Infarct-related Cardiogenic Shock Research Articles

Beyond one-size-fits-all in cardiogenic shock: impella, extracorporeal membrane oxygenation or tailored use of mechanical circulatory support?

This article offers an overview of recent randomized controlled trials (RCTs) testing the efficacy of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and microaxial flow pump (mAFP) in treating cardiogenic shock, including findings from the DanGer shock trial. It summarizes the clinical implications and limitations of these studies and key decision-making considerations for cardiogenic shock device use. Despite important limitations in all published RCTs, the routine use of VA ECMO for acute myocardial infarction related cardiogenic shock did not demonstrate benefit and should be reserved for selected patients with extreme forms of cardiogenic shock. Conversely, mAFP (Impella CP) appears promising for cardiogenic shock due to ST elevation myocardial infarction. A stepwise approach - initial mAFP use for cardiogenic shock with left ventricular failure, supplemented by VA ECMO if mAFP is inadequate or if severe right ventricular failure is present - may be preferable, but requires validation through RCTs. High complication rates in device arms underscore the need for careful patient selection, preventive strategies, education for centers and operators, and further research. Recent trials offer insights into mechanical circulatory support in cardiogenic shock, but their real-world applicability is limited. Despite potential benefits, the use of VA ECMO and mAFP is associated with significant complication rates, emphasizing the need for personalized use.

Residual ischaemia in acute myocardial infarction-related cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation: does complete revascularization hold the key?

Residual ischaemia in acute myocardial infarction-related cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation: does complete revascularization hold the key?

Balancing benefits and risks: the role of microaxial flow pumps in managing ST-segment elevation myocardial infarction-related cardiogenic shock

Balancing benefits and risks: the role of microaxial flow pumps in managing ST-segment elevation myocardial infarction-related cardiogenic shock

D-19 | Acute Myocardial Infarction-related Cardiogenic Shock Survivorship: A Pilot Study in Quality of Life

D-19 | Acute Myocardial Infarction-related Cardiogenic Shock Survivorship: A Pilot Study in Quality of Life

A randomized controlled trial of ivabradine in patients with acute myocardial infarction related cardiogenic shock.

. Acute myocardial infarction-related cardiogenic shock (AMI-CS) is often accompanied by tachycardia, which, in turn, increases myocardial oxygen consumption and hinders the use of ventricular assist devices, such as intra-aortic balloon pump. Evidence suggests that ivabradine may reduce heart rate (HR) without affecting other hemodynamic parameters. The aim of the present study was to determine the effect of ivabradine on reducing HR and changes in other hemodynamic parameters such as cardiac index (CI), in patients with AMI-CS and tachycardia. . A single-center, open label, randomized clinical trial included patients diagnosed with AMI-CS and tachycardia with >100 beats per minute (BPM). Heart rate, cardiac index, and other hemodynamic parameters measured by pulmonary flotation catheter were compared at 0, 6, 12, 24, and 48 hours after randomization. . A total of 12 patients were randomized; 6 received standard therapy, and 6 received ivabradine in addition to standard therapy. Baseline clinical characteristics were similar at randomization. A statistically significant lower heart rate was found at 12 hours (p=0.003) and 48 hours (p=0.029) after randomization, with differences of -23.3 (-8.2 to -38.4) BPM and -12.6 (-0.5 to -25.9) BPM, respectively. No differences in cardiac index, or any other evaluated hemodynamic parameters, length of hospital stay, nor mortality rate were noted between both groups. . The use of ivabradine in patients with AMI-CS was associated with a significant reduction in heart rate at 12 and 48 h, without affecting other hemodynamic parameters.

Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock

BackgroundThe effects of temporary mechanical circulatory support with a microaxial flow pump on mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock remains unclear.MethodsIn an international, multicenter, randomized trial, we assigned patients with STEMI and cardiogenic shock to receive a microaxial flow pump (Impella CP) plus standard care or standard care alone. The primary end point was death from any cause at 180 days. A composite safety end point was severe bleeding, limb ischemia, hemolysis, device failure, or worsening aortic regurgitation.ResultsA total of 360 patients underwent randomization, of whom 355 were included in the final analysis (179 in the microaxial-flow-pump group and 176 in the standard-care group). The median age of the patients was 67 years, and 79.2% were men. Death from any cause occurred in 82 of 179 patients (45.8%) in the microaxial-flow-pump group and in 103 of 176 patients (58.5%) in the standard-care group (hazard ratio, 0.74; 95% confidence interval [CI], 0.55 to 0.99; P=0.04). A composite safety end-point event occurred in 43 patients (24.0%) in the microaxial-flow-pump group and in 11 (6.2%) in the standard-care group (relative risk, 4.74; 95% CI, 2.36 to 9.55). Renal-replacement therapy was administered to 75 patients (41.9%) in the microaxial-flow-pump group and to 47 patients (26.7%) in the standard-care group (relative risk, 1.98; 95% CI, 1.27 to 3.09).ConclusionsThe routine use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. The incidence of a composite of adverse events was higher with the use of the microaxial flow pump. (Funded by the Danish Heart Foundation and Abiomed; DanGer Shock ClinicalTrials.gov number, NCT01633502.)

