness in the ICU; however, there are no reports on the pathogenesis and early predictors of ICU-AW specifically associated with cardiogenic shock (CS). Therefore, this study aimed to investigate the clinical characteristics of ICU-AW in patients with CS requiring mechanical circulatory support (MCS). This study was a single-center, prospective, and observational study. Patients aged 16 years and older who underwent MCS for CS were included. ICU-AW was diagnosed based on Medical Research Council (MRC) score after awakening. The ICU-AW group included patients with the MRC score < 48 points, and the non-ICU-AW group included those with ≥ 48 points. Twenty-eight cases were enrolled on admission and MRC score was evaluated in 23 cases after awakening. Eleven patients were included in the non-ICU-AW group and 12 patients (52%) were in the ICU-AW group. The ICU-AW group showed a higher prevalence of extracorporeal membrane oxygenation and ventilator use. Creatine kinase, troponin T, interleukin (IL)-15 levels on admission were significantly higher, whereas hemoglobin and albumin levels were significantly lower in the ICU-AW group. A strong negative correlation was observed between the initial MRC scores and IL-15 levels. ICU-AW occurred 52% of patients with CS using MCS, indicating the significance of recognizing and managing this complication for those patients. In addition, IL-15 can be a potential biomarker for the early prediction of ICU-AW.

Temporary mechanical circulatory support utilization and outcomes in cardiogenic shock phenotypes: A comparative analysis of heart failure and acute myocardial infarction

INTRODUCTION

Cardiogenic shock (CS) is marked by substantial morbidity and mortality. The two major CS etiologies include heart failure (HF) and acute myocardial infarction (AMI). The utilization trends of mechanical circulatory support (MCS) and their clinical outcomes are not well described.

METHODS

This study compares the rates of MCS utilization, factors associated with utilization, and clinical outcomes in patients who present with HF-CS and AMI-CS, using 2016-2020 National Inpatient Sample data.

RESULTS

The study included 329,280 patients, comprising 204,660 cases of AMI-CS and 124,620 of HF-CS. MCS utilization increased over the study period with variable degree among devices, and CS-phenotype. AMI-CS had higher intraaortic balloon pump (32.4 % vs. 8.9 %), extracorporeal membrane oxygenation (2.8 % vs. 2.4 %), and percutaneous ventricular assist device use (14.5 % vs. 8.1 %) compared to HF-CS (p < 0.01). Factors linked to lower MCS use were female sex, age over 60 years, Black race, atrial fibrillation, chronic obstructive lung disease, diabetes mellitus, cirrhosis, previous stroke, or myocardial infarction. After adjusting for various factors, patients with HF-CS vs. AMI-CS had significantly fewer adverse outcomes, including inpatient death, stroke, tracheostomy, mechanical ventilation, and blood transfusion. However, HF-CS had higher odds of acute renal failure requiring dialysis. AMI-CS was associated with shorter hospital stays (8.8 vs. 15.0 days, p < 0.001), lower charges ($251,580 vs. $294,792, p < 0.001), and were less likely to discharge home.

CONCLUSION

Despite the evolving trends in MCS utilization over time, CS patients still face high morbidity and mortality rates. The underlying shock etiology has a substantial impact on outcomes, with AMI cases demonstrating worse complications. This highlights the need for a standardized approach that also takes into consideration etiology, patient-specific factors, care availability, and equitable access.

