Advances in the Management of Cardiogenic Shock

Association of triglyceride-glucose-body mass index with all-cause mortality among individuals with cardiovascular disease: results from NHANES

Background

The objective of this study was to explore the relationship between the triglyceride-glucose-body mass index (TyG-BMI) and all-cause mortality rate and to determine valuable predictive factors for the survival status of patients with cardiovascular disease (CVD).

Methods

Conduct a study on CVD patients in the NHANES database from 2007 to 2016. Patients were divided into four groups based on the weighted quartiles of TyG-BMI. Kaplan-Meier curves, Cox regression, and restricted cubic spline (RCS) were used to analyze the correlation between this index and all-cause mortality. Receiver operating characteristic (ROC) curves were used to evaluate its predictive ability, sensitivity, and specificity.

Results

This study included 1085 patients, and revealed significant differences in survival rates among patients with different TyG-BMI levels. Patients in the higher TyG-BMI group have a lower mortality risk, yet there is no evident non-linear relationship. The ROC curve indicates that this indicator can serve as a predictive value for mortality in CVD patients, demonstrating good sensitivity and specificity.

Conclusion

This study found a significant association between TyG-BMI index and all-cause mortality in patients with CVD. TyG-BMI can be used as a predictive indicator of all-cause mortality in CVD patients.

Biventricular dysfunction predicts mortality in ST elevation myocardial infarction patients with cardiogenic shock

BACKGROUND

The incidence of mortality in patients with cardiogenic shock due to ST elevation myocardial infarction (STEMI) remains high even with prompt reperfusion therapy. Ventricular systolic dysfunction is the primary condition causing cardiogenic shock in STEMI. Studies have been widely conducted on the left ventricle (LV) and right ventricle (RV) systolic dysfunction related to mortality events. However, the parameters of biventricular systolic dysfunction predicting mortality as a stronger predictor of mortality are still unclear. Accordingly, we evaluated the predictor mortality value of biventricular systolic dysfunction in STEMI patients with cardiogenic shocks. Based on The Society for Cardiovascular Angiography and Intervention classification, we analyzed data from November 2021 to September 2023 at Dr. Sardjito General Hospital in Yogyakarta, Indonesia, using the Sardjito Cardiovascular Intensive Care (SCIENCE) registry with a retrospective cohort design. Multivariate logistic regression analysis was used to assess predictors of in-hospital mortality.

RESULTS

There were 1,059 subjects with a mean ± SD age of 59 ± 11 years, dominated by men (80.5%) who met the inclusion and exclusion criteria. Based on multivariate analysis, biventricular dysfunction (BVD) is a factor that significantly increases the risk of in-hospital mortality (Odds ratio [OR], 1.771: 95% confidence interval [CI] 1.113-2.819; p = 0.016). Other significant factors affecting mortality were renal failure (OR, 5.122; 95% CI 3.233-8.116; p < 0.001), percutaneous coronary intervention (PCI) (OR, 0.493; 95% CI 0.248-0.981; p = 0.044), and inotropic/vasopressor (OR, 6.876; 95% CI 4.583-10.315; p < 0.001).

CONCLUSIONS

Biventricular dysfunction significantly increases the risk of in-hospital mortality in STEMI patients with cardiogenic shock. Renal failure, PCI, and the requirement for inotropic or vasopressor drugs are also factors that influence in-hospital mortality.

Invasive Arterial BP Measurements in the Emergency Department-When, if Ever, is it Indicated?

PURPOSE OF REVIEW

Extremes of blood pressure (BP) are common among patients that visit emergency departments. In this review article, we discuss the specific indications for invasive blood pressure monitoring in the ED, particularly in the context of undifferentiated shock and hypertensive emergencies.

RECENT FINDINGS

In most cases, non-invasive techniques suffice for blood pressure monitoring, however, in certain patient presentations intermittent automated oscillometry bears significant drawbacks. The most evident drawback is the extended intervals between measurements. Invasive BP (IBP) monitoring offers a pivotal tool for patients with critical illness who require accurate, timely, blood pressure monitoring and indirectly monitors for complications involving vital organ systems. In the management of patients with critical illness or at risk for end organ injury, invasive methods that directly measure BP via arterial cannulation continues to be an established standard. Overall, evaluating patients on an individual basis, with the understanding that patients who present with extreme blood pressure values need closer monitoring, should prompt consideration of invasive methods of blood pressure monitoring.

