cardiovascular-agents and Shock--Cardiogenic

To discuss the use of vasopressors and inotropes in cardiogenic shock.. The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial.. Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.

Topics: Cardiotonic Agents; Cardiovascular Agents; Dobutamine; Humans; Shock; Shock, Cardiogenic; Vasoconstrictor Agents

Sepsis-induced cardiogenic shock is a lethal condition and the management of it is challenging. Cardiogenic shock in the septic patient involves myocardial systolic and diastolic dysfunction. The limited ability of the ventricles to contract effectively results in a decrease in oxygen delivery to the organs and tissues. Supportive therapy is provided to patients with sepsis and no specific drug can reverse the myocardial dysfunction. Rapid diagnosis, prompt antibiotic therapy, cautious protocol-driven fluid resuscitation and vasoactive agents, control of infectious source, and expeditious coronary artery revascularization is recommended to achieve a positive outcome.

Topics: Anti-Bacterial Agents; Cardiovascular Agents; Critical Care Nursing; Early Diagnosis; Evidence-Based Medicine; Fluid Therapy; Humans; Sepsis; Shock, Cardiogenic

The technology available to offer acute hemodynamic support to critically ill patients has evolved exponentially in recent years. As our experience grows, and our armamentarium of mechanical therapies expands, devices are becoming increasingly important to providing acute hemodynamic support. This review article will describe approaches to providing acute support and a concise review of the percutaneous mechanical support devices currently available. In an effort to define how and when to use them in acute situations, we will also describe some advantages and disadvantages of each platform, and highlight the primary limitations in defining safety and efficacy.

Topics: Cardiovascular Agents; Extracorporeal Membrane Oxygenation; Heart Failure; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Myocardial Contraction; Prosthesis Design; Recovery of Function; Shock, Cardiogenic; Treatment Outcome; Ventricular Function

Cardiogenic shock is a life-threatening condition that occurs in response to reduced cardiac output in the presence of adequate intravascular volume and results in tissue hypoxia. Cardiogenic shock has several underlying aetiologies, with the most common being acute myocardial infarction (AMI). Refractory cardiogenic shock presents as persistent tissue hypoperfusion despite administration of adequate doses of two vasoactive medications and treatment of the underlying aetiology. Investigators of the SHOCK trial reported a long-term mortality benefit of emergency revascularization for shock complicating AMI. Since the publication of the SHOCK trial and subsequent guideline recommendations, the increase in community-based use of percutaneous coronary intervention for this condition has resulted in a significant decline in mortality. Despite these successes in the past 15 years, mortality still remains exceptionally high, particularly in patients with refractory cardiogenic shock. In this Review, we discuss the aetiology and pathophysiology of cardiogenic shock and summarize the data on the available therapeutics and their limitations. Although new mechanical circulatory support devices have been shown to improve haemodynamic variables in patients with shock complicating AMI, they did not improve clinical outcomes and are associated with high costs and complications.

Topics: Cardiovascular Agents; Extracorporeal Membrane Oxygenation; Heart-Assist Devices; Hemodynamics; Hospital Mortality; Humans; Intra-Aortic Balloon Pumping; Myocardial Revascularization; Prosthesis Design; Recovery of Function; Risk Factors; Shock, Cardiogenic; Time Factors; Treatment Outcome; Ventricular Function

Cardiogenic shock (CS) is still the predominant cause of in-hospital death in patients with acute myocardial infarction, although mortality has been reduced in recent years. Early percutaneous coronary intervention and coronary artery bypass grafting are causal therapies implemented in CS, supported by catecholamines, fluids, intra-aortic balloon pumping, and also active percutaneous assist devices. There is only limited evidence from randomized studies of any of these treatments in CS, except for early revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This review will present treatment pathways of CS complicating acute myocardial infarction, with a major focus on revascularization, intensive care unit treatment, and mechanical support devices.

Topics: Cardiovascular Agents; Coronary Artery Bypass; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Myocardial Infarction; Percutaneous Coronary Intervention; Prosthesis Design; Recovery of Function; Risk Factors; Shock, Cardiogenic; Time Factors; Treatment Outcome; Ventricular Function, Left

Topics: Adult; Cardiovascular Agents; Combined Modality Therapy; Continuous Positive Airway Pressure; Electrocardiography; Extracorporeal Membrane Oxygenation; Female; Heart Failure; Hemodynamics; Humans; Influenza B virus; Influenza, Human; Pacemaker, Artificial; Shock, Cardiogenic; Signal Processing, Computer-Assisted

Acute cardiogenic pulmonary edema and cardiogenic shock are two of the main forms of presentation of acute heart failure. Both entities are serious, with high mortality, and require early diagnosis and prompt and aggressive management. Acute pulmonary edema is due to the passage of fluid through the alveolarcapillary membrane and is usually the result of an acute cardiac episode. Correct evaluation and clinical identification of the process is essential in the management of acute pulmonary edema. The initial aim of treatment is to ensure hemodynamic stability and to correct hypoxemia. Other measures that can be used are vasodilators such as nitroglycerin, loop diuretics and, in specific instances, opioids. Cardiogenic shock is characterized by sustained hypoperfusion, pulmonary wedge pressure > 18 mmHg and a cardiac index < 2.2l/min/m(2). The process typically presents with hypotension (systolic blood pressure < 90 mmHg or a decrease in mean arterial pressure > 30 mmHg) and absent or reduced diuresis (< 0.5 ml/kg/h). The most common cause is left ventricular failure due to acute myocardial infarction. Treatment consists of general measures to reverse acidosis and hypoxemia, as well as the use of vasopressors and inotropic drugs. Early coronary revascularization has been demonstrated to improve survival in shock associated with ischaemic heart disease.