Current and novel biomarkers in cardiogenic shock

Cardiogenic shock (CS) carries a 30-50% in-hospital mortality rate, with little improvement in outcomes in the last decade. Challenges in improving outcomes are closely linked to the frequent late presentation or diagnosis of CS where the 'point of no return' has often passed, leading to haemodynamic dysregulation, progressive myocardial depression, hypotension, and a downward spiral of hypoperfusion, organ dysfunction and decreasing myocardial function, driven by inflammation and metabolic derangements. Novel therapeutic interventions may have varying efficacy depending on the type and stage of shock in which they are applied. Biomarkers that aid prediction and early detection of CS, provide early signs of organ dysfunction and define prognosis could help optimize management. Temporal change in such biomarkers, particularly in response to pharmacological interventions and/or mechanical circulatory support, can guide management and predict outcome. Several novel biomarkers enhance the prediction of mortality in CS, compared to conventional parameters such as lactate, with some, such as adrenomedullin and circulating dipeptidyl peptidase 3, also able to predict the development of CS. Some biomarkers reflect systemic inflammation (e.g. interleukin-6, angiopoietin 2, fibroblast growth factor 23 and suppressor of tumorigenicity 2) and are not specific to CS, yet inform on the activation of important pathways involved in the downward shock spiral. Other biomarkers signal end-organ hypoperfusion and could guide targeted interventions, while some may serve as novel therapeutic targets. We critically review current and novel biomarkers that guide prediction, detection, and prognostication in CS. Future use of biomarkers may help improve management in these high-risk patients.

Can a mechanical circulatory support comprehensive approach to cardiogenic shock at referral centers reduce 30-day mortality?

Although mortality risk prediction in cardiogenic shock (CS) is possible, assessing the impact of the multitude of therapeutic efforts on outcomes is not straightforward. We assessed whether a temporary mechanical circulatory support comprehensive approach to the treatment of CS may reduce 30-day mortality as compared to expected mortality predicted by the recently proposed Cardiogenic Shock Score (CSS). Consecutive CS patients supported by pVAD Impella (Abiomed, Danvers, MA) at two national referral centers were included. 170 patients were included: age was 65 ± 13 years, and 75.9% were male and acute myocardial infarction was the prevalent cause of shock (71.1%). Expected mortality according to CSS was higher than observed (51.8% vs. 41.5%, p < 0.001), this trend being particularly evident for CSS > 4. The AUC ROC curve confirmed poor diagnostic accuracy in this population (AUC 0.53 CI: 0.23-0.82, p = 0.83). The lower observed mortality compared to the expected mortality in critical cardiogenic shock population underscores the role of a comprehensive approach to acute cardiac care patients at referral centers, which should consider including temporary mechanical circulatory support.

Myocardial Infarction-Associated Shock: A Comprehensive Analysis of Phenotypes, SCAI Classification, and Outcome Assessment

Background and Objectives: In-hospital mortality associated with myocardial infarction complicated by cardiogenic shock (MI-CS) remains critically high. A particularly challenging form, mixed shock (MS), combines features of cardiogenic shock (CS) with distributive elements such as vasodilation and reduced vascular resistance. MS is associated with elevated mortality rates and presents unique diagnostic and therapeutic challenges. This study aimed to analyze the clinical, historical, instrumental, and laboratory characteristics of the primary phenotypes of MI-CS, stratified according to the Society for Cardiovascular Angiography and Interventions (SCAI) shock severity scale. Materials and Methods: In this single-center, retrospective observational study, we reviewed the medical records of 1289 patients admitted to the emergency cardiology department from 1 January to 12 December 2020. Among them, 117 patients were identified as having MI-CS and were divided into two groups: MS (n = 48) and isolated CS (n = 69). The data were analyzed using the SCAI shock classification. Logistic regression analysis was employed to identify predictors of mortality and improved survival outcomes. Results: Patients with MS were older (80 years [71.0; 83.0] vs. 73 years [64.0; 81.0], p = 0.035). The overall mortality rate was significantly higher in the MS group (68% vs. 53%, RR = 1.438, 95% CI: 1.041-1.986, p = 0.03). Logistic regression identified mechanical ventilation (OR = 8.33, 95% CI: 2.54-22.80, p = 0.012), elevated lactate levels (OR = 1.20, 95% CI: 1.02-1.41, p = 0.026), and cardiopulmonary resuscitation (CPR) (OR = 7.97, 95% CI: 2.51-24.40, p < 0.0001) as independent predictors of mortality. Conversely, the use of an intra-aortic balloon pump (IABP) (OR = 0.22, 95% CI: 0.06-0.80, p = 0.021) and a higher body mass index (BMI) (OR = 0.91, 95% CI: 0.84-0.99, p = 0.038) were associated with reduced mortality risk. Conclusions: MS in the context of MI-CS represents a distinct clinical phenotype with specific hemodynamic features and significantly worsened outcomes. The identification of mortality predictors, such as mechanical ventilation, elevated lactate levels, and CPR, alongside protective factors like IABP use and a higher BMI, underscores the importance of early and tailored therapeutic interventions. These findings highlight the need for further studies to refine treatment protocols and improve outcomes in this high-risk population.

