Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association

Mechanical circulatory support: when, how, and for whom

Cardiogenic shock represents a critical condition in which the heart is unable to maintain adequate circulation leading to insufficient tissue perfusion and end-organ failure. Temporary mechanical circulatory support offers the potential to stabilize patients, provide a bridge-to-recovery, provide a bridge-to-decision, or facilitate definitive heart replacement therapies. Although randomized controlled trials have been performed in infarct-related cardiogenic shock and refractory cardiac arrest, the optimal timing, appropriate patient selection, and optimal implementation of these devices remain complex and predominantly based on observational data and expert consensus, especially in non-ischaemic shock. This review explores the details of 'when, how, and for whom' temporary mechanical circulatory support devices should be used, examining specific clinical scenarios, the mechanisms by which they operate, and the patient populations that may benefit. The review also highlights the many gaps in evidence and need for better understanding of the interaction between human biology and these devices.

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).

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

ECLS-SHOCK and DanGer Shock: Implications for Optimal Temporary Mechanical Circulatory Support Use for Cardiogenic Shock Due to Acute Myocardial Infarction

Despite concerted efforts to rapidly identify patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS) and provide timely revascularization, early mortality remains stubbornly high. Although artificially augmenting systemic flow by using temporary mechanical circulatory support (tMCS) devices would be expected to reduce the rate of progression to multiorgan dysfunction and thereby enhance survival, reliable evidence for benefit has remained elusive with lingering questions regarding the appropriate selection of both patients and devices, as well as the timing of device implantation relative to other critical interventions. Further complicating matters are the resource-intensive multidisciplinary systems of care that must be brought to bear in this complex patient population. Until recently, studies of tMCS were extremely heterogeneous in design, populations treated, and timing of device implantation with regard to shock onset and revascularization. Attempts at summarizing the available data had resulted in a lack of clear benefit for any type of tMCS modality. On this background, 2 landmark trials of tMCS in the setting of AMI-CS---ECLS-SHOCK and DanGer Shock---have recently been published with divergent results that deserve detailed consideration. Thus, we provide a detailed narrative review of the current state of knowledge regarding tMCS for AMI-CS. The most common types of tMCS and related evidence are presented, as well as evidence for organizational considerations, such as the shock team. We also provide some insight into how this new evidence may be incorporated into practice and influence future research.

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

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

Veno-arterial ECMO support for severe amlodipine toxicity combined with cardiogenic shock: A case report

INTRODUCTION

Management of severe circulatory collapse in the setting of amlodipine toxicity can be challenging. High doses of vasopressors and conventional therapies fail to improve hemodynamics, resulting in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to treat severe cardiogenic shock and peripheral vasodilatation. Therapeutic plasma exchange (TPE), which helps remove plasma protein-bound toxins and significantly reduces mortality, may be a useful adjunct to invasive hemodynamic support in severe cases of amlodipine poisoning.

CASE SUMMARY

A 32-year-old female with a history of intentional consumption of ninety 5-mg amlodipine tablets (totaling 450 mg) was admitted to our intensive care unit (ICU) after 3 h. Her amlodipine serum concentration was 147 ng/mL. She presented with cardiogenic shock and fatal vasoplegia and received VA-ECMO and TPE. The patient was weaned off ECMO after 4 days and discharged home on Day 10 of hospitalization.

CONCLUSION

Amlodipine toxicity can result in severe cardiac failure with circulatory collapse. We describe the case of a patient with cardiovascular collapse who successfully bridged to recovery from refractory shock secondary to severe amlodipine toxicity as a result of ECMO and TPE treatment.

Association of the systemic immune-inflammation index with clinical outcomes in acute myocardial infarction patients with hypertension

BACKGROUND

A new indicator of immunological and inflammatory condition, the Systemic Immunoinflammatory Index (SII), has been linked to a bad prognosis in a number of disorders.

METHODS

Two thousand three hundred seventeen ICU patients were admitted with hypertension and acute myocardial infarction (AMI). Patients were grouped according to their baseline SII tertile number into Q1, Q2, and Q3 groups. The main outcomes were death from all causes at 30 days, 365 days, cardiogenic shock, and congestive heart failure.

RESULTS

The case fatality rate increases with increasing SII. The correlation between SII and 30-day all-cause mortality [hazard ratio (HR) 1.765, 95% confidence interval (CI) 1.330-2.343 (Q3 versus Q1 group)], 365-day all-cause mortality [HR 2.713, 95% CI 2.250-3.272 (Q3 versus Q1 group), HR 1.603, 95% CI 1.312-1.959 (Q3 vs. Q1 group)], congestive heart failure [odds ratio (OR) 1.255, 95% CI 1.006-1.565 (Q2 vs. Q1 group), OR 1.565, 95% CI 1.220-2.009 (Q3 vs. Q1 group)] and cardiogenic shock [OR 1.930. 95% CI 1.271-2.974 (Q2 vs. Q1 group)] were all validated. According to subgroup analysis, individuals who had chosen to have CABG surgery had a stronger correlation between SII and a worse outcome. According to Kaplan-Meier (K-M) survival curves, patients in the Q3 group with SII had the highest rates of morbidity and death. The RCS curves demonstrated an essentially linear connection between SII and 30 days, 365 days, and congestive heart failure even after controlling for covariates.