A practical approach to the diagnosis and initial management of acute right ventricular failure during pregnancy using point-of-care ultrasound

Acute right ventricular failure is a critical condition in pregnancy that can lead to severe maternal and fetal complications. This expert review discusses the instrumental role of point-of-care ultrasound in diagnosing and managing ARVF in pregnant patients, highlighting its benefits for immediate clinical decision-making in obstetric emergencies. The unique physiological changes during pregnancy, such as increased blood volume and cardiac output, can exacerbate underlying or latent cardiac issues, making pregnant patients particularly susceptible to acute right ventricular failure. Common causes during pregnancy include pulmonary embolism, peripartum cardiomyopathy, and congenital heart diseases, each presenting distinct challenges in diagnosis and management. The real-time capability of point-of-care ultrasound allows for the immediate assessment of right ventricular size and function, evaluation of fluid status via the inferior vena cava, and identification of potential pulmonary embolism, offering a non-invasive, rapid, and dynamic diagnostic tool right at the bedside. The expert review details specific point-of-care ultrasound techniques adapted for pregnant patients, including the parasternal long and short axis and apical 4-chamber view, essential for evaluating right heart function and guiding acute management strategies. These include fluid management, adjustment of pharmacological treatment, and immediate interventions to support cardiac function and reduce ventricular overload. Point-of-care ultrasound enhances clinical outcomes by allowing clinicians to make informed decisions quickly, reducing the time to intervention, and tailoring management strategies to individual patient needs. However, despite its apparent advantages, the adoption of point-of-care ultrasound requires specialized training and familiarity with obstetric-specific protocols. This review advocates for the integration of point-of-care ultrasound into standard obstetric care protocols, emphasizing the need for clear guidelines and structured protocols that equip healthcare providers with the skills necessary to utilize this technology effectively. Future research should aim to refine these protocols and expand the evidence base to solidify the role of point-of-care ultrasound in improving maternal and fetal outcomes in acute right ventricular failure.

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.

Long-term outcomes of cardiogenic shock and cardiac arrest complicating ST-elevation myocardial infarction according to timing of occurrence

Aims

Cardiogenic shock (CS) and cardiac arrest (CA) are serious complications in ST-elevation myocardial infarction (STEMI) patients, with lack of long-term data according to their timing of occurrence. This study sought to determine the incidence and relationship between the timing of occurrence and prognostic impact of CS and CA complicating STEMI in the long-term follow-up.

Methods and results

We conducted a retrospective analysis of consecutive STEMI patients treated between 2004 and 2017. Patients were divided into four groups based on the occurrence of neither CA nor CS, CA only, CS only, and both CA and CS (CA-CS-, CA+, CS+, and CA+CS+, respectively). Adjusted Cox regression analysis was used to assess the independent association between the CS and CA categories and mortality. A total of 1603 STEMI patients were followed for a median of 3.6 years. CA and CS occurred in the 12.2% and 15.9% of patients, and both impacted long-term mortality [adjusted hazard ratio (HR) = 2.59, 95% confidence interval (CI): 1.53-4.41, P < 0.001; HR = 3.16, 95% CI: 2.21-4.53, P < 0.001, respectively). CA+CS+ occurred in 7.3%, with the strongest association with higher mortality (adjusted HR = 5.36; 95% CI: 3.80-7.55, P < 0.001). Using flexible parametric models with B-splines, the increased mortality was restricted to the first ∼10 months. In addition, overall mortality rates were higher at all timings (all with P < 0.001), except for CA during initial cardiac catheterization (P < 0.183).

Conclusion

CS and CA complicating patients presenting with STEMI were associated with higher long-term mortality rate, especially in the first 10 months. Both CS+ and CA+ at any timeframe impacted outcomes, except for CA+ during the initial cardiac catheterization, although this will have to be confirmed in larger future studies, given the relatively small number of patients.

Cardiogenic Shock Challenges and Priorities: A Clinician Survey

BACKGROUND

Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia's geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described.

METHOD

We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities.

RESULTS

There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required.

CONCLUSIONS

Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value.

ICU management of cardiogenic shock before mechanical support

PURPOSE OF REVIEW

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS).

RECENT FINDINGS

Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock.

SUMMARY

Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

The medical treatment of cardiogenic shock

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

Association between triglyceride glucose-body mass index and all-cause mortality in critically ill patients with acute myocardial infarction: retrospective analysis of the MIMIC-IV database

Background

Insulin resistance (IR) is closely related to the development of cardiovascular diseases. Triglyceride-glucose-body mass index (TyG-BMI) has been proven to be a reliable surrogate of IR, but the relationship between TyG-BMI and acute myocardial infarction (AMI) is unknown. The present study aims to determine the effects of TyG-BMI on the clinical prognosis of critically ill patients with AMI.

Methods

The data of AMI patients were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. All patients were divided into four groups according to the TyG-BMI quartile. Outcomes were defined as 30-, 90-, 180-, and 365-day all-cause mortality. Kaplan-Meier (K-M) curve was used to compare survival rate between groups. Meanwhile, Cox regression analysis and restricted cubic splines (RCS) were used to explore the relationship between TyG-BMI index and outcome events.