Tailored Approach to Temporary Mechanical Circulatory Support for Cardiogenic Shock: Strategies to Facilitate Patient Mobilization

PURPOSE OF REVIEW

This article discusses a tailored approach to managing cardiogenic shock and temporary mechanical circulatory support (tMCS). We also outline specific mobilization strategies for patients with different tMCS devices and configurations, which can be enabled by this tailored approach to cardiogenic shock management.

RECENT FINDINGS

Safe and effective mobilization of patients with cardiogenic shock receiving tMCS can be accomplished. Appropriate patient selection, tailored device management, and dynamic multidisciplinary approaches to mobilization are critical to success. Cardiogenic shock is a heterogeneous condition characterized by end-organ dysfunction due to hypoperfusion and low cardiac output. Temporary mechanical circulatory support (tMCS) is an increasingly valuable tool in managing these patients, with various devices and configurations available. Critically ill patients receiving tMCS are at risk for complications and deconditioning associated with prolonged bed rest, making it essential to implement strategies that promote mobility when feasible. We advocate for a tailored approach to the selection and management of tMCS in patients with cardiogenic shock. This approach focuses on the early identification of patients who may benefit from tMCS before further deterioration, alongside the selection of devices that provide ventricular-specific support and facilitate upper-body cannulation to enhance mobilization while also considering patients' potential exit strategies from tMCS. Understanding this approach is vital to appropriately facilitating safe and effective mobilization.

Clinical Review of Cardiogenic Shock After Acute Myocardial Infarction - Revascularization, Mechanical Circulatory Support, and Beyond

Owing to recent advances in early reperfusion and pharmacological therapies, the prognosis of patients with acute myocardial infarction (AMI) has considerably improved over the past decades. However, the mortality rate remains high at ~40-50% after AMI when complicated by cardiogenic shock. Although immediate coronary revascularization of the infarct-related artery has been the only evidence-based treatment, temporary mechanical circulatory support with a microaxial flow pump (Impella) has become another therapeutic option supported by randomized trial data in highly selected patients. Here we summarize the latest evidence concerning clinical challenges in patients with AMI and cardiogenic shock.

Prediction of Acute Kidney Injury for Critically Ill Cardiogenic Shock Patients with Machine Learning Algorithms

Background

The aim of this study was to use five machine learning approaches and logistic regression to design and validate the acute kidney injury (AKI) prediction model for critically ill individuals with cardiogenic shock (CS).

Methods

All patients who diagnosed with CS from the MIMIC-IV database, the eICU database, and Zhongnan hospital of Wuhan university were included in this study. Clinical information, including demographics, comorbidities, vital signs, critical illness scores and laboratory tests was retrospectively collected. Five machine learning algorithms (LightGBM, decision tree, XGBoost, random forest, and ensemble model) and one conventional logistic regression were applied for the prediction of AKI in critically ill individuals with CS. ROC curves were generated via python software to assess the overall performance of machine learning algorithms and the SHAP analysis was adopted to reveal the impact of prediction for each feature.

Results

The ensemble model exhibited the best predictive ability (AUC:0.91, 95% CI, 0.88-0.94), followed by random forest (AUC:0.90, 95% CI, 0.86-0.94) and XGBoost (AUC:0.89, 95% CI, 0.84-0.92). While the logistic regression model obtained the worst predictive performance (AUC:0.62, 95% CI, 0.56-0.68). When validated the prediction models with eICU database, the ensemble model exhibited the best predictive ability (AUC:0.92, 95% CI, 0.89-0.96), while the logistic model obtained the worst predictive performance (AUC:0.61, 95% CI, 0.56-0.67). Finally, we verified the prediction models using the data from our hospital and ensemble model still exhibited the best predictive ability (AUC:0.74, 95% CI, 0.62-0.86), while the decision tree model obtained the worst predictive performance (AUC:0.52, 95% CI 0.35-0.70).