Topics: Acute Disease; Cardiovascular Agents; Combined Modality Therapy; Diagnosis, Differential; Diuresis; Heart Failure; Humans; Hypotension; Hypoxia; Myocardial Infarction; Myocardial Revascularization; Narcotics; Oxygen Inhalation Therapy; Pulmonary Edema; Respiration, Artificial; Sepsis; Shock; Shock, Cardiogenic; Sodium Potassium Chloride Symporter Inhibitors; Vasoconstrictor Agents; Vasodilator Agents; Ventricular Dysfunction, Left

How can an earthquake cause cardiogenic shock? Can a bereft lover really die from a broken heart? Takotsubo cardiomyopathy is an intriguing reversible condition which still mystifies and excites the layman and physician alike. This article explores the clinical essentials for recognizing and managing this group of complex patients.

Topics: Biomarkers; Cardiac Catheterization; Cardiovascular Agents; Echocardiography; Electrocardiography; Extracorporeal Membrane Oxygenation; Heart-Assist Devices; Hemodynamics; Humans; Hydrazones; Magnetic Resonance Imaging; Prognosis; Pyridazines; Shock, Cardiogenic; Simendan; Takotsubo Cardiomyopathy

Cardiogenic shock (CS) is a condition in which a marked reduction in cardiac output and inadequate end-organ perfusion results from an array of cardiac insults, the most common of which is acute myocardial infarction. CS is a systemic disease involving a vicious cycle of inflammation, ischemia, and progressive myocardial dysfunction, which often results in death. This life-threatening emergency requires intensive monitoring accompanied by aggressive hemodynamic support; other therapies are tailored to the specific pathophysiology. The development of novel therapeutic strategies is urgently required to reduce the unacceptably high mortality rates currently associated with CS.

Topics: Assisted Circulation; Cardiovascular Agents; Coronary Care Units; Extracorporeal Membrane Oxygenation; Heart Rupture, Post-Infarction; Heart-Assist Devices; Hemodynamics; Humans; Myocardial Revascularization; Prognosis; Randomized Controlled Trials as Topic; Shock, Cardiogenic; Ventricular Dysfunction, Right

Acute heart failure is a disease with various etiologies that is difficult to treat and has a poor prognosis. If causal treatment--revascularization, treatment of a hypertensive crisis--is not possible, symptomatic treatment takes over, based primarily on intravenous treatment with diuretics, vasodilators and/or positive inotropes. Despite undoubted progress in this form of treatment, large, randomised clinical studies have never proved the success of this treatment or confirmed an improvement in prognosis. For this reason most recommendations are based only on clinical experience and surrogate targets such as a reduction in BNP or shortening of the hospitalisation period. Great attention is directed in particular to natriuretic peptides (nesiritide, ularitide) and to levosimendan, which is a calcium sensitizer with a vasodilatory and positive inotropic effect. Nevertheless, even this medicine has not yet been shown to reduce mortality in large studies.

Topics: Cardiovascular Agents; Heart Failure; Humans; Infusions, Intravenous; Shock, Cardiogenic

The treatment of cardiogenic shock complicating the acute coronary syndromes consists of medical therapy, percutaneous revascularization procedures, cardiac surgery, and the implantation of devices. Medical therapy is limited to different positive inotropic and vasoactive drugs, without any firm evidence of survival benefit using these drugs. Several new pharmacologic compounds are at different stages of clinical research, but are not yet routinely approved for the treatment of cardiogenic shock. The only evidence-based therapy with proven survival benefit is timely revascularization. Intra-aortic balloon pump counterpulsation maintains its central role as supportive treatment in cardiogenic shock patients. Anecdotal evidence is available about the use of ventricular assist devices, cardiac resynchronization therapy, and emergent heart transplantation.

Topics: Cardiac Catheterization; Cardiovascular Agents; Counterpulsation; Echocardiography; Humans; Myocardial Revascularization; Shock, Cardiogenic

Acute coronary syndromes (ACSs), which include the clinical entities of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), account for more than 1.5 million hospital admissions annually in the United States alone. Approximately 1 million of these admissions are classified as UA/NSTEMI and approximately 500,000 are STEMI. Because of the overwhelming number of studies on ACSs over the past several years, this article focuses on new trials and therapies for treating patients diagnosed with STEMI.