CONCLUSIONS

SII was substantially correlated with 30-day all-cause mortality, 365-day all-cause mortality, in-hospital congestive heart failure, and cardiogenic shock in patients who had both hypertension and acute myocardial infarction. In individuals with acute myocardial infarction and hypertension, a greater SII would be regarded as an independent risk factor for a higher death rate.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Geospatial Access to Extracorporeal Membrane Oxygenation in the United States

OBJECTIVES

To conduct a Geospatial Information System analysis of extracorporeal membrane oxygenation (ECMO) centers in the United States utilizing data from the U.S. Census Bureau to better understand access to ECMO care and identify potential disparities.

DESIGN

A cross-sectional descriptive and statistical analysis of geospatial access to ECMO-capable centers in the United States, accounting for demographic variables.

SETTING

The unit of analysis were U.S. Census block groups and demographic variables of interest obtained from the American Community Survey.

PATIENTS

Patients accounted for in the U.S. Census data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven percent of the U.S. population had direct access to ECMO-capable centers. Disparities were present, with Puerto Rico, Wyoming, North Dakota, and Alaska having no access. Poverty, increased age, and lower population density consistently correlated with limited access. We identified significant racial and ethnic disparities in the Midwest and Northeast.

CONCLUSIONS

While 67% of the U.S. population had access to ECMO-capable centers by ground transportation, significant disparities in access exist. These findings emphasize the need for thoughtful implementation of ECMO systems of care to ensure equitable access. Future work should focus on developing novel systems of care that increase access utilizing advanced technology, such as aeromedical transport services.

Impact of lactate levels on admission in STEMI patients with cardiogenic shock treated with IMPELLA

The concomitant use of IMPELLA and veno-arterial extracorporeal membrane oxygenation (V-A ECMO) (ECPELLA) has been increasingly used to treat severe cardiogenic shock. However, the relationship between severity of heart failure on admission and prognosis based on differences in the mechanical circulatory support (MCS) is not fully understood. This study evaluated the association between lactate levels on admission and clinical outcomes based on differences in MCS. We identified 852 patients (median age 71 years; 78% male) with cardiogenic shock due to ST-elevation myocardial infarction (STEMI) from the Japanese Registry for Percutaneous Ventricular Assist Devices. The primary endpoint was the in-hospital mortality rate. Additionally, patients were classified into three groups based on lactate levels according to the SCAI SHOCK classification for the assessment of in-hospital mortality: group 1 (lactate level < 2 mmol/L), group 2 (lactate level 2-8 mmol/L), and group 3 (lactate level ≥ 8 mmol/L). The in-hospital mortality rate was 41.8%. The rate of V-A ECMO combined with IMPELLA use was 37.6%. The in-hospital mortality rates of the IMPELLA alone and ECPELLA group were 30.1% and 61.3%, respectively. The median lactate level was significantly higher in non-survivors than in survivors (5.7 mmol/L vs. 3.5 mmol/L, p < 0.0001). The in-hospital mortality rate with IMPELLA alone was significantly higher in group 3 compared to groups 1 and 2; however, there was no difference in in-hospital mortality with ECPELLA among the three groups. A lactate cut-off value of 6.9 mmol/L showed the best discrimination for in-hospital mortality. Patients classified as the SCAI SHOCK stage E have a higher mortality rate with IMPELLA support alone. Further research is needed to optimize management strategies for this high-risk group.

Mixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions

This state-of-the-art review describes the potential etiologies, pathophysiology, and management of mixed shock in the context of a proposed novel classification system. Cardiogenic-vasodilatory shock occurs when cardiogenic shock is complicated by inappropriate vasodilation, impairing compensatory mechanisms, and contributing to worsening shock. Vasodilatory-cardiogenic shock occurs when vasodilatory shock is complicated by myocardial dysfunction, resulting in low cardiac output. Primary mixed shock occurs when a systemic insult triggers both myocardial dysfunction and vasoplegia. Regardless of the etiology of mixed shock, the hemodynamic profile can be similar, and outcomes tend to be poor. Identification and treatment of both the initial and complicating disease processes is essential along with invasive hemodynamic monitoring given the evolving nature of mixed shock states. Hemodynamic support typically involves a combination of inotropes and vasopressors, with few data available to guide the use of mechanical circulatory support. Consensus definitions and novel treatment strategies are needed for this dangerous condition.

Timing of veno-arterial extracorporeal membrane oxygenation support in patients with cardiogenic shock

AIMS

The optimal timing for implementing mechanical circulatory support (MCS) in cardiogenic shock (CS) remains indeterminate. This study aims to evaluate patient characteristics and outcome associated with the time interval between CS onset and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implementation.