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

What's new in VA-ECMO for acute myocardial infarction-related cardiogenic shock.

What's new in VA-ECMO for acute myocardial infarction-related cardiogenic shock.

Second Edition of the German–Austrian S3 Guideline “Infarction-Related Cardiogenic Shock: Diagnosis, Monitoring and Treatment”

The mortality of patients with MI has significantly decreased in recent decades, mainly due to early reperfusion therapy with a probability of surviving of more than 90% if the patient reaches the hospital [...]

Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: A retrospective cohort study

PurposeManagement of dual antiplatelet therapy (DAPT) in patients on venoarterial-extracorporeal membrane (VA-ECMO) after acute myocardial infarction (AMI) is challenging. Our objective was to describe the frequency, management and outcomes of severe bleeding complications and determine their occurrence risk factors. Material and methodsWe conducted a retrospective observational cohort study including post-AMI cardiogenic shock patients requiring VA-ECMO. Severe bleeding was defined based on the Bleeding Academic Research Consortium classification. We calculated multivariable Fine–Gray models to assess factors associated with risk of severe bleeding. ResultsFrom January 2015 to July 2019, 176 patients received VA-ECMO after AMI and 132 patients were included. Sixty-five (49%) patients died. Severe bleeding occurred in 39% of cases. Severe thrombocytopenia (< 50 G/L) and hypofibrinogenemia (<1,5 g/L) occurred in respectively 31% and 19% of patients. DAPT was stopped in 32% of patients with a 6% rate of stent thrombosis. Anticoagulation was stopped in 39% of patients. Using a multivariate competing risk model, female sex, time on ECMO, troponin at admission and Impella® implantation were independently associated with severe bleeding. ConclusionsBleeding complications and coagulation disorders were frequent and severe in patients on VA-ECMO after AMI, leading of antiplatelet therapy withdrawal in one third of patients.

Impact of the Timing of Mechanical Circulatory Support on the Outcomes in Myocardial Infarction-Related Cardiogenic Shock: Subanalysis of the PREPARE CS Registry.

(1) Background: Mechanical circulatory support (MCS) in myocardial infarction-associated cardiogenic shock is subject to debate. This analysis aims to elucidate the impact of MCS's timing on patient outcomes, based on data from the PREPARE CS registry. (2) Methods: The PREPARE CS prospective registry includes patients who experienced cardiogenic shock (SCAI classes C-E) and were subsequently referred for cardiac catheterization. Our present analysis included a subset of this registry, in whom MCS was used and who underwent coronary intervention due to myocardial infarction. Patients were categorized into an Upfront group and a Procedural group, depending on the timing of MCS's introduction in relation to their PCI. The endpoint was in-hospital mortality. (3) Results: In total, 71 patients were included. MCS was begun prior to PCI in 33 (46%) patients (Upfront), whereas 38 (54%) received MCS during or after the initiation of PCI (Procedural). The groups' baseline characteristics and hemodynamic parameters were comparable. The Upfront group had a higher utilization of the Impella® device compared to extracorporeal membrane oxygenation (67% vs. 33%), while the Procedural group exhibited a balanced use of both (50% vs. 50%). Most patients suffered from multi-vessel disease in both groups (82% vs. 84%, respectively; p = 0.99), and most patients required a complex PCI procedure; the latter was more prevalent in the Upfront group (94% vs. 71%, respectively; p = 0.02). Their rates of complete revascularization were comparable (52% vs. 34%, respectively; p = 0.16). Procedural CPR was significantly more frequent in the Procedural group (45% vs. 79%, p < 0.05); however, in-hospital mortality was similar (61% vs. 79%, respectively; p = 0.12). (4) Conclusions: The upfront implantation of MCS in myocardial infarction-associated CS did not provide an in-hospital survival benefit.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Annual review of clinical research on extracorporeal life support in 2023