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Cardiovascular Agents; Clinical Trials as Topic; Humans; Hypothermia, Induced; Myocardial Infarction; Oxygen; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Shock, Cardiogenic; Stents; Thrombectomy; Thrombolytic Therapy

The elderly constitute an increasingly important sector of patients with acute coronary syndromes (ACS), although they have been under-represented in many therapeutic trials. Elderly patients with ACS usually have more complex co-morbidities and worse outcomes than their younger counterparts, and they are less likely to undergo revascularisation or to receive short- and long-term evidence-based medications. The most common ACS in the elderly is non-ST-segment elevation myocardial infarction (STEMI), which is associated with high mortality. For this reason, elderly patients with non-STEMI and unstable angina should be treated invasively early in the course of the episode. In elderly patients with STEMI, primary angioplasty seems to be more effective than fibrinolysis, and in patients aged >85 years a more conservative approach to fibrinolysis is also warranted because of the higher risk for cerebral haemorrhage. Therefore, angioplasty should be preferred when feasible, although more trials are needed before this strategy can definitely be documented as the preferred option. Drug-eluting stents afford greater benefit than bare metal stents in elderly patients and are more cost effective. After fibrinolysis, low-molecular-weight heparin appears to be superior to unfractionated heparin in elderly patients with STEMI but major bleeding and intracranial haemorrhages occur more frequently, especially in women aged >75 years. It is very important to understand that the elderly with ACS constitute a subgroup of atherosclerotic patients for whom decision making must be guided by the patients''physiological age' (determined by their physical condition and other co-morbidities) and not strictly by their 'chronological age'.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Drug-Eluting Stents; Fibrinolytic Agents; Humans; Middle Aged; Myocardial Infarction; Prognosis; Shock, Cardiogenic; Stents

Topics: Analgesics, Opioid; Angina, Unstable; Biomarkers; Cardiovascular Agents; Electrocardiography; Europe; Humans; Morphine; Myocardial Infarction; Myocardial Reperfusion; Oxygen Inhalation Therapy; Shock, Cardiogenic

Topics: Blood Pressure; Cardiovascular Agents; Fluid Therapy; Goals; Hematocrit; Hemoglobins; Humans; Intensive Care Units; Resuscitation; Shock, Cardiogenic

Topics: Angioplasty, Balloon, Coronary; Cardiopulmonary Bypass; Cardiovascular Agents; Humans; Myocardial Infarction; Prognosis; Randomized Controlled Trials as Topic; Shock, Cardiogenic; Survival Rate; Thrombolytic Therapy; Treatment Outcome

This review analyzes important facets of contemporary percutaneous coronary interventions. The optimal strategy of acute myocardial infarction and shock is addressed, as is the role of angioplasty in multivessel coronary disease. Vascular Brachytherapy is essentially the sole available treatment modality for in-stent restenosis. The WRIST trials have provided the foundation for clinical experience and are discussed in detail. Finally, drug-eluting stents may become the next revolution in interventional cardiology and offer the hope of a "cure" for restenosis.

Topics: Angioplasty, Balloon; Animals; Brachytherapy; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Graft Occlusion, Vascular; Humans; Myocardial Infarction; Myocardial Revascularization; Shock, Cardiogenic; Stents

Topics: Acute Disease; Cardiovascular Agents; Combined Modality Therapy; Critical Care; Emergencies; Heart Failure; Humans; Shock, Cardiogenic

The effective treatment of patients with acute myocardial infarction (AMI) and acute congestive heart failure (CHF) requires quick triage, accurate identification, and appropriate pharmacologic management. This article describes the initial assessment and management of adult patients with AMI and CHF, beginning with the first interaction of such patients with the emergency department staff.

Topics: Acute Disease; Cardiovascular Agents; Heart Failure; Humans; Myocardial Infarction; Shock, Cardiogenic; Thrombolytic Therapy

Respiratory muscle dysfunction has been demonstrated in several clinical situations including chronic respiratory disease, such as chronic obstructive pulmonary disease, as well as cardiac insufficiency. In the latter case, respiratory muscle dysfunction has been demonstrated in acute situation (cardiogenic shock) and in chronic cardiac insufficiency. In the former case, it has been shown in an animal model that respiratory muscle dysfunction could influence markedly the outcome of cardiogenic shock. In chronic cardiac insufficiency histologic, biochemical and contractile abnormalities of the respiratory muscles have been demonstrated in an animal model as well as in humans. These alterations may account, at least in part, for the sensation of dyspnea that these patients encountered. Finally, several pharmacological agents such as angiotensin-converting enzyme inhibitors have been shown to restore muscle abnormalities observed during chronic cardiac insufficiency.