METHODS AND RESULTS

In this study, patients with CS treated with MCS at 15 tertiary care centres in three countries were enrolled. Patients treated with MCS were stratified into early (<2 h), intermediate (2-12 h) and delayed (≥12-24 h) MCS implantation by using the time interval between CS onset and MCS device implementation. Adjusted logistic and Cox regression models were fitted to assess the association between timing of MCS implementation, patient characteristics and 30-day mortality. A total of 330 patients with CS treated with VA-ECMO and/or microaxial flow pump were included in this study; 20.9% received early, 55.8% intermediate, and 23.3% delayed MCS. Although crude 30-day mortality was slightly lower in patients with early MCS (58.1% vs. 64.7% vs. 64.3%), adjusted analyses showed no significant association between timing of MCS implantation and 30-day all-cause mortality (hazard ratio [HR] for early vs. intermediate MCS: 0.93, 95% confidence interval [CI] 0.59-1.46, p = 0.74; HR for early vs. delayed MCS: 1.29, 95% CI 0.78-2.13, p = 0.33). Moreover, the incidence of complications, related and unrelated to MCS, did not differ significantly among groups.

CONCLUSION

In this exploratory study of patients with CS treated with MCS, the timing of device implantation within 24 h after CS onset was not associated with mortality. This supports a restrictive MCS approach, reserving its application for patients experiencing CS deterioration despite conventional therapy.

Burden and predictors of mortality related to cardiogenic shock in the South Bronx Population

OBJECTIVES

Cardiogenic shock is a significant economic burden on healthcare facilities and patients. The prevalence and outcome of cardiogenic shock in the South Bronx are unknown. The aim of the study was to examine the burden of non-AMI CS in Hispanic and Black population in South Bronx and characterize their in-hospital outcomes.

METHODS

We reviewed patient charts between 1/1/2022 and 1/1/2023 to identify patients with a primary diagnosis of cardiogenic shock (ICD codes R57.0, R57, R57.8, R57.9) residing in the following zip codes: 10451-59 and 10463. Student's T-test was used to assess differences for continuous variables; chi-square statistic was used for categorical variables. A logistic regression analysis model was used to assess independent predictors of mortality. A P-value of < 0.05 was considered significant.

RESULTS

87 patients were admitted with cardiogenic shock (60% African American, 67% male, mean age =62±15 years) of which 54 patients (62%) died. Those who died were older, had > 1 pressor, out-of-hospital arrest, arrested within 24 hours of admission, and had higher SCAI class, lactate, and ALT levels than those who were discharged. The logistic regression analysis model showed that older age ((RR=3.4 [95% CI: 3.3-3.45]), > 1 pressor (RR=3.4 [95% CI: 2.6-4.2]) and higher SCAI class (2.1 [95% CI: 1.5-2.1], all P < 0.05)) were independent predictors of mortality in patients with cardiogenic shock. Additionally, most of the patients had either Medicare or Medicaid insurance in predominantly African American study population.

CONCLUSIONS

Cardiogenic shock carries a significant risk of death. Factors such as advanced age, the administration of more than one vasopressor, and a higher SCAI classification have been identified as independent predictors of mortality among inpatients with cardiogenic shock. Additionally, the progression and outcomes of the condition are influenced by variables like race (e.g., African American individuals in this study) and economic challenges, including the type of insurance coverage (e.g., Medicaid or Medicare). Further research is essential to explore strategies that could enhance survival rates in cardiogenic shock patients, with a particular focus on addressing economic and racial disparities.

Mechanical circulatory support in cardiogenic shock patients

Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.

The Effect of Percutaneous Coronary Intervention on Patients with Acute Myocardial Infarction and Cardiogenic Shock Supported by Extracorporeal Membrane Oxygenation

Background

Patients suffering from acute myocardial infarction complicated by cardiogenic shock (AMICS), who undergo veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy, typically exhibit high mortality rates. The benefits of percutaneous coronary intervention (PCI) in these patients remains unclear. This study aims to investigate whether PCI can mitigate mortality among patients with AMICS supported by ECMO.

Methods

Data from patients ≥18 years, who underwent VA-ECMO assistance in China between January 1, 2017, and June 30, 2022, were retrieved by searching the Chinese Society of Extracorporeal Life Support (CSECLS) Registry. A total of 1623 patients were included and categorised based on whether they underwent PCI. Using propensity score matching, 320 patient pairs were successfully matched. The primary outcome was in-hospital mortality rate. The secondary outcomes included VA-ECMO duration, Hospital stay, ECMO weaning and ECMO related complications.

Results

In the cohort of 1623 patients, 641 (39.5%) underwent PCI. Upon conducting multivariate logistic regression analysis, it was observed that those who underwent PCI had a lower prevalence of hyperlipidemia (13.1% versus [vs.] 17.8%), chronic respiratory disease (2.5% vs. 4.3%) and lower lactic acid (5.90 vs. 8.40). They also had a more significant history of PCI (24.8% vs. 19.8%) and were more likely to be smokers (42.6% vs. 37.0%). Patients in the PCI group exhibited lower in-hospital mortality before and after matching (40.3% vs. 51.6%; p = 0.005), which persisted in multivariable modeling (adjusted odds ratio [aOR]: 0.69; 95% confidence interval 0.50-0.95; p = 0.024). Patients who received PCI were more successfully weaned from ECMO (88.6% vs. 75.8% before matching). PCI was not a risk factor for ECMO related complications.

Conclusions

Among patients who received ECMO support for AMICS, PCI was associated with a lower rate of in-hospital mortality.

