Novel treatment strategies in cardiogenic shock: an update on ongoing clinical trials.

The utility of pulmonary artery catheterization (PAC) in treatment of cardiogenic shock (CS) is questionable. In this meta-analysis we aimed to evaluate the impact of PAC guided treatment on survival in CS patients. We performed a comprehensive literature search of multiple databases for studies that evaluated the clinical utility of PAC-guided management versus standard care for patients with CS. The primary outcome of interest was short-term mortality. The secondary outcomes were the use of mechanical circulatory support (MCS) and inotropes. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. A total of 9 studies including 364,001 patients with CS (29609 managed with PAC guided therapy vs. 334392 managed with slandered of care) were included in the final analysis. There was a significant difference in short-term mortality favoring PAC guided management (RR:0.83; 95% CI:0.76-0.92; P <0.00001). Standard of care guided management was associated with higher use of MCS and inotropic agents (RR:1.30; 95% CI:1.15-1.46; P <0.0001) and (RR:1.18; 95% CI:1.09-1.29; P <0.001) respectively. Our meta-analysis demonstrates that PAC-guided therapy for patients with CS was associated with lower short-term mortality and a lower likelihood to use MCS and inotropes with their potential associated complications. Further randomized clinical trials are needed to evaluate the utility of PAC as an adjunct tool in the management of CS.

OR7-1 | Use of Mechanical Circulatory Support for Cardiogenic Shock in Patients Undergoing Transcatheter Aortic Valve Replacement: A Nationwide Analysis from The Vizient Clinical Database

A continuous-flow external ventricular assist device for cardiogenic shock: Evolution over 10 years

Mushroom poisoning caused by the ingestion of Russula subnigricans has been reported to cause rhabdomyolysis and cardiac dysfunction, leading to death. There have been few reports of cardiogenic shock induced by mushroom poisoning that was successfully treated using mechanical circulatory support devices. A 38-year-old man presented with gastrointestinal symptoms a day after consuming a curry made with forest-collected mushrooms and was admitted with a diagnosis of rhabdomyolysis. Despite appropriate fluid management for severe rhabdomyolysis, the patient experienced anuria and cardiogenic shock with a remarkably reduced left ventricular ejection function, followed by the development of ventricular fibrillation. Mechanical support using Impella CP, veno-arterial extracorporeal membranous oxygenation (VA-ECMO), and continuous haemodiafiltration were administered for cardiogenic shock and severe rhabdomyolysis. His cardiac and renal function gradually improved, and the patient was successfully weaned off VA-ECMO on day 4, Impella CP on day 5, and renal replacement therapy on day 23. The left ventricular ejection fraction returned to normal without any neurological, respiratory, or renal sequelae. The remaining mushroom samples were identified as R. subnigricans by polymerase chain reaction testing. This is the first reported case of cardiogenic shock caused by R. subnigricans poisoning, successfully treated with Impella CP and VA-ECMO. The optimal use of mechanical circulatory support devices plays an important role in the treatment of cardiogenic shock caused by mushroom toxicity.

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43–0.57; p < 0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06–1.34; p < 0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51–0.72; p < 0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

The use of mechanical circulatory support (MCS) to provide acute haemodynamic support for cardiogenic shock or to support high-risk percutaneous coronary intervention (HRPCI) has grown over the past decade. There is currently no consensus on best practice regarding its use in these two distinct indications. Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. The authors outline technical specifications of the individual Impella heart pumps and their accompanying technology, the Automated Impella Controller and SmartAssist, their indications for use and patient selection, implantation techniques, device weaning and escalation, closure strategies, anticoagulation regimens, complications, future directions and upcoming trials.

Use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock.