Topics: Animals; Cardiac Output, Low; Cardiovascular Agents; Chronic Disease; Diaphragm; Humans; Intercostal Muscles; Shock, Cardiogenic

Topics: Cardiovascular Agents; Catecholamines; Drug Therapy, Combination; Heart Failure; Hemodynamics; Humans; Shock, Cardiogenic

Topics: Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiovascular Agents; Emergencies; Heart Failure; Hemodynamics; Humans; Shock, Cardiogenic

Topics: Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Spinal; Anesthetics; Cardiovascular Agents; Heart Failure; Hemodynamics; Humans; Hypotension, Orthostatic; Intraoperative Complications; Postoperative Complications; Shock, Cardiogenic

Topics: Anti-Arrhythmia Agents; Bicarbonates; Cardiotonic Agents; Cardiovascular Agents; Drug Therapy, Combination; Fluid Therapy; Heart Arrest; Hemodynamics; Humans; Resuscitation; Shock, Cardiogenic; Sodium; Sodium Bicarbonate; Vasoconstrictor Agents

In acute as well as in chronic ischemic heart disease, congestive heart failure indicates a poor prognosis. Treatment after acute myocardial infarction should differentiate between specific subsets. In cardiogenic shock due to extensive ischemic damage, acute revascularization by PTCA or CABG improves the otherwise poor outcome substantially. In congestive heart failure, pre- and afterload reduction by nitrates should be combined with dopamine if systolic blood pressure is below 100 mmHG or dobutamine if an inotropic substance is necessary despite systolic blood pressure greater than 100 mmHg. Amrinone is a potent alternative which combines positive inotropic and vasodilating properties. In chronic ischemic heart disease, congestive heart failure is a clearly defined indication for complete revascularization, if possible. As to drug treatment, progression of the disease characterized by a cardiomyopathy of overload as well as neurohormonal and peripheral maladaptation should be stopped in parallel with symptom relief. Therefore, ACE-Inhibitors are combined very early with diuretic treatment, and digitalis should be added in refractory patients.

Topics: Amrinone; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Digitalis Glycosides; Diuretics; Heart Failure; Humans; Myocardial Infarction; Shock, Cardiogenic; Vasodilator Agents

Topics: Assisted Circulation; Cardiovascular Agents; Heart; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Myocardial Infarction; Myocardial Revascularization; Shock, Cardiogenic

Cardiogenic shock (CS) is a systemic disorder associated with dismal short-term prognosis. Given its time-dependent nature, mechanical circulatory support may improve survival. Intra-aortic balloon pump (IABP) had gained widespread use because of the easiness to implant and the low rate of complications; however, a randomized trial failed to demonstrate benefit on mortality in the setting of acute myocardial infarction. Acute decompensated heart failure with cardiogenic shock (ADHF-CS) represents a growing resource-intensive scenario with scant data and indications on the best management. However, a few data suggest a potential benefit of IABP in this setting. We present the design of a study aimed at addressing this research gap.. The Altshock-2 trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with ADHF-CS will be randomized to early IABP implantation or to vasoactive treatments. The primary end point will be 60 days patients' survival or successful bridge to heart replacement therapy. The key secondary end point will be 60-day overall survival; 60-day need for renal replacement therapy; in-hospital maximum inotropic score, maximum duration of inotropic/vasopressor therapy, and maximum sequential organ failure assessment score. Safety end points will be in-hospital occurrence of bleeding events (Bleeding Academic Research Consortium >3), vascular access complications and systemic (noncerebral) embolism. The sample size for the study is 200 patients.. The Altshock-2 trial will provide evidence on whether IABP should be implanted early in ADHF-CS patients to improve their clinical outcomes.

Topics: Acute Disease; Cardiovascular Agents; Heart Failure; Heart-Assist Devices; Humans; Intra-Aortic Balloon Pumping; Prospective Studies; Renal Replacement Therapy; Sample Size; Shock, Cardiogenic; Time Factors

An elevated heart rate (HR) is an independent risk factor for mortality and morbidity in patients with acute heart failure (HF). The purpose of this study was to evaluate the impact of ivabradine, a selective HR-lowering agent, in patients with cardiogenic shock (CS) complicating ST-elevation acute myocardial infarction (AMI).. Patients with post-AMI CS were randomized to standard treatment (SDT, 28 patients) or to standard treatment plus ivabradine (I + SDT, 30 patients). In the presence of orotracheal intubation (OTI), ivabradine was administered by nasogastric intubation. HR, BP, New York Heart Association (NYHA) class, NT-proBNP, left ventricular ejection fraction (LVEF) and diastolic function (LVDF) were monitored at specific times after the onset of AMI. The primary (surrogate) end-point was the in-hospital halving of plasma NT-proBNP levels. The secondary end-points were cardiovascular death, hospital re-admission for worsening HF, and clinical and haemodynamic improvement.. Treatment groups were statistically similar with regard to age, gender distribution, cardiovascular risk factors, number of diseased vessels and overall treated lesions, AMI site and occurrence of OTI. In-hospital mortality was double in the SDT group in comparison with the I + SDT group (14.3 vs. 6.7 %), but the difference was not statistically significant. HR, BP, NT-proBNP and LVEF favorably changed in both groups, but the change was more relevant in the I + SDT group. LVDF significantly changed only in the I + SDT group (p < 0.01). Patients in the I + SDT group did not experience adverse effects.. Ivabradine in CS complicating AMI is safe, is associated with a short-term favourable outcome and can be effectively administered by nasogastric intubation.