The clinical research in the field of extracorporeal life support (ECLS) in 2023 has focused on the efficacy of veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with infarct-related cardiogenic shock. Additionally, the research also explored the efficacy of prone positioning during veno-venous ECMO, transfusion strategies, and the impact of obesity on outcomes. Awake veno-venous ECMO has shown novel therapeutic potential, but its optimal practice methods and management strategies remain to be determined. In in-hospital cardiac arrest patients, extracorporeal cardiopulmonary resuscitation has demonstrated higher survival rates and better neurological recovery compared to conventional cardiopulmonary resuscitation. The effectiveness of extracorporeal carbon dioxide removal varies among patients with different types of respiratory failure. Future research should focus on optimizing the application strategies and process management of ECLS technologies, investigating personalized therapy, and studying how to improve long-term rehabilitation and quality of life for survivors.

Prognostic performance of the IABP-SHOCK II Risk Score among cardiogenic shock subtypes in the critical care cardiology trials network registry

BackgroundRisk stratification has potential to guide triage and decision-making in cardiogenic shock (CS). We assessed the prognostic performance of the IABP-SHOCK II score, derived in Europe for acute myocardial infarct-related CS (AMI-CS), in a contemporary North American cohort, including different CS phenotypes. MethodsThe Critical Care Cardiology Trials Network (CCCTN) coordinated by the TIMI Study Group is a multicenter network of cardiac intensive care units (CICU). Participating centers annually contribute ≥2 months of consecutive medical CICU admissions. The IABP-SHOCK II risk score includes age >73 years, prior stroke, admission glucose >191 mg/dl, creatinine >1.5 mg/dl, lactate >5 mmol/l, and post-PCI TIMI flow grade <3. We assessed the risk score across various CS etiologies. ResultsOf 17,852 medical CICU admissions 5,340 patients across 35 sites were admitted with CS. In patients with AMI-CS (n=912), the IABP-SHOCK II score predicted a >3-fold gradient in in-hospital mortality (low risk = 26.5%, intermediate risk =52.2%, high risk = 77.5%, p<0.0001; c-statistic=0.67; Hosmer-Lemeshow p=0.79). The score showed a similar gradient of in-hospital mortality in patients with non-AMI-related CS (n=2,517, p<0.0001) and mixed shock (n=923, p<0.001), as well as in left ventricular (<0.0001), right ventricular (p = 0.0163) or biventricular (<0.0001) CS. The correlation between the IABP-SHOCK II score and SOFA was moderate (r2=0.17) and the IABP-SHOCK II score revealed a significant risk gradient within each SCAI Stage. ConclusionsIn an unselected international multicenter registry of patients admitted with CS, the IABP- SHOCK II score only moderately predicted in-hospital mortality in a broad population of CS regardless of etiology or irrespective of right, left, or bi-ventricular involvement.

The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis.

Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of infarct-related cardiogenic shock. However, there is limited evidence regarding its beneficial impact on mortality. The aim of this study was to systematically review studies reporting the impact of VA-ECMO on mortality in patients with acute myocardial infarction complicated by cardiogenic shock. A comprehensive search of medical databases (Cochrane Register and PubMed) was conducted. Studies that reported mortality outcomes in patients treated with VA-ECMO for infarct-related cardiogenic shock were included. The database search yielded 1194 results, of which 11 studies were included in the systematic review. Four of these studies, with a total of 586 patients, were randomized controlled trials and were included in the meta-analysis. This demonstrated that there was no significant difference in 30-day all-cause mortality with the use of VA-ECMO compared with standard medical therapy [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.65-1.27]. Meta-analysis of two studies showed that VA-ECMO was associated with a significant reduction in 12-month all-cause mortality (OR 0.31; 95% CI 0.11-0.86). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality. Veno-arterial extracorporeal membrane oxygenation does not improve 30-day all-cause mortality in patients with cardiogenic shock following acute myocardial infarction; however, there may be significant reduction in all-cause mortality at 12 months. Further studies are needed to delineate the potential benefit of VA-ECMO in long-term outcomes. The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023461740).

Left ventricle unloading during acute myocardial infarction-related cardiogenic shock and reperfusion

Left ventricle unloading during acute myocardial infarction-related cardiogenic shock and reperfusion

SCAI Staging Application for Acute Myocardial Infarction-Related Cardiogenic Shock at a Single-Center Russian Registry.