Conclusion

Machine learning algorithms could be utilized for the AKI prediction among critically ill CS patients, and exhibit superior predictive performance compared to the conventional logistic regression analysis.

Strategies to Improve Clinical Outcomes of Women with Cardiogenic Shock

Women with cardiogenic shock have a higher risk of mortality compared with men. There is an increasing need to identify existing barriers to care and formulate tailored strategies to improve outcomes in women.

Safety and utility of mechanical circulatory support in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a major cause of morbidity and mortality. Although mechanical circulatory support (MCS) is an increasingly utilized therapeutic option in AMI-CS, studies evaluating the efficacy and safety of different forms of MCS have yielded conflicting results. This systematic review and meta-analysis aims to evaluate the safety and efficacy of different forms of MCS.

METHODS

A database search was performed for studies reporting on the association of different forms of MCS with clinical outcomes in patients with AMI-CS. The primary efficacy endpoints were short term (≤30 days) and long term (>30 days) all-cause mortality. Secondary efficacy endpoints included recurrent AMI, cardiovascular (CV) mortality, device-related limb complications, moderate to severe bleeding events, and cerebrovascular accidents (CVA).

RESULTS

2752 patients with AMI-CS met inclusion criteria. Results were available comparing ECMO to other MCS or medical therapy alone, comparing IABP to medical therapy alone, and comparing pLVAD to IABP. Use of ECMO was not associated with lower risk of 30-day or long-term mortality compared to pVAD or standard medical therapy with or without IABP placement but was associated with higher risk of device-related limb complications and moderate to severe bleeding compared to pVAD. IABP use was not associated with a lower risk of 30 day or long-term mortality but was associated with higher risk of recurrent AMI and moderate to severe bleeding compared to medical therapy. Compared to IABP, pVAD use was associated with lower risk of CV mortality but not recurrent AMI. pVAD was associated with a higher risk of device-related limb complications and moderate to severe bleeding compared to IABP use.

CONCLUSION

Use of ECMO or IABP in patients with AMI-CS is not associated with significant improvement in mortality. pVAD is associated with a lower risk of CV mortality. All MCS types are associated with increased risk of complications. Additional high-quality studies are needed to determine the optimal MCS therapy for patients with AMI-CS.

Tailored Therapies for Cardiogenic Shock in Hypertrophic Cardiomyopathy: Navigating Emerging Strategies

Hypertrophic cardiomyopathy (HCM) is a complex and heterogeneous cardiac disorder, often complicated by cardiogenic shock, a life-threatening condition marked by severe cardiac output failure. Managing cardiogenic shock in HCM patients presents unique challenges due to the distinct pathophysiology of the disease, which includes dynamic left ventricular outflow tract obstruction, diastolic dysfunction, and myocardial ischemia. This review discusses current and emerging therapeutic strategies tailored to address the complexities of HCM-associated cardiogenic shock and other diseases with similar pathophysiology that provoke left ventricular outflow tract obstruction. We explore the role of pharmacological interventions, including the use of vasopressors and inotropes, which are crucial in stabilizing hemodynamics but require careful selection to avoid exacerbating the outflow obstruction. Additionally, the review highlights advancements in mechanical circulatory support devices such as extracorporeal membrane oxygenation (ECMO) and left ventricular assist devices (LVADs), which have become vital in the acute management of cardiogenic shock. These devices provide temporary support and bridge patients to recovery, definitive therapy, or heart transplantation, which remains a critical option for those with end-stage disease. Furthermore, the review delves into the latest research and clinical trials that are refining these therapeutic approaches, ensuring they are optimized for HCM patients. The impact of these treatments on patient outcomes, including survival rates and quality of life, is also critically assessed. In conclusion, this review underscores the importance of a tailored therapeutic approach in managing cardiogenic shock in HCM patients, integrating pharmacological and mechanical support strategies to improve outcomes in this high-risk population.