Topics: Acute Disease; Adult; Aged; Benzazepines; Cardiovascular Agents; Female; Heart Failure; Humans; Ivabradine; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Risk Factors; Shock, Cardiogenic; ST Elevation Myocardial Infarction; Ventricular Function, Left

Slow flow, no reflow and distal embolization often occur during primary angioplasty in ST segment elevation myocardial infarction (STEMI), compromising optimal myocardial reperfusion.. This study aimed at assessing the impact of deferred stenting (DS) on periprocedural events as compared to immediate stenting (IS). The second objective was to gather the reasons advocated by the physicians for deferring stenting.. All consecutive patients referred for primary angioplasty were included between September 2010 and November 2011. Physicians were free to choose the strategy between DS and IS but had to justify their choice. DS patients underwent a coronary angiogram control in a delay > 24h.. Ninety-eight patients were included. Forty patients underwent DS and 58 IS. DS strategy involved thrombus management by thromboaspiration (33 patients 82.5%) and by the use of AntiGpIIbIIIa (23 patients 62.2%). This strategy could be achieved with a low complication rate. In particular, one patient had a reocclusion leading to a rapid reintervention and one had a distal embolization. In comparison, 11 periprocedural events occurred in the IS subgroup. In addition, among DS patients, 7 were treated medically because of a non-significant stenosis. The major criteria considered by the operator to prefer DS in the presence of a TIMI 3 flow concerned thrombotic load.. This mono-centric experience confirmed the feasibility and the safety of DS. On top of reducing periprocedural events, it may allow for other treatment options in selected STEMI patients, e.g. surgery or medical treatment. The reasons leading physicians to choose DS were large thrombus burden on top of resolution of chest pain and normalization of the ECG. These criteria could help selecting situations in which DS may be of particular value as compared to IS.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Catheterization; Cardiovascular Agents; Chest Pain; Comorbidity; Coronary Angiography; Coronary Thrombosis; Electrocardiography; Embolism; Feasibility Studies; Female; Heart Arrest; Hemorrhage; Hospital Mortality; Humans; Male; Middle Aged; Motivation; Myocardial Infarction; No-Reflow Phenomenon; Percutaneous Coronary Intervention; Physicians; Risk Factors; Shock, Cardiogenic; Stents; Thrombectomy; Time Factors

Independent adjudication of clinical trial events is traditionally performed by physicians on a clinical event classification (CEC) committee.. The experience of the centralized CEC group of the APEX-AMI trial is described. This group adjudicated key secondary pre-specified outcome measures of congestive heart failure (CHF) and cardiogenic shock through 90 days using an algorithmic approach for some events.. Data were collected via an electronic data capture (EDC) tool on all subjects, and additional information was provided via EDC for patients identified by site investigators with CHF or shock. Two strategies were used to adjudicate potential events: 1) a computer algorithm (followed by physician confirmation) analyzed data to determine whether events met trial end point definitions; or 2) physician review was used if EDC data were inadequate to allow classification by algorithm.. Of 5745 patients, 282 suspected cardiogenic shock and 465 suspected CHF events were identified. The computer algorithm or physicians confirmed 196/282 cardiogenic shock and 277/465 CHF end points. Overall, 242/742 (32.6%) of suspected events were classified by algorithm. Of the 500 events not resolved by computer algorithm, the CEC physicians agreed with site investigator assessments in 126/277 (45%) of CHF and 151/196 (77%) of cardiogenic shock events. The CEC committee completed adjudication of all suspected 30- and 90-day CHF and cardiogenic shock events within 7 days of the last patient 30-day follow-up visit and within 1 day of the last patient 90-day follow-up visit. Only 27% of patients required source document collection in addition to EDC-collected information.. A complementary approach of a computerized assessment and physician review was used in the CEC effort of the APEX-AMI trial. The algorithm categorized approximately one third of suspected CHF/cardiogenic shock events. The APEX-AMI CEC experience shows that an algorithmic approach may be a useful strategy for end point evaluation but requires validation.

Topics: Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Bundle-Branch Block; Cardiovascular Agents; Diagnosis, Computer-Assisted; Double-Blind Method; Heart Failure; Humans; Kaplan-Meier Estimate; Myocardial Infarction; Observer Variation; Randomized Controlled Trials as Topic; Shock, Cardiogenic; Single-Chain Antibodies; Time Factors

Topics: Aged; Cardiovascular Agents; Catheterization, Peripheral; Device Removal; Extracorporeal Membrane Oxygenation; Femoral Artery; Humans; Male; Shock, Cardiogenic; ST Elevation Myocardial Infarction; Stroke Volume; Vascular Closure Devices

Topics: Acute Coronary Syndrome; Adult; Cardiac Catheterization; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Coronavirus Infections; COVID-19; Diabetes Mellitus, Type 2; Diagnosis, Differential; Extracorporeal Membrane Oxygenation; Female; Heart Failure; Heart Transplantation; Humans; Hyperlipidemias; Hypertension; Hypertrophy, Left Ventricular; Immunosuppressive Agents; Intra-Aortic Balloon Pumping; Kidney Transplantation; Male; Middle Aged; Pandemics; Pericarditis; Pneumonia, Viral; Postoperative Complications; Respiration, Artificial; Respiratory Distress Syndrome; Shock, Cardiogenic