Effect of a patient health engagement (PHE) model on rehabilitation participation in patients with acute myocardial infarction after PCI: a study protocol for a randomized controlled trial

BACKGROUND

Participation in cardiac rehabilitation is low in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Although existing rehabilitation methods have achieved certain results, patient participation in exercise rehabilitation is not ideal. The Patient Health Engagement (PHE) model is designed to ensure that patients improve their participation in cognitive, emotional, behavioral, and other aspects in all phases of exercise rehabilitation. The purpose of this study is to confirm whether the rehabilitation method based on the PHE model improves the rate of patient participation and enhances the rehabilitation effect during cardiac rehabilitation in patients with acute myocardial infarction compared with the traditional rehabilitation model.

METHODS/DESIGN

This is a single-center, double-blind, randomized, controlled trial that will enroll 128 patients. Patients with stable acute myocardial infarction after undergoing PCI who received cardiac rehabilitation and postoperative LVEF ≥ 40%, categorized into Killip class I ~ II and with age ≥ 18 years, will be included in the study. Exclusion criteria are mainly malignant arrhythmias, acute heart failure, congestive heart failure, and patients requiring intra-aortic balloon counterpulsation. Patients will be randomized in a 1:1 ratio to the intervention (1) and control (2) groups. Physicians, rehabilitation specialists, patients, and data collectors will be blinded during the study. A rehabilitator and a specialist nurse will conduct the cardiac rehabilitation. The specialist nurse will hand over the sealed bag containing patient information (group 1 or 2) to the physician. Group 1 will undergo cardiac rehabilitation through the PHE model, three times a week for 3 months. The rehabilitation program will be evaluated and adjusted in time from each period of the rehabilitation. Group 2 will be treated with routine cardiac rehabilitation. The rehabilitation participation rate of the two groups will be evaluated before and after 3 months of intervention. The primary outcome will be the level of patient participation in rehabilitation, and the secondary outcome will include general data of patients, postoperative rehabilitation indicators, cardiac rehabilitation knowledge-attitude-practice questionnaire, cardiovascular adverse events, and a brief mood scale.

EXPECTED OUTCOMES

We expect improved cardiac rehabilitation participation rates and rehabilitation outcomes in patients with acute myocardial infarction after undergoing PCI using the PHE model.

DISCUSSION

This approach may increase patient participation in rehabilitation, improve rehabilitation outcomes, and be widely implemented in hospitals and rehabilitation centers.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2400085276 (Version 2.0 June 04, 2024),  https://www.chictr.org.cn .

TRIAL SPONSOR

Shandong Second Medical university, Weifang, Shandong. Contact name: Dechun Qin, Address: Shandong Second Medical university, Weifang Shandong. Email: 13562666589@163.com.

Cardiogenic shock

Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock.

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

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

Prognostic Factors Associated with Mortality in Cardiogenic Shock - A Systematic Review and Meta-Analysis

BACKGROUND

Cardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock.

METHODS

We performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock.

RESULTS

We identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality.

CONCLUSIONS

This analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI

ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.

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.

Association between lactate/albumin ratio and 28-day all-cause mortality in critically ill patients with acute myocardial infarction

Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality worldwide. Early identification of high-risk patients is crucial for timely interventions and improved outcomes. The lactate/albumin ratio (LAR) has been suggest as a significant correlate for assessing the risk of mortality in critically ill patients. This study aimed to utilize the American eICU Collaborative Research Database to explore the association between baseline LAR and all-cause mortality within 28 days in ICU of critically ill patients diagnosed with AMI. We conducted a retrospective cohort study of 989 AMI patients from the eICU Collaborative Research Database. Patients were included based on ICD-9 code 410 and the universal definition of AMI. LAR was calculated as the ratio of baseline lactate to albumin levels within the first 24 h of ICU admission. The outcome was all-cause mortality within 28 days after ICU admission. Multivariable logistic regression models were used to evaluate the independent association between LAR and the risk of death, adjusting for potential confounders including demographics, comorbidities, vital signs, and laboratory parameters. Subgroup analyses and nonlinear modeling were performed to further explore the relationship. Of the 989 AMI patients, 171 (17.3%) died within 28 days after ICU admission. Patients who died had significantly higher LAR compared to survivors (1.66 vs. 0.96, p < 0.001). Multivariable analysis showed that each unit increase in LAR was associated with a 2.15-fold higher risk of all-cause mortality within 28 days after ICU admission (95% CI: 1.64-2.83, p < 0.001). Subgroup analyses confirmed the consistent association across different patient characteristics. Nonlinear modeling revealed a threshold effect, where LAR above 2.15 was no longer significantly associated with mortality. Kaplan-Meier survival analysis demonstrated lower survival probabilities for patients with higher LAR(1.0526-5.8235). The findings suggest that a higher LAR was associated with an increased risk of 28-day all-cause mortality for critically ill patients with AMI after ICU admission.