Cardiogenic Shock: Focus on Non-Cardiac Biomarkers

PURPOSE OF REVIEW

To examine the evolving multifaceted nature of cardiogenic shock (CS) in the context of non-cardiac biomarkers that may improve CS management and risk stratification.

RECENT FINDINGS

There are increasing data highlighting the role of lactate, glucose, and other markers of inflammation and end-organ dysfunction in CS. These biomarkers provide a more comprehensive understanding of the concurrent hemo-metabolic and cellular disturbances observed in CS and offer insights beyond standard structural and functional cardiac assessments. Non-cardiac biomarkers both refine the diagnostic accuracy and improve the prognostic assessments in CS. Further studies revolving around novel biomarkers are warranted to support more targeted and effective therapeutic and management interventions in these high-risk patients.

The CMLA score: A novel tool for early prediction of renal replacement therapy in patients with cardiogenic shock

BACKGROUND

Early identification of cardiogenic shock (CS) patients at risk for renal replacement therapy (RRT) is crucial for improving clinical outcomes. This study aimed to develop and validate a prediction model using readily available clinical variables.

METHODS

A retrospective cohort study was conducted using data from 4,133 CS patients from the MIMIC and eICU-CRD databases. Patients from MIMIC databases were randomly divided into 80 % training and 20 % validation cohorts, while those from eICU-CRD constituted the test cohort. Feature selection involved univariate logistic regression (LR), LASSO, and Boruta methods. Prediction models for RRT were developed using stepwise selection by LR and five machine learning (ML) algorithms (naive bayes, support vector machines, k-nearest neighbors, random forest, extreme gradient boosting) in the training cohort. Model performance was evaluated in both validation and test cohorts. A nomogram was constructed based on LR model. Kaplan-Meier survival analysis assessed 28-day mortality.

RESULTS

The incidence of RRT was approximately 13 % across all cohorts. Ten variables were selected: age, anion gap, chloride, bun, creatinine, potassium, ast, lactate, estimated glomerular filtration rate (eGFR), and mechanical ventilation. Compared with ML models, the LR model showed superior predictive performance with an AUC of 0.731 in the validation cohort and 0.714 in the test cohort. Four variables that best predicted the need for RRT (age, lactate, mechanical ventilation, and creatinine) were used to generate the CMLA nomogram risk score. The CMLA model showed better predictive accuracy for RRT in the test cohort compared to the previous CALL-K model (AUC: 0.731 vs. 0.699, DeLong test P < 0.05). Calibration curves and decision curve analysis (DCA) indicated that the CMLA model also had good calibration (Hosmer-Lemeshow P=0.323) and clinical utility in the test cohort. Kaplan-Meier analysis indicated significantly higher 28-day mortality in the high-risk CMLA group.

CONCLUSIONS

A clinically applicable nomogram with four key variables was developed to predict RRT risk in CS patients. It demonstrated good performance, promising enhanced clinical decision-making.

Impact of Inpatient Percutaneous Coronary Intervention Volume on 30-Day Readmissions After Acute Myocardial Infarction-Cardiogenic Shock

BACKGROUND

There are limited data on volume-outcome relationships in acute myocardial infarction (AMI) with cardiogenic shock (CS).

OBJECTIVES

In this study, the authors sought to evaluate the association between hospital percutaneous coronary intervention (PCI) volume and readmission after AMI-CS.

METHODS

Adult AMI-CS patients were identified from the Nationwide Readmissions Database for 2016-2019 and were categorized into hospital quartiles (Q1 lowest volume to Q4 highest) based on annual inpatient PCI volume. Outcomes of interest included 30-day all-cause, cardiac, noncardiac, and heart-failure (HF) readmissions.

