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JAMA Nov 2021Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction. (Review)
Review
IMPORTANCE
Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction.
OBSERVATIONS
Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization-only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction.
CONCLUSIONS AND RELEVANCE
Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.
Topics: Cardiotonic Agents; Extracorporeal Membrane Oxygenation; Heart-Assist Devices; Humans; Myocardial Infarction; Myocardial Revascularization; Percutaneous Coronary Intervention; Shock, Cardiogenic; Time-to-Treatment
PubMed: 34751704
DOI: 10.1001/jama.2021.18323 -
JACC. Heart Failure Nov 2020Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite... (Review)
Review
Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform. Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. Lastly, they discuss future research opportunities to address current gaps in clinical knowledge.
Topics: Disease Management; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Registries; Shock, Cardiogenic
PubMed: 33121700
DOI: 10.1016/j.jchf.2020.09.005 -
Current Opinion in Critical Care Aug 2021Cardiogenic shock remains a major cause of mortality today. With recent advancements in invasive mechanical support strategies, reperfusion practice, and a new... (Review)
Review
PURPOSE OF REVIEW
Cardiogenic shock remains a major cause of mortality today. With recent advancements in invasive mechanical support strategies, reperfusion practice, and a new classification scheme is proposed for cardiogenic shock, an updated review of the latest hemodynamic monitoring techniques is important.
RECENT FINDINGS
Multiple recent studies have emerged supporting the use of pulmonary artery catheters in the cardiogenic shock population. Data likewise continues to emerge on the use of echocardiography and biomarker measurement in the care of these patients.
SUMMARY
The integration of multiple forms of hemodynamic monitoring, spanning noninvasive and invasive modalities, is important in the diagnosis, staging, initial treatment, and subsequent management of the cardiogenic shock patient.
Topics: Catheterization, Swan-Ganz; Echocardiography; Hemodynamic Monitoring; Humans; Shock, Cardiogenic
PubMed: 33967209
DOI: 10.1097/MCC.0000000000000838 -
Journal of the American Heart... Apr 2019
Review
Topics: Cardiac Catheterization; Continuous Renal Replacement Therapy; Coronary Angiography; Diagnosis, Differential; Electrocardiography; Extracorporeal Membrane Oxygenation; Fluid Therapy; Heart Failure; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Monitoring, Physiologic; Myocardial Infarction; Noninvasive Ventilation; Oxygen Inhalation Therapy; Percutaneous Coronary Intervention; Respiration, Artificial; Shock, Cardiogenic; Vasoconstrictor Agents
PubMed: 30947630
DOI: 10.1161/JAHA.119.011991 -
Methodist DeBakey Cardiovascular Journal 2020Cardiogenic shock (CGS) is common and highly morbid. According to the National Inpatient Sample, there are more than 100,000 cases per year, and 30-day mortality... (Review)
Review
Cardiogenic shock (CGS) is common and highly morbid. According to the National Inpatient Sample, there are more than 100,000 cases per year, and 30-day mortality approaches 50% despite improvements in critical care practices and novel mechanical therapies targeted at restoring normal hemodynamics. This issue aims to enhance clinicians' understanding of CGS, and this review specifically focuses on the underlying pathophysiology. We examine the definition and etiologies of CGS, approaches to risk assessment, and the pressure-volume loop framework that is the foundation for conceptualizing ventricular mechanics, ventricular-vascular interactions, and the derangements observed in CGS. This overview will also contextualize subsequent chapters that discuss nuances of CGS encountered in particular scenarios (ie, post-myocardial infraction, acutely decompensated chronic heart failure, post-cardiac surgery), address pharmacological and mechanical treatments for CGS, and review CGS in a case-based format.
Topics: Diagnostic Techniques, Cardiovascular; Hemodynamics; Humans; Models, Cardiovascular; Predictive Value of Tests; Prognosis; Risk Factors; Shock, Cardiogenic; Ventricular Function, Left; Ventricular Function, Right
PubMed: 32280412
DOI: 10.14797/mdcj-16-1-7 -
EuroIntervention : Journal of EuroPCR... Aug 2021Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%,... (Review)
Review
Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.
Topics: Humans; Intra-Aortic Balloon Pumping; Myocardial Infarction; Shock, Cardiogenic
PubMed: 34413010
DOI: 10.4244/EIJ-D-20-01296 -
Circulation. Heart Failure Sep 2018Venoarterial extracorporeal membrane oxygenation (VA-ECMO)-also referred to as extracorporeal life support-is a form of temporary mechanical circulatory support and... (Review)
Review
Venoarterial extracorporeal membrane oxygenation (VA-ECMO)-also referred to as extracorporeal life support-is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange. The initiation of VA-ECMO has emerged as a salvage intervention in patients with cardiogenic shock, even cardiac arrest refractory to standard therapies. Analogous to veno-venous ECMO for acute respiratory failure, VA-ECMO provides circulatory support and allows time for other treatments to promote recovery or may be a bridge to a more durable mechanical solution in the setting of acute or acute on chronic cardiopulmonary failure. In this review, we provide a brief overview of VA-ECMO, the attendant physiological considerations of peripheral VA-ECMO, and its complications, namely that of left ventricular distention, bleeding, heightened systemic inflammatory response syndrome, thrombosis and thromboembolism, and extremity ischemia or necrosis.