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Female; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Percutaneous Coronary Intervention; Retrospective Studies; Risk Assessment; Risk Factors; Shock, Cardiogenic; Time Factors; Treatment Outcome

Topics: Cardiac Output, Low; Cardiovascular Agents; Humans; Shock, Cardiogenic; Vasodilator Agents

Percutaneous mechanical circulatory support devices are increasingly used in acute myocardial infarction complicated by cardiogenic shock (AMI-CS), despite limited evidence for their effectiveness. The aim of this study was to evaluate outcomes associated with use of the Impella device compared with intra-aortic balloon pump (IABP) and medical treatment in patients with AMI-CS.. Data of patients with AMI-CS treated with the Impella device at European tertiary care hospitals were collected retrospectively. All patients underwent early revascularization and received optimal medical treatment. Using IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial inclusion and exclusion criteria, 372 patients were identified and included in this analysis. These patients were matched to 600 patients from the IABP-SHOCK II trial. The following baseline criteria were used as matching parameters: age, sex, mechanical ventilation, ejection fraction, prior cardiopulmonary resuscitation, and lactate. Primary end point was 30-day all-cause mortality.. In total, 237 patients treated with an Impella could be matched to 237 patients from the IABP-SHOCK II trial. Baseline parameters were similarly distributed after matching. There was no significant difference in 30-day all-cause mortality (48.5% versus 46.4%, P=0.64). Severe or life-threatening bleeding (8.5% versus 3.0%, P<0.01) and peripheral vascular complications (9.8% versus 3.8%, P=0.01) occurred significantly more often in the Impella group. Limiting the analysis to IABP-treated patients as a control group did not change the results.. In this retrospective analysis of patients with AMI-CS, the use of an Impella device was not associated with lower 30-day mortality compared with matched patients from the IABP-SHOCK II trial treated with an IABP or medical therapy. To further evaluate this, a large randomized trial is warranted to determine the effect of the Impella device on outcome in patients with AMI-CS.. URL: https://www.clinicaltrials.gov . Unique identifier: NCT03313687.

Topics: Aged; Cardiovascular Agents; Europe; Female; Heart-Assist Devices; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Prosthesis Design; Recovery of Function; Registries; Retrospective Studies; Risk Factors; Shock, Cardiogenic; Time Factors; Treatment Outcome

Background The Heart Team ( HT ) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease ( CAD ). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion. Methods and Results This observational study was conducted at St Thomas' Hospital (London, UK). Case mixture included unprotected left main, 2-vessel (including proximal left anterior descending artery) CAD , 3-vessel CAD , or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy ( OMT ) alone, OMT +percutaneous coronary intervention ( PCI ), or OMT +coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23-39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3-vessel CAD . Three-year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT + PCI cohort, and 90.2% in the OMT +coronary artery bypass grafting cohort (92 of 102). Conclusions In our experience, the HT approach involved a careful selection process resulting in appropriate patient-specific decision making and good long-term outcomes in patients with complex CAD .

Topics: Age Factors; Aged; Aged, 80 and over; Cardiology; Cardiovascular Agents; Clinical Decision-Making; Cooperative Behavior; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Patient Care Team; Percutaneous Coronary Intervention; Prospective Studies; Severity of Illness Index; Shock, Cardiogenic; Survival Rate; Thoracic Surgery; United Kingdom; Ventricular Dysfunction, Left

We sought to assess the angiographic and long-term clinical outcomes in a predominantly medically treated population with spontaneous coronary artery dissection (SCAD).. There are little data on the angiographic and long-term outcome in patients with SCAD.. We studied 64 patients with SCAD (mean age 53 years, 94% females, three peripartum) with acute coronary syndrome who were treated using coronary bypass grafting (n = 1), percutaneous coronary intervention (n = 7), or medical therapy (n = 56). A repeat angiogram was performed in 40/64 (63%) patients. The median clinical follow-up was 4.5 years.. Five (8%) patients had a major cardiac event. One patient with peripartum left main SCAD and cardiogenic shock died during PCI. One patient with conservatively treated SCAD of the posterior descending artery suffered out-of-hospital cardiac arrest 16 days after the initial angiogram but survived. Three patients experienced a second SCAD in another vessel 3.7, 4.7, and 7.9 years after the index event while the initial dissection had healed. Thirty medically treated patients underwent a scheduled repeat angiogram showing healing of the dissection in all but one patient. After a median follow-up of 4.5 (1.8-8.4) years, all 63 patients surviving the index event were alive and free of symptoms suggestive of myocardial ischemia.. In general, the long-term outcome of patients with SCAD is excellent, and medical therapy can be safely applied in the majority of patients. However, SCAD can be a life-threatening and sometimes catastrophic event, and some patients experience early or late complications including SCAD of another vessel. © 2015 Wiley Periodicals, Inc.