On 3 legs shall we stand: Combined innovation for treatment of ischemic cardiomyopathy

Recent trends on outcomes in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) suggest improvements in early survival. However, with the ever-changing landscape in management of CS, we sought to identify age-based trends in these outcomes and mechanical circulatory support (MCS) use among patients with both AMI and non-AMI associated shock. We queried the 2005-2014 Nationwide Inpatient Sample databases to identify patients with a diagnosis of cardiogenic shock. Trends in the incidence of hospital-mortality, and use of MCS such as intra-aortic balloon pump (IABP), Impella/TandemHeart (IMP), and extra corporeal membrane oxygenation (ECMO) were analyzed within the overall population and among different age-categories (50 and under, 51-65, 66-80 and 81-99 years). We also made comparisons between patient groups admitted with CS complicating AMI and those with non-AMI associated CS. We studied 144,254 cases of CS, of which 55.4% cases were associated with an AMI. Between 2005 and 2014, an overall decline in IABP use (29.8-17.7%; ptrend < 0.01), and an uptrend in IMP use (0.1-2.6%; ptrend < 0.01), ECMO use (0.3-1.8%; ptrend < 0.01) and in-hospital mortality (44.1-52.5% AMI related, 49.6-53.5% non-AMI related; ptrend < 0.01) was seen. Patients aged 81-99 years had the lowest rate of MCS use (14.8%), whereas those aged 51-65 years had highest rate of MCS use (32.3%). Multivariable analysis revealed that patients aged 51-65 years (aOR 1.46, 95% CI 1.40-1.52; p<0.001), 66-80 years (aOR 2.51, 95% CI 2.39-2.63; p<0.01) and 81-99 years (aOR 5.04, 95% CI 4.78-5.32; p<0.01) had significantly higher hospital mortality compared to patients aged ≤ 50 years. Patients admitted with CS complicating AMI were older and had more comorbidities, but lower hospital mortality (45.0 vs. 48.2%; p < 0.001) when compared to non-AMI related CS. We also noted that the proportion of patients admitted with CS complicating AMI significantly decreased from 2005 to 2014 (65.3-45.6%; ptrend < 0.01) whereas those admitted without an associated AMI increased. IABP use has declined whereas IMP and ECMO use has increased over time among CS admissions. Older age was associated with an incrementally higher independent risk for hospital mortality. Recent trends indicate an increase in both proportion of patients admitted with CS without associated AMI and in-hospital mortality across all CS admissions irrespective of AMI status.

The adverse outcomes of a ventricular heart failure (left, right or biventricular) caused by cardiogenic shock are aggravated by lung oedema and organ mal perfusion. Despite advances in medical sciences, revascularisation and mechanical hemodynamic support have proved ineffective in reducing the mortality rate in such patients. A thorough study of the data available about cardio-vascular diseases reveals that the application of conventional methods of treatment are least helpful to practically restore normal functions of heart when it experiences end-stage systolic ventricular failure. Thus, to overcome the challenges and find alternatives to address this issue, percutaneous ventricular support devices/machines were designed and successfully introduced. These devices have revolutionized the treatment of ventricular heart failures and are now in use all over the world. In this review paper a newer mechanical circulatory support (MCS) device, Impella, has been discussed and compared with a few other devices like (Intra-aortic Balloon Pump (IABP), Extracorporeal Circulation (ECLS) and Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO). This article studies the challenges being faced during the treatment of cardiogenic shock, and thoroughly discusses the use and effectiveness of Impella Cardiac Axial Pump in each emergency. It can be said that mechanical circulatory support (MCS) device use during percutaneous coronary intervention (PCI) should be individualized based on multiple factors with a recommended use in patients with the greatest potential benefit and a relatively low risk of device-related complications. The current literature suggests that the outcomes of use of Impella and other mechanical circulatory support devices like IABP and VA-ECMO are comparable. Though there seem to be a few advantages of Impella over the others, sufficiently powered, multi-centric, randomised control trials are needed to establish its superiority.

To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock. A multicenter retrospective and prospective observational cohort study. The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study. None. Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up. High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation.