Hydrogel formulations for orthotopic treatment of myocardial infarction

INTRODUCTION

Myocardial infarction (MI) causes extensive structural and functional damage to the cardiac tissue due to the significant loss of cardiomyocytes. Early reperfusion is the standard treatment strategy for acute MI, but it is associated with adverse effects. Additionally, current therapies to alleviate pathological changes post-MI are not effective. Subsequent pathological remodeling of the damaged myocardium often results in heart failure. Oral drugs aimed at reducing myocardial damage and remodeling require repeated administration of high doses to maintain therapeutic levels. This compromises efficacy and patient adherence and may cause adverse effects, such as hypotension and liver and/or kidney dysfunction. Hydrogels have emerged as an effective delivery platform for orthotopic treatment of MI due to their high water content and excellent tissue compatibility.

AREA COVERED

Hydrogels create an optimal microenvironment for delivering drugs, proteins, and cells, preserving their efficacy and increasing their bioavailability. Current research focuses on discovering functional hydrogels for mitigating myocardial damage and regulating repair processes in MI treatment.

EXPERT OPINION

Hydrogels offer a promising approach in enhancing cardiac repair and improving patient outcomes post-MI. Advancements in hydrogel technology are poised to transform MI therapy, paving the way for personalized treatment strategies and enhanced recovery.

Frequency of Comfort Care and Palliative Care Consultation after ST-Elevation Myocardial Infarction

INTRODUCTION

ST-elevation myocardial infarction (STEMI) remains a leading cause of death despite advances in revascularization and post-STEMI care. Especially for patients with a poor prognosis, there is increasing emphasis on comfort-focused care.

METHODS

We conducted a single-center retrospective cohort study of patients with STEMI at a large tertiary care academic medical center, abstracting patient-level data, causes of death, and use of palliative care consultation from the medical records. We sought to investigate the frequency of comfort-focused approaches and palliative care consultation after STEMI.

RESULTS

A total of 536 patients presented with or were transferred with STEMI from January 2010 to July 2018, of whom 61/536 (11.4%) died during index hospitalization. Among those who underwent percutaneous intervention (PCI), the in-hospital mortality rate was 6.8%. Median (IQR) and time to death was two (0-6) days. Among those who died, 25/61 (41%) were treated with mechanical circulatory support (MCS). A total of 25/61 (41%) patients died following transition to a comfort-focused approach. Rate of MCS utilization during hospitalization was higher in the group that was ultimately transitioned to comfort-focused measures than the group who received full treatment measures. Palliative care was consulted in the case of 6/61 (9.8%) patients. Median time to consultation was 5 (1-7) days and time to death was 6.5 (2-28) days.

DISCUSSION

Transition to comfort-focused care before death after STEMI is common, particularly in those with cardiogenic shock and/or treated with MCS, highlighting the critical status of such patients. Although increasingly employed in recent years, palliative care consults remain rare and are often employed late in the hospitalization.

Construction of cirRNA-miRNA-mRNA network and MAPK1 protein signaling pathway in patients with valvular disease affected by artificial heart valve replacement surgery

The progress of modern medical technology has made artificial heart valve replacement an effective means to treat valvular disease, but the impact of cardiac function on patients after surgery is still a key issue. The purpose of this study was to construct the cirRNA-miRNA-mRNA network after artificial heart valve replacement in valvular disease patients, and to explore the regulatory mechanism related to MAPK1 protein, so as to reveal its potential role in affecting cardiac function. We downloaded cyclic cRNA expression profiles from the GEO database. Use the limma package to identify dec. WGCNA is used to identify key modules of circular rna. The target miRNAs of circular rna and the corresponding target genes of miRNAs were screened by ring intertome and target scan database. GO and KEGG analysis using the DAVID database. The genes associated with iron sag disease were derived from FerrDb database. The overlapping genes were obtained by Wien analysis. Next, the CircrNa-mirNa-mrna network was constructed based on the circRNA-miRNA pair and miRNA-mRNA pair and their cyclic landscape software. This study revealed the changes in the structure and expression of MAPK1 protein in the cirRNA-miRNA-mRNA network after artificial heart valve replacement in valvular disease patients, suggesting the potential role of MAPK1 protein in regulating cardiac function, and laying a foundation for further revealing its mechanism and clinical application.

Contemporary optimal therapeutic strategy with escalation/de-escalation of temporary mechanical circulatory support in patients with cardiogenic shock and advanced heart failure in Japan

The utilization of temporary mechanical circulatory support (MCS) in the management of cardiogenic shock is experiencing a notable surge. Acute myocardial infarction remains the predominant etiology of cardiogenic shock, followed by heart failure. Recent findings from the DanGer Shock trial indicate that the percutaneous micro-axial flow pump support, in conjunction with standard care, significantly reduced 6-month mortality in patients with acute myocardial infarction-related cardiogenic shock compared to those receiving standard care alone. However, real-world registry data reveal that the 30-day mortality among patients with acute myocardial infarction-related cardiogenic shock, who received concomitant veno-arterial extracorporeal membrane oxygenation support along with micro-axial flow pump, remain suboptimal. The persistent challenge in the field is how to incorporate, escalate, and de-escalate these temporary MCS to further improve clinical outcomes in such clinical scenarios. This review aims to elucidate the current practices surrounding the escalation and de-escalation of temporary MCS in real-world clinical settings and proposes considerations for future advancements in this critical area.