RESULTS

There were 49,558 AMI-CS admissions at 3,954 PCI-performing hospitals. Median annual PCI volume was 174 (Q1-Q3: 70-316). Patients treated at Q1 hospitals were on average older, female, and with higher comorbidity burden. Patients at Q4 hospitals had higher rates of noncardiac organ dysfunction, complications, and use of cardiac support therapies. Overall, 30-day readmission rate was 18.5% (n = 9,179), of which cardiac, noncardiac, and HF readmissions constituted 56.2%, 43.8%, and 25.8%, respectively. From Q1 to Q4, there were no differences in 30-day all-cause (17.6%, 18.4%, 18.2%, 18.7%; P = 0.55), cardiac (10.9%, 11.0%, 10.6%, 10.2%; P = 0.29), and HF (5.0%, 4.8%, 4.8%, 4.8%; P = 0.99) readmissions. Noncardiac readmissions were noted more commonly in higher quartiles (6.7%, 7.4%, 7.7%, 8.5%; P = 0.001) but was not significant after multivariable adjustment. No relationship was noted between hospital PCI volume as a continuous variable and readmissions.

CONCLUSIONS

In AMI-CS, there was no association between hospital annual PCI volume and 30-day readmissions despite higher acuity in the higher volume PCI centers suggestive of better care pathways for CS at higher volume centers.

Cardiac power output ratio: Novel survival predictor after percutaneous ventricular assist device in cardiogenic shock

AIMS

Currently, there is limited data on prognostic indicators after insertion of percutaneous ventricular assist device (PVAD) in the treatment of cardiogenic shock (CS). This study evaluated the prognostic role of cardiac power output (CPO) ratio, defined as CPO at 24 h divided by early CPO (30 min to 2 h), in CS patients after PVAD.

METHODS AND RESULTS

Consecutive CS patients from the QEH-PVAD Registry were followed up for survival at 90 days after PVAD. Among 121 consecutive patients, 98 underwent right heart catheterization after PVAD, with CPO ratio available in 68 patients. The CPO ratio and 24-h CPO, but not the early CPO post PVAD, were significantly associated with 90-day survival, with corresponding area under curve in ROC analysis of 0.816, 0.740, and 0.469, respectively. In multivariate analysis, only the CPO ratio and lactate level at 24 h remained as independent survival predictors. The CPO ratio was not associated with age, sex, and body size. Patients with lower CPO ratio had significantly lower coronary perfusion pressure, worse right heart indices, and higher pulmonary vascular resistance. A lower CPO ratio was also significantly associated with mechanical ventilation and higher creatine kinase levels in myocardial infarction patients.

CONCLUSION

In post-PVAD patients, the CPO ratio outperformed the absolute CPO values and other haemodynamic metrics in predicting survival at 90 days. Such a proportional change of CPO over time, likely reflecting native heart function recovery, may help to guide management of CS patients post-PVAD.

Imaging in acute percutaneous mechanical circulatory support in adults: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC and the European branch of the Extracorporeal Life Support Organization (EuroELSO)

The use of temporary mechanical circulatory support (tMCS) in cardiogenic shock patients has increased during the last decades with most management strategies relying on observational studies and expert opinion, including hemodynamic monitoring, device selection, and timing of support institution/duration. In this context, imaging has a pivotal role throughout the patient pathway, from identification to initiation, monitoring, and weaning. This manuscript summarizes the consensus of an expert panel from the European Society of Cardiology Association for Acute CardioVascular Care, the European Association of CardioVascular Imaging, and the European Extracorporeal Life Support Organization, providing the rationale for and practical guidance of imaging to tMCS based on existing evidence and consensus on best current practice.

Impact of Left Ventricular Venting on Acute Brain Injury in Patients with Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis

Background

While left ventricular (LV) venting reduces LV distension in cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO), it may also amplify risk of acute brain injury (ABI). We investigated the hypothesis that LV venting is associated with increased risk of ABI. We also compared ABI risk of the two most common LV venting strategies, percutaneous microaxial flow pump (mAFP) and intra-aortic balloon pump (IABP).

Methods

The Extracorporeal Life Support Organization registry was queried for patients on peripheral VA-ECMO for cardiogenic shock (2013-2024). ABI was defined as hypoxic-ischemic brain injury, ischemic stroke, or intracranial hemorrhage. Secondary outcome was hospital mortality. We compared no LV venting with 1) LV venting, 2) mAFP, and 3) IABP using multivariable logistic regression. To compare ABI risk of mAFP vs. IABP, propensity score matching was performed.