Topics: Acute Coronary Syndrome; Adult; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Vessel Anomalies; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Percutaneous Coronary Intervention; Predictive Value of Tests; Pregnancy; Recurrence; Registries; Risk Assessment; Risk Factors; Shock, Cardiogenic; Switzerland; Time Factors; Treatment Outcome; Vascular Diseases

To analyze the use and impact of the intra-aortic balloon pump (IABP) upon the 30-day mortality rate and short-term clinical outcome of non-selected patients with ST-elevation acute myocardial infarction (acute STEMI) complicated by cardiogenic shock (CS).. A single-center retrospective case-control study was carried out.. Coronary Care Unit.. Data were collected from 825 consecutive patients with acute STEMI admitted to a Coronary Care Unit from January 2009 to August 2015. Seventy-three patients with CS upon admission subjected to emergency percutaneous coronary intervention (PCI) were finally included in the analysis and were stratified according to IABP use (44 patients receiving IABP).. Cardiovascular history, hemodynamic situation upon admission, angiographic and procedural characteristics, and variables derived from admission to the Coronary Care Unit.. Cumulative 30-day mortality was similar in the patients subjected to IABP and in those who received conventional medical therapy only (29.5% and 27.6%, respectively; HR with IABP 1.10, 95% CI 0.38-3.11; p=0.85). Similarly, no significant differences were found in terms of the short-term clinical outcome between the groups: time on mechanical ventilation, days to hemodynamic stabilization, vasoactive drug requirements and stay in the Coronary Care Unit. Poorer renal function (HR 3.9, 95% CI 1.4-10.6; p=0.008), known peripheral artery disease (HR 3.3, 95% CI 1.2-9.1; p=0.019) and a history of diabetes mellitus (HR 3.2, 95% CI 1.2-8.1; p=0.018) were the only variables independently associated to increased 30-day mortality.. In our "real life" experience, IABP does not modify 30-day mortality or the short-term clinical outcome in patients presenting STEMI complicated with CS and subjected to emergency percutaneous coronary revascularization.

Topics: Aged; Cardiovascular Agents; Case-Control Studies; Catecholamines; Combined Modality Therapy; Female; Hospitals, General; Hospitals, University; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Percutaneous Coronary Intervention; Retrospective Studies; Risk Factors; Shock, Cardiogenic; Spain; ST Elevation Myocardial Infarction; Treatment Outcome

Elevated resting heart rate has been linked to poor outcomes in patients with chronic systolic heart failure. Blockade of funny current channel with ivabradine reduces heart rate without inotropic effects. Ivabradine was recently approved by US Food and Drug Administration for patients with stable, symptomatic chronic heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35 %, who are in sinus rhythm with resting heart rate (HR) ≥ 70 bpm and either are on maximally tolerated doses of beta-blockers, or have a contraindication to beta-blockers. This article will review and evaluate the data supporting the use of ivabradine in patients with HF and explore its mechanisms and physiologic effects.

Topics: Arrhythmias, Cardiac; Benzazepines; Cardiomyopathies; Cardiovascular Agents; Clinical Studies as Topic; Heart Failure; Heart Rate; Heart Transplantation; Humans; Ivabradine; Shock, Cardiogenic; Ultrasonography

The effectiveness of drug remaxol inclusion in the scheme of treatment of patients with myocardial infarction on the background of degree III - III acute cardiac insufficiency was evaluated by the analysis of clinical and laboratory data of 126 patients with newly diagnosed acute myocardial infarction including ST-segment elevation on the background of acute cardiac insufficiency. Depending on the regimen, patients were divided into two groups. The first (control) group included 60 patients who received conventional thrombolytic therapy; the second (main) group included 66 patients which, after thrombolytic therapy, received remaxol (single daily intravenous administration, 400 mL at 3 - 4 mL/min rate) with controlled central venous pressure, arterial pressure, and diuresis. The course lasted for 3 - 5 days, depending on the severity of condition. A high efficiency of the treatment regimen including remaxol was established as characterized by more rapid (in comparison to conventional therapy) stabilization of disturbed systemic hemodynamics and recovery of weakened myocardial contractility, decreased risk of cardiac arrhythmias, and relieved hyperhomocysteinemia that, in turn, reduced the risk of complications such as thrombosis and thromboembolism.

Topics: Aged; Arrhythmias, Cardiac; Blood Pressure; Cardiovascular Agents; Case-Control Studies; Drug Administration Schedule; Female; Fibrinolytic Agents; Heart Rate; Humans; Hyperhomocysteinemia; Injections, Intravenous; Male; Middle Aged; Shock, Cardiogenic; Succinates; Thromboembolism; Thrombolytic Therapy; Thrombosis; Treatment Outcome

Overdose of cardiovascular medications is increasingly associated with morbidity and mortality. We present a case of substantial atenolol, chlorthalidone, and lisinopril overdose treated by multiple modalities with an excellent outcome.. Aggressive medical intervention did not provide sufficient hemodynamic stability in this patient with refractory cardiogenic and distributive shock. Impella® percutaneous left ventricular assist device and extracorporeal membrane oxygenation provided support while the effects of the overdose subsided. We present concentrations demonstrating removal of atenolol with continuous venovenous hemodiafiltration. This is the first report of esophagogastroduo denoscopy decontamination of this overdose with a large pill fragment burden.