Abnormal expression of circ_0013958 in patients with acute myocardial infarction (AMI) and its influence on prognosis

OBJECTIVE

The purpose of this study was to investigate the diagnostic value of circ_0013958 in acute myocardial infarction (AMI) patients and its influence on the prognosis of AMI patients.

METHODS

The GSE160717 dataset was downloaded from the NCBI database and differentially expressed genes were analyzed between the control group and the AMI group. The up-regulated genes included circ_0013958. The expression of circ_0013958 in both groups was further verified by RT-qPCR. The Receiver Operating Characteristic curve was used to evaluate the diagnostic value of circ_0013958 in AMI. Pearson correlation analysis was used to examine the correlation between circ_0013958 levles and biochemical indicators. Binary logistic regression was used to analyze the risk factors affecting the occurrence of AMI. Prognostic analysis was performed using COX regression analysis and the Kaplan-Meier Curve.

RESULTS

Compared to the control group, the level of circ_0013958 in AMI patients increased. Circ_0013958 can effectively distinguish AMI patients from non-AMI patients. Circ_0013958 levels were positively correlated with cTnI, LDH, CRP and TC levels. The elevated level of circ_0013958 was an independent risk factor for the occurrence of AMI. Higher circ_0013958 levels were also associated with the occurrence of major adverse cardiac events (MACEs) in AMI patients. Additionally, elevated circ_0013958 levels reduced the survival probability of AMI patients.

CONCLUSION

Circ_0013958 levels were up-regulated in AMI patients. It can be used as a diagnosis biomarker for AMI. The level of circ_0013958 was correlated with the disease severity and was an independent risk factor for the occurrence of AMI. Elevated circ_0013958 levels were associated with poor prognosis in AMI patients.

Clinical Characteristics and Outcomes of Patients Suffering Acute Decompensated Heart Failure Complicated by Cardiogenic Shock

BACKGROUND

Cardiogenic shock (CS) can stem from multiple causes and portends poor prognosis. Prior studies have focused on acute myocardial infarction-CS; however, acute decompensated heart failure (ADHF)-CS accounts for most cases. We studied patients suffering ADHF-CS to identify clinical factors, early in their trajectory, associated with a higher probability of successful outcomes.

METHODS

Consecutive patients with CS were evaluated (N=1162). We studied patients who developed ADHF-CS at our hospital (N=562). Primary end point was native heart survival (NHS), defined as survival to discharge without receiving advanced HF therapies. Secondary end points were adverse events, survival, major cardiac interventions, and hospital readmissions within 1 year following index hospitalization discharge. Association of clinical data with NHS was analyzed using logistic regression.

RESULTS

Overall, 357 (63.5%) patients achieved NHS, 165 (29.2%) died, and 41 (7.3%) were discharged post advanced HF therapies. Of 398 discharged patients (70.8%), 303 (53.9%) were alive at 1 year. Patients with NHS less commonly suffered cardiac arrest, underwent intubation or pulmonary artery catheter placement, or received temporary mechanical circulatory support, had better hemodynamic and echocardiographic profiles, and had a lower vasoactive-inotropic score at shock onset. Bleeding, hemorrhagic stroke, hemolysis in patients with mechanical circulatory support, and acute kidney injury requiring renal replacement therapy were less common compared with patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS likelihood included younger age, history of systemic hypertension, absence of cardiac arrest or acute kidney injury requiring renal replacement therapy, lower pulmonary capillary wedge pressure and vasoactive-inotropic score, and higher tricuspid annular plane systolic excursion at shock onset (all P<0.05).

CONCLUSIONS

By studying contemporary patients with ADHF-CS, we identified clinical factors that can inform clinical management and provide future research targets. Right ventricular function, renal function, pulmonary artery catheter placement, and type and timing of temporary mechanical circulatory support warrant further investigation to improve outcomes of this devastating condition.

Artificial intelligence algorithms permits rapid acute kidney injury risk classification of patients with acute myocardial infarction

Objective

This study aimed to develop and validate several artificial intelligence (AI) models to identify acute myocardial infarction (AMI) patients at an increased risk of acute kidney injury (AKI) during hospitalization.

Methods

Included were patients diagnosed with AMI from the Medical Information Mart for Intensive Care (MIMIC) III and IV databases. Two cohorts of AMI patients from Changzhou Second People's Hospital and Xuzhou Center Hospital were used for external validation of the models. Patients' demographics, vital signs, clinical characteristics, laboratory results, and therapeutic measures were extracted. Totally, 12 AI models were developed. The area under the receiver operating characteristic curve (AUC) were calculated and compared.

Results

AKI occurred during hospitalization in 1098 (28.3 %) of the 3882 final enrolled patients, split into training (3105) and test (777) sets randomly. Among them, Random Forest (RF), C5.0 and Bagged CART models outperformed the other models in both the training and test sets. The AUCs for the test set were 0.754, 0.734 and 0.730, respectively. The incidence of AKI was 9.8 % and 9.5 % in 2202 patients in the Changzhou cohort and 807 patients in the Xuzhou cohort with AMI, respectively. The AUCs for patients in the Changzhou cohort were RF, 0.761; C5.0, 0.733; and bagged CART, 0.725, respectively, and Xuzhou cohort were RF, 0.799; C5.0, 0.808; and bagged CART, 0.784, respectively.