Topics: Cardiovascular System; Clinical Decision-Making; Extracorporeal Membrane Oxygenation; Heart Arrest; Hemodynamics; Humans; Lung; Patient Selection; Recovery of Function; Respiration; Risk Assessment; Risk Factors; Shock, Cardiogenic; Treatment Outcome
PubMed: 30354364
DOI: 10.1161/CIRCHEARTFAILURE.118.004905 -
Journal of the American College of... May 2014Inotropes have been fundamental to resuscitation of acute cardiogenic shock for decades. Heart failure and cardiogenic shock, in severe cases, are syndromes... (Review)
Review
Inotropes have been fundamental to resuscitation of acute cardiogenic shock for decades. Heart failure and cardiogenic shock, in severe cases, are syndromes characterized in many patients by a reduction in myocardial contractile force. While inotropes successfully increase cardiac output, their use has been plagued by excessive mortality due to increased tachycardia and myocardial oxygen consumption leading to arrhythmia and myocardial ischemia. There is a pressing need for new inotropic agents that avoid these harmful effects. This review describes the mechanism of action and the clinical utility of some of the older inotropic agents, which are still commonly used, and provides an update for physicians on the development of newer inotropic drugs. The field is rapidly changing, and it is likely that new agents will be designed that improve systolic performance without necessarily increasing the myocardial oxygen consumption.
Topics: Cardiotonic Agents; Heart Failure; Humans; Myocardial Contraction; Shock, Cardiogenic; Systole; Treatment Outcome
PubMed: 24530672
DOI: 10.1016/j.jacc.2014.01.016 -
Methodist DeBakey Cardiovascular Journal 2020Cardiogenic shock in the setting of acute myocardial infarction remains a major cause of morbidity and mortality. In fact, acute myocardial infarction accounts for 81%... (Review)
Review
Cardiogenic shock in the setting of acute myocardial infarction remains a major cause of morbidity and mortality. In fact, acute myocardial infarction accounts for 81% of patients in cardiogenic shock. Despite advances in pharmacologic and device-based approaches to support patients with cardiogenic shock, no significant improvement in mortality has been observed over the past 20 years, although multiple registries are providing new insight into this complex syndrome. Key elements for optimal treatment include integration of hemodynamic and metabolic data for diagnosis and risk stratification, early evaluation and appropriate initiation of acute mechanical circulatory support devices, and an organized algorithmic approach to decision making.
Topics: Algorithms; Clinical Decision-Making; Decision Support Techniques; Hemodynamics; Humans; Myocardial Infarction; Predictive Value of Tests; Recovery of Function; Risk Factors; Shock, Cardiogenic; Treatment Outcome; Ventricular Function
PubMed: 32280413
DOI: 10.14797/mdcj-16-1-16 -
Journal of the American Heart... Jul 2021Background Cardiogenic shock (CS) is a heterogeneous syndrome with varied presentations and outcomes. We used a machine learning approach to test the hypothesis that...
Background Cardiogenic shock (CS) is a heterogeneous syndrome with varied presentations and outcomes. We used a machine learning approach to test the hypothesis that patients with CS have distinct phenotypes at presentation, which are associated with unique clinical profiles and in-hospital mortality. Methods and Results We analyzed data from 1959 patients with CS from 2 international cohorts: CSWG (Cardiogenic Shock Working Group Registry) (myocardial infarction [CSWG-MI; n=410] and acute-on-chronic heart failure [CSWG-HF; n=480]) and the DRR (Danish Retroshock MI Registry) (n=1069). Clusters of patients with CS were identified in CSWG-MI using the consensus k means algorithm and subsequently validated in CSWG-HF and DRR. Patients in each phenotype were further categorized by their Society of Cardiovascular Angiography and Interventions staging. The machine learning algorithms revealed 3 distinct clusters in CS: "non-congested (I)", "cardiorenal (II)," and "cardiometabolic (III)" shock. Among the 3 cohorts (CSWG-MI versus DDR versus CSWG-HF), in-hospital mortality was 21% versus 28% versus 10%, 45% versus 40% versus 32%, and 55% versus 56% versus 52% for clusters I, II, and III, respectively. The "cardiometabolic shock" cluster had the highest risk of developing stage D or E shock as well as in-hospital mortality among the phenotypes, regardless of cause. Despite baseline differences, each cluster showed reproducible demographic, metabolic, and hemodynamic profiles across the 3 cohorts. Conclusions Using machine learning, we identified and validated 3 distinct CS phenotypes, with specific and reproducible associations with mortality. These phenotypes may allow for targeted patient enrollment in clinical trials and foster development of tailored treatment strategies in subsets of patients with CS.
Topics: Adult; Aged; Denmark; Female; Hemodynamics; Hospital Mortality; Humans; Male; Middle Aged; Registries; Risk Assessment; Risk Factors; Shock, Cardiogenic; United States
PubMed: 34227396
DOI: 10.1161/JAHA.120.020085