Results

Of 13,276 patients (median age=58.2, 69.9% male), 1,456 (11.0%) received LV venting (65.5% mAFP and 29.9% IABP), and 525 (4.0%) had ABI. After multivariable regression, LV-vented patients had increased odds of ABI (adjusted odds ratio (aOR)=1.76, 95% CI=1.29, 2.37, p<0.001) but no difference in mortality (aOR=1.08, 95% CI=0.91-1.28, p=0.39) compared to non-LV-vented patients. In the propensity- matched cohort of IABP (n=231) vs. mAFP (n=231) patients, there was no significant difference in odds of ABI (aOR=1.35, 95%CI=0.69-2.71, p=0.39) or mortality (aOR=0.88, 95%CI=0.58-1.31, p=0.52).

Conclusions

LV venting was associated with increased odds of ABI but not mortality in patients receiving peripheral VA-ECMO for cardiogenic shock. There was no difference in odds of ABI or mortality for IABP vs. mAFP patients.

Clinical Perspective

In patients receiving peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock, left ventricular venting is associated with increased odds of acute brain injury (ABI) but not mortality. However, mode of venting-intra-aortic balloon pump (IABP) or percutaneous microaxial flow pump (mAFP)-does not appear to impact either odds of ABI or mortality. These findings highlight a link between venting strategies and neurological outcomes in this high-risk population. Clinicians must weigh the benefits of venting against ABI risk when managing neurocritically ill patients, though our findings provide reassurance clinicians that both IABP and mAFP may offer comparable neurologic safety profiles.

Pragmatic approach to temporary mechanical circulatory support in acute right ventricular failure

Acute right ventricular failure (RVF) is prevalent in multiple disease states and is associated with poor clinical outcomes. Right-sided temporary mechanical circulatory support (tMCS) devices are used to unload RV congestion and increase cardiac output in cardiogenic shock (CS) with hemodynamically significant RVF. Several RV-tMCS device platforms are available; however consensus is lacking on patient selection, timing of escalation to RV-tMCS, device management, and device weaning. The purposes of this review are to 1) describe the current state of tMCS device therapies for acute RVF with CS, 2) discuss principles of escalation to RV-tMCS device therapy, 3) examine important aspects of clinical management for patients supported by RV-tMCS devices including volume management, anticoagulation, and positive pressure ventilation, and 4) provide a framework for RV-tMCS weaning.

Identifying and mitigating risk of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy

OBJECTIVES

To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function.

METHODS

From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors.

RESULTS

Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min-1 m-2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group.

CONCLUSIONS

Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock.

Versatility of Impella® Ventricular Assist Devices in High-risk Cardiac Patients During Complex Procedures: A Case Series

High-risk cardiac patients undergoing complex electrophysiology procedures face potential hemodynamic instability, necessitating effective mechanical circulatory support. The catheter-based Impella® ventricular assist device (Abiomed, Danvers, MA, USA) is crucial to stabilizing hemodynamics by improving the flow of blood from the left ventricle to the aorta. Its automated controller ensures cerebral hemodynamic stability, allowing for bedside adjustments. Herein, we present a case series illustrating the versatility of the Impella® device in managing patients during complex electrophysiology procedures and highlighting its role in mitigating hemodynamic compromise.

Blueprint for Building and Sustaining a Cardiogenic Shock Program: Qualitative Survey of 12 US Programs

Background

Multidisciplinary cardiogenic shock (CS) programs have been associated with improved outcomes, yet practical guidance for developing a CS program is lacking.

Methods

A survey on CS program development and operational best practices was administered to 12 institutions in diverse sociogeographic regions and practice settings. Common steps in program development were identified.

Results

Key steps for program development were identified: measuring baseline outcomes; identifying subspecialty champions; gaining leadership and team buy-in; developing institution-specific CS protocols; educating staff and referring providers; consulting with external experts; and developing quality assessment and process improvement.

Conclusions

An assessment of 12 US CS programs highlights a blueprint for establishing and maintaining a successful, multidisciplinary shock program.

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

DISCLAIMER

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

PURPOSE

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

SUMMARY

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

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.