Conclusion

Several machines learning-based prediction models for AKI after AMI were developed and validated. The RF, C5.0 and Bagged CART model performed robustly in identifying high-risk patients earlier.

Clinical trial approval statement

This Trial was registered in the Chinese clinical trials registry: ChiCTR1800014583. Registered January 22, 2018 (http://www.chictr.org.cn/searchproj.aspx).

Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited.

METHODS

The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI.

RESULTS

After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07).

CONCLUSIONS

In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

Impact of symptom duration and mechanical circulatory support on prognosis in cardiogenic shock complicating acute myocardial infarction

BACKGROUND

Mortality rates in patients with cardiogenic shock complicating acute myocardial infarction (AMICS) remain high despite advancements in AMI care. Our study aimed to investigate the impact of prehospital symptom duration on the prognosis of AMICS patients and those receiving mechanical circulatory support (MCS).

METHODS AND RESULTS

We conducted a retrospective cohort study with data registered in the Netherlands Heart Registration. A total of 1,363 patients with AMICS who underwent percutaneous coronary intervention between 2017 and 2021 were included. Patients presenting after out-of-hospital cardiac arrest were excluded. Most patients were male (68%), with a median age of 69 years (IQR 61-77), predominantly presenting with ST-elevation myocardial infarction (86%). The overall 30-day mortality was 32%. Longer prehospital symptom duration was associated with a higher 30-day mortality with the following rates: < 3 h, 26%; 3-6 h, 29%; 6-24 h, 36%; ≥ 24 h, 46%; p < 0.001. In a subpopulation of AMICS patients with MCS (n = 332, 24%), symptom duration of > 24 h was associated with significantly higher mortality compared to symptom duration of < 24 h (59% vs 45%, p = 0.029). Multivariate analysis identified > 24 h symptom duration, age and in-hospital cardiac arrest as predictors of 30-day mortality in MCS patients.

CONCLUSION

Prolonged prehospital symptom duration was associated with significantly increased 30-day mortality in patients presenting with AMICS. In AMICS patients treated with MCS, a symptom duration of > 24 h was an independent predictor of poor survival. These results emphasise the critical role of early recognition and intervention in the prognosis of AMICS patients.

MicroRNA-15b promotes cardiac ischemia injury by the inhibition of Mitofusin 2/PERK pathway

MicroRNA and mitofusin-2 (Mfn2) play an important role in the myocardial apoptosis induced by acute myocardial infarction (AMI). However, the target relationship and underlying mechanism associated with interorganelle interaction between endoplasmic reticulum (ER) and mitochondria under ischemic condition is not completely clear. MI-induced injury, Mfn2 expression, Mfn2-mediated mitochondrial function and ER stress, and target regulation by miRNA-15b (miR-15b) were evaluated by animal MI and cellular hypoxic models with advanced molecular techniques. The results confirmed that Mfn2 was down-regulated and miR-15b was up-regulated upon the target binding profile under ischemic/hypoxic condition. Our data showed that miR-15b caused cardiac apoptotic injury that was reversed by rAAV9-anti-miR-15b or AMO-15b. The damage effect of miR-15b on Mfn2 expression and mitochondrial function was observed and rescued by rAAV9-anti-miR-15b or AMO-15b. The targeted regulation of miR-15b on Mfn2 was verified by luciferase reporter and microRNA-masking. Importantly, miR-15b-mediated Mfn2 suppression activated PERK/CHOP pathway, by which leads to ER stress and mitochondrial dysfunction, and cardiac apoptosis eventually. In conclusion, our research, for the first time, revealed the missing molecular link in Mfn2 and apoptosis and elucidated that pro-apoptotic miR-15b plays crucial roles during the pathogenesis of AMI through down-regulation of Mfn2 and activation of PERK-mediated ER stress. These findings may provide an opportunity to develop new therapies for prophylaxis and treatment of ischemic heart disease.

In-hospital cardiac arrest after STEMI: prevention strategies and post-arrest care

INTRODUCTION

In-Hospital Cardiac Arrest (IHCA) after ST-segment Elevation Myocardial Infarction (STEMI) is a subset of IHCA with high morbidity. While information on this selected group of patients is limited, closer inspection reveals that this is a challenging patient population with certain risk factors for IHCA following treatment of STEMI.

AREAS COVERED

In this review article, strategies for prevention of IHCA post STEMI are reviewed, as well as best-practices for the care of STEMI patients post-IHCA.

EXPERT OPINION

Early and successful reperfusion is key for the prevention of IHCA and has a significant impact on in-hospital mortality. A number of pharmacological treatments have also been studied that can impact the progression to IHCA. Development of cardiogenic shock post-STEMI increases mortality and raises the risk of cardiac arrest. The treatment of IHCA follows the ACLS algorithm with some notable exceptions.

What is cardiogenic shock? New clinical criteria urgently needed

PURPOSE OF REVIEW

Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods.

RECENT FINDINGS

Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure.

SUMMARY

Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.

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.

From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock

BACKGROUND

There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear.

METHODS

The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period.

RESULTS

The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372).

CONCLUSIONS

From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.