To access the features of the course of myocardial infarction (MI) in patients with different stages of MI complicated by cardiogenic shock (MI CS) according to the SCAI scale. We retrospectively described the portrait of CS MI (n = 117) at different stages of SCAI from the hospital MI registry (n = 1253). Hospital mortality increased from stage to stage (p ≤ 0.001). Significant differences in biochemical parameters were found both for indicators characterizing intensive care measures, such as the presence of mechanical lung ventilation or an intra-aortic balloon pump, and for indicators of organ hypoperfusion such as lactate level, pHv (7.39 (7.36; 7.44) at stage A-B; 7.14 (7.06; 7.18) at stage E), creatinine, and glomerular filtration rate. Parameters related to MI characteristics, such as instrumental and laboratory data, anamnesis of ischemia, and performed treatment, did not differ between groups. Polynomial logistic regression showed that lactate level, mechanical ventilation, and monocyte count upon admission (1.15 (0.96; 1.23) at stage A-B; 0.78 (0.49; 0.94) at stage E, p = 0.005) correlated with CS severity. The characteristics of MI at different stages of SCAI do not have differences and do not determine the severity of shock. We revealed a high discriminatory potential of the pH level in predicting refractory shock. The value of monocytes at admission may be a promising predictor of the severity of MI CS. The question of the causes of heterogeneity of MI CS, taking into account the homogeneity of MI characteristics, remains open and promising.

The demise of extracorporeal membrane oxygenation in infarct-related cardiogenic shock.

The demise of extracorporeal membrane oxygenation in infarct-related cardiogenic shock.

Sex-related differences on short-term prognosis in patients with acute myocardial infarction related cardiogenic shock receiving Impella support in Japan

Abstract Background Sex-specific outcomes in patients with acute myocardial infarction related cardiogenic shock (AMI-CS) receiving temporary MCS remains controversial in the United States. Survival benefit of Impella support in female patients in Japan also remains uncertain. Purpose This study examined sex-related differences in clinical outcomes among patients with AMI-CS receiving Impella support using the prospective multi-center J-PVAD registry data. Methods We included patients with AMI-CS who received Impella-incorporated temporary MCS and were enrolled in the J-PVAD registry between Jan 2021 and Dec 2022. Patients with out-of-hospital cardiac arrest were excluded. The primary outcome was 30-day survival. Results A total of 979 patients (average 71 y; female 21%; LVEF 30%) were included. All patients received revascularization and 69% of them received during Impella support. Female patients had a lower 30-day survival compared to male patients (60.2% vs 67.9%, p = 0.0089). Of note, female patients who received Impella support before revascularization had a greater survival compared to those who received Impella support after revascularization (69.2% vs 41.8%, Figure 1). Conclusions Female patients in AMI-CS had a lower short-term prognosis compared to male. Early initiation of Impella support before revascularization is highly recommended for those with AMI-CS.

Obesity and outcomes in cardiogenic shock due to acute myocardial infarction

Abstract Background Obesity paradox in heart failure (HF) is defined as better outcomes associated with higher body mass index (BMI). Purpose We explored the relationship between BMI and outcomes in cardiogenic shock (CS) due to acute myocardial infarction. Methods The Cardiogenic Shock Working Group (CSWG) registry includes patients with CS, regardless of etiology, from 17 clinical sites across the USA. In- hospital mortality, as a main outcome measure, was analyzed depending on BMI as a continuous variable, as well as BMI quartiles (BMI≤24.4 kg/m2, 24.433.1 kg/m2) for the subset of CS due to acute myocardial infarction (AMI-CS). We also explored mortality in categorized BMI subsets (underweight, normal weight, overweight, obese, and morbidly obese). Results A total of 969 patients with AMI-CS were included. The in-hospital mortality was 42.4%. When analyzed as a continuous variable, BMI had no association with survival to discharge. When the cohort was divided into quartiles according to BMI, mortality was consistent with 42.2%, 38.5%, 39.5%, and 49.3%, respectively, p=0.082. In categorized subsets, mortality was 30% in the underweight, 42.9% in the normal weight, 37.4% in the overweight, 44.5.% in the obese, and 47.9% in morbidly obese, p=0.15. Conclusions In acute myocardial infarction-related cardiogenic shock, obesity creates no survival advantage.