Results

A total of 1,188 critically ill patients with AMI were included in this study. They were divided into four groups according to TyG-BMI quartiles, there were significant differences in 90-, 180-, and 365-day all-cause mortality while there was no difference in 30-day all-cause mortality. Interestingly, with the increase of TyG-BMI, the 90-, 180-, and 365-day survival rate increased first and then gradually decreased, but the survival rate after decreasing was still higher than that in the group with the lowest TyG-BMI. U-shaped relationships between TyG-BMI index and 90-, 180-, and 365-day all-cause mortality were identified using RCS curve and the inflection point was 311.1, 316.5, and 320.1, respectively, whereas the TyG-BMI index was not non-linearly associated with 30-day all-cause mortality. The results of Cox proportional hazard regression analysis are consistent with those of RCS analysis.

Conclusion

U-shaped relationships are existed between the TyG-BMI index and 90-, 180-, and 365-day all-cause mortality in critically ill patients with AMI, but not 30-day all-cause mortality. The TyG-BMI index can be used as an effective index for early prevention of critically ill patients with AMI.

Application of Cardiovascular Physiology to the Critically Ill Patient

OBJECTIVES

To use the ventricular pressure-volume relationship and time-varying elastance model to provide a foundation for understanding cardiovascular physiology and pathophysiology, interpreting advanced hemodynamic monitoring, and for illustrating the physiologic basis and hemodynamic effects of therapeutic interventions. We will build on this foundation by using a cardiovascular simulator to illustrate the application of these principles in the care of patients with severe sepsis, cardiogenic shock, and acute mechanical circulatory support.

DATA SOURCES

Publications relevant to the discussion of the time-varying elastance model, cardiogenic shock, and sepsis were retrieved from MEDLINE. Supporting evidence was also retrieved from MEDLINE when indicated.

STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS

Data from relevant publications were reviewed and applied as indicated.

CONCLUSIONS

The ventricular pressure-volume relationship and time-varying elastance model provide a foundation for understanding cardiovascular physiology and pathophysiology. We have built on this foundation by using a cardiovascular simulator to illustrate the application of these important principles and have demonstrated how complex pathophysiologic abnormalities alter clinical parameters used by the clinician at the bedside.

Cardiogenic shock as a health issue. Physiology, classification, and detection

Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.

A Case Report of Mycoplasma pneumoniae-induced fulminant myocarditis in a 15-year-old male leading to cardiogenic shock and electrical storm

Mycoplasma pneumoniae (M. pneumoniae) is a well-recognized pathogen primarily associated with respiratory tract infections. However, in rare instances, it can lead to extrapulmonary manifestations, including myocarditis. We present a case of a 15-year-old male who developed fulminant myocarditis, cardiogenic shock, and cardiac electrical storm attributed to M. pneumoniae infection. He underwent a combination of intra-aortic balloon pump (IABP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiac support, ultimately surviving despite the intracardiac thrombus formation and embolic stroke. Following comprehensive treatment and rehabilitation, he was discharged in stable condition. This case underscores the importance of considering atypical pathogens as potential etiological factors in patients presenting with cardiac complications, especially in the adolescents. It also emphasizes the need for clinical vigilance and effective support for potential cardiac complications arising from M. pneumoniae infection.

Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology

Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.

Outcomes of Patients With Cancer With Myocardial Infarction-Associated Cardiogenic Shock Managed With Mechanical Circulatory Support

Background

Cardiogenic shock (CS) is the leading cause of death among patients with acute myocardial infarction (AMI) and is managed with temporary mechanical circulatory support (tMCS) in advanced cases. Patients with cancer are at high risk of AMI and CS. However, outcomes of patients with cancer and AMI-CS managed with tMCS have not been rigorously studied.

Methods

Adult patients with AMI-CS managed with tMCS from 2006 to 2018 with and without cancer were identified using the National Inpatient Sample. Propensity score matching (PSM) was performed for variables associated with cancer. Primary outcome was in-hospital death, and secondary outcomes were major bleeding and thrombotic complications.

Results

After PSM, 1287 patients with cancer were matched with 12,870 patients without cancer. There was an increasing temporal trend for prevalence of cancer among patients admitted with AMI-CS managed with tMCS (P trend < .001). After PSM, there was no difference in in-hospital death (odds ratio [OR], 1.00; 95% CI, 0.88-1.13) or thrombotic complications (OR, 1.10; 95% CI, 0.91-1.34) between patients with and without cancer. Patients with cancer had a higher risk of major bleeding (OR, 1.29; 95% CI, 1.15-1.46).

Conclusions

Among patients with AMI-CS managed with tMCS, cancer is becoming increasingly frequent and associated with increased risk of major bleeding, although there was no difference in in-hospital death. Further studies are needed to further characterize outcomes, and inclusion of patients with cancer in trials of tMCS is needed.

In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019

BACKGROUND

Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS).

HYPOTHESIS

Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients.

METHODS

The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05).

RESULTS

We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints.

CONCLUSIONS

These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.