Hemodynamics with mechanical circulatory support devices using a cardiogenic shock model

Mechanical circulatory support (MCS) devices, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella, have been widely used for patients with cardiogenic shock (CS). However, hemodynamics with each device and combination therapy is not thoroughly understood. We aimed to elucidate the hemodynamics with MCS using a pulsatile flow model. Hemodynamics with Impella CP, VA-ECMO, and a combination of Impella CP and VA-ECMO were assessed based on the pressure and flow under support with each device and the pressure-volume loop of the ventricle model. The Impella CP device with CS status resulted in an increase in aortic pressure and a decrease in end-diastolic volume and end-diastolic pressure (EDP). VA-ECMO support resulted in increased afterload, leading to a significant increase in aortic pressure with an increase in end-systolic volume and EDP and decreasing venous reservoir pressure. The combination of Impella CP and VA-ECMO led to left ventricular unloading, regardless of increase in afterload. Hemodynamic support with Impella and VA-ECMO should be a promising combination for patients with severe CS.

Early temporary mechanical circulatory support for cardiogenic shock: Real-life data from a regional cardiac assistance network

BACKGROUND

Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network.

METHODS

Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality.

RESULTS

Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others with longer Intensive Care Unit and hospital stays.

CONCLUSIONS

In the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit.

Right Ventricular Myocardial Infarction-A Tale of Two Ventricles: JACC Focus Seminar 1/5

Right ventricular infarction (RVI) complicates 50% of cases of acute inferior ST-segment elevation myocardial infarction, and is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. RV systolic performance is generated by left ventricular contractile contributions mediated by the septum. Augmented right atrial contraction optimizes RV performance, whereas very proximal occlusions induce right atrial ischemia exacerbating hemodynamic compromise. RVI is associated with vagal mediated bradyarrhythmias, both during acute occlusion and abruptly with reperfusion. The ischemic dilated RV is also prone to malignant ventricular arrhythmias. Nevertheless, RV is remarkably resistant to infarction. Reperfusion facilitates RV recovery, even after prolonged occlusion and in patients with severe shock. However, in some cases hemodynamic compromise persists, necessitating pharmacological and mechanical circulatory support with dedicated RV assist devices as a "bridge to recovery."

RBM15 Protects From Myocardial Infarction by Stabilizing NAE1

RNA-binding proteins play multiple roles in several biological processes. However, the roles of RBM15-an important RNA-binding protein and a significant regulator of RNA methylation-in cardiovascular diseases remain elusive. This study aimed to investigate the biological function of RBM15 and its fundamental mechanisms in myocardial infarction (MI). Methylated RNA immunoprecipitation sequencing was used to explore the N6-methyladenosine (m6A) difference between MI and normal tissues. Our findings showed the elevated level of m6A in MI, and its transcription profile in both MI and normal tissues. RBM15 was the main regulator and its overexpression attenuated apoptosis in cardiomyocytes and improved cardiac function in mice after MI. Then, we used one target NEDD8 activating enzyme E1 subunit and its inhibitor (MLN4924) to investigate the impact of RBM15 targets on cardiomyocytes. Finally, the enhanced m6A methylation in the presence of RBM15 overexpression led to the increased expression and stability of NEDD8 activating enzyme E1 subunit. Our findings suggest that the enhanced m6A level is a protective mechanism in MI, and RBM15 is significantly upregulated in MI and promotes cardiac function. This study showed that RBM15 affected MI by stabilizing its target on the cell apoptosis function, which might provide a new insight into MI therapy.

Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia

OBJECTIVES

We aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock.

DESIGN

We conducted a population-based cohort study, where EMS-treated patients were individually linked to hospital-wide and state-wide administrative datasets. Direct healthcare costs (Australian dollars, AUD) were estimated for each element of care using a casemix funding method. The impact on productivity was assessed using a Markov state-transition model with a 3-year horizon.

SETTING

Patients older than 18 years of age with shock not related to trauma who received care by EMS (1 January 2015-30 June 2019) in Victoria, Australia were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome assessed was the total healthcare expenditure. Secondary outcomes included healthcare expenditure stratified by shock aetiology, years of life lived (YLL), productivity-adjusted life-years (PALYs) and productivity losses.

RESULTS

A total of 21 334 patients (mean age 65.9 (±19.1) years, and 9641 (45.2%) females were treated by EMS with non-traumatic shock with an average healthcare-related cost of $A11 031 per episode of care and total cost of $A280 million. Annual costs remained stable throughout the study period, but average costs per episode of care increased (Ptrend=0.05). Among patients who survived to hospital, the average cost per episode of care was stratified by aetiology with cardiogenic shock costing $A24 382, $A21 254 for septic shock, $A19 915 for hypovolaemic shock and $A28 057 for obstructive shock. Modelling demonstrated that over a 3-year horizon the cohort lost 24 355 YLLs and 5059 PALYs. Lost human capital due to premature mortality led to productivity-related losses of $A374 million. When extrapolated to the entire Australian population, productivity losses approached $A1.5 billion ($A326 million annually).

CONCLUSION

The direct healthcare costs and indirect loss of productivity among patients with non-traumatic shock are high. Targeted public health measures that seek to reduce the incidence of shock and improve systems of care are needed to reduce the financial burden of this syndrome.