Background: Atrial fibrillation frequently complicates cardiogenic shock, yet optimal rhythm management remains unclear. Early cardioversion aims to restore sinus rhythm and improve hemodynamics, but its effect on outcomes in cardiogenic shock is not well defined. We evaluated the association between early cardioversion and clinical outcomes in patients hospitalized with concurrent atrial fibrillation and cardiogenic shock. Research Question/Hypothesis: What is the association between early cardioversion (within 2 days of hospitalization) and clinical outcomes in patients hospitalized with cardiogenic shock and atrial fibrillation?: Methods: We analyzed National Inpatient Sample data identifying adults with atrial fibrillation and cardiogenic shock using ICD-10 codes. Early cardioversion was defined as cardioversion within 2 days of admission. Survey-weighted multivariable logistic and linear regression models adjusted for demographics (age, sex, race) and hospital factors (region, teaching status, bed size) assessed associations with mortality, acute myocardial infarction, stroke, acute kidney injury, use of mechanical circulatory support, length of stay and hospital charges. Results: Among 23,703 patients with both cardiogenic shock and atrial fibrillation, 7.03% underwent early cardioversion. Compared to those without early cardioversion, these patients had shorter length of stay (mean 7.75 vs. 11.00 days, p&lt;0.001) and lower charges (mean $195,062 vs. $251,742, p&lt;0.001). Adjusted analyses showed no significant association with in-hospital mortality (OR 1.10, 95% CI 0.98–1.23, p=0.094). Early cardioversion was associated with higher odds of acute myocardial infarction (OR 1.16, p=0.005) and higher odds of use of mechanical circulatory support (OR 1.70, p &lt; 0.001) but lower odds of stroke (OR 0.73, p=0.028) and acute kidney injury (OR 0.87, p=0.011). Conclusions: Early cardioversion in cardiogenic shock patients with atrial fibrillation is associated with shorter hospitalizations, lower odds of stroke and acute kidney injury but higher odds of acute myocardial infarction and use of mechanical circulatory support. This suggests there may be increased risks in cardioverting patients early in cardiogenic shock. Prospective studies are needed to optimize rhythm management and identify appropriate patients for early cardioversion to improve outcomes in this high-risk population.

BackgroundWomen are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock.Main bodyCochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26–1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06–1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57–0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71–0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71–0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51–1.33, p = 0.42).ConclusionEven when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock. Particular attention is given to pharmacologic advances. Cardiogenic shock continues to occur in 5-10% of patients who suffer a myocardial infarction and the mortality remains over 50% in most studies. Treatment preference is referral to a cardiac center capable of reperfusion using multiple therapies. While no delay in reperfusion is acceptable, emphasis on implementing supportive treatment such as vasopressors, inotropes, and fluids remains critical. There is a wide variance in treatment standards despite established guidelines. Overall mortality from cardiogenic shock has decreased but the incidence remains unchanged. Emerging pharmacological interventions designed to counteract the underlying proinflammatory pathophysiologic mechanisms may, in combination with early revascularization, result in improved patient outcomes, but there is no magic bullet on the horizon. Attention to the timeliness of transport and treatment of patients with a focus on revascularization is required for cardiogenic shock patients.

Introduction: Although cardiogenic shock is a rare presentation in pregnant patients, recent advances in advanced heart failure improved the survival in this particular group. In this abstract, we will present the trend of mechanical circulatory support (MCS) use in pregnancy and its inpatient outcomes. Methods: We used the national inpatient sample database between 2016 and 2019 to select all pregnancy admissions who underwent mechanical circulatory support using the tenth revision international classification of diseases. Results: The trend of MCS use did not change significantly during the study period (Figure 1). Around 23.9% of patients died during the same admission. Patients who survived had a mean of 16 days of hospital stay. About 31% of patients were discharged home, 15.5% were discharged to skilled nursing facilities and 15.5% were discharged to short-term hospitals or rehab (Table 1 and 2) Conclusions: The trend of mechanical circulatory support use in pregnant patients did not change significantly during the study period. Around one fourth of patients died during the same admission.