Topics: Adrenergic beta-1 Receptor Antagonists; Adult; Atenolol; Cardiovascular Agents; Chlorthalidone; Combined Modality Therapy; Decontamination; Drug Overdose; Emergency Service, Hospital; Endoscopy, Digestive System; Extracorporeal Membrane Oxygenation; Female; Humans; Lisinopril; Multiple Organ Failure; Renal Dialysis; Shock, Cardiogenic; Tablets; Transcutaneous Electric Nerve Stimulation; Treatment Outcome

Topics: Acute Coronary Syndrome; Aged; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Disease Management; Electric Countershock; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Purkinje Fibers; Recurrence; Shock, Cardiogenic; Stents; Tachycardia, Ventricular; Ventricular Fibrillation

Topics: Adenoviridae Infections; Adult; Biopsy; Cardiovascular Agents; Combined Modality Therapy; Defibrillators; Disease Progression; Emergencies; Female; Fever; Heart-Assist Devices; Hemodynamics; Humans; Myocarditis; Myocardium; Parvoviridae Infections; Pericarditis; Shock, Cardiogenic; Spironolactone; Ventricular Dysfunction, Left

The presented work relates to the procedure followed for the automation of a portable extracorporeal circulatory support system. Such a device may help increase the chances of survival after suffering from cardiogenic shock outside the hospital, additionally a controller can provide of optimal organ perfusion, while reducing the workload of the operator. Animal experiments were carried out for the acquisition of haemodynamic behaviour of the body under extracorporeal circulation. A mathematical model was constructed based on the experimental data, including a cardiovascular model, gas exchange and the administration of medication. As the base of the controller fuzzy logic was used allowing the easy integration of knowledge from trained perfusionists, an adaptive mechanism was included to adapt to the patient's individual response. Initial simulations show the effectiveness of the controller and the improvements of perfusion after adaptation.

Topics: Algorithms; Ambulatory Care; Animals; Automation; Cardiovascular Agents; Computer Simulation; Electrocardiography; Extracorporeal Circulation; Fuzzy Logic; Heart Rate; Hemodynamics; Humans; Models, Cardiovascular; Pulmonary Gas Exchange; Shock, Cardiogenic; Sus scrofa

Acute coronary syndromes (ACS) may precipitate up to a third of acute heart failure (AHF) cases. We assessed the characteristics, initial management, and survival of AHF patients with (ACS-AHF) and without (nACS-AHF) concomitant ACS.. Data from 620 AHF patients were analyzed in a prospective multicenter study. The ACS-AHF patients (32%) more often presented with de novo AHF (61% vs. 43%; P < .001). Although no differences existed between the 2 groups in mean blood pressure, heart rate, or routine biochemistry on admission, cardiogenic shock and pulmonary edema were more common manifestations in ACS-AHF (P < .01 for both). Use of intravenous nitrates, furosemide, opioids, inotropes, and vasopressors, as well as noninvasive ventilation and invasive coronary procedures (angiography, percutaneous coronary intervention, coronary artery bypass graft surgery), were more frequent in ACS-AHF (P < .001 for all). Although 30-day mortality was significantly higher for ACS-AHF (13% vs. 8%; P = .03), survival in the 2 groups at 5 years was similar. Overall, ACS was an independent predictor of 30-day mortality (adjusted odds ratio 2.0, 95% confidence interval 1.07-3.79; P = .03).. Whereas medical history and the manifestation and initial treatment of AHF between ACS-AHF and nACS-AHF patients differ, long-term survival is similar. ACS is, however, independently associated with increased short-term mortality.

Topics: Acute Coronary Syndrome; Acute Disease; Aged; Cardiovascular Agents; Disease Management; Female; Finland; Heart Failure; Hospital Mortality; Hospitalization; Humans; Male; Myocardial Revascularization; Prospective Studies; Pulmonary Edema; Shock, Cardiogenic; Survival Analysis

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.. Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.. Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.. While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.

Topics: Acute Coronary Syndrome; Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiac Catheterization; Cardiovascular Agents; Chest Pain; Diagnosis, Differential; Electrocardiography; Female; Follow-Up Studies; Heart Arrest; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Platelet Aggregation Inhibitors; Pulmonary Edema; Queensland; Shock, Cardiogenic; Stress, Psychological; Stroke Volume; Takotsubo Cardiomyopathy; Ultrasonography; Ventricular Dysfunction, Left

A 58-year-old man underwent an elective coronary bypass graft for severe four-vessel stenosis. Cardiogenic shock developed just after coronary bypass grafting with a left internal mammary artery (LIMA) to left anterior descending (LAD) artery and superficial venous graft to 1st and 2nd obtuse marginal (OM1/OM2) arteries the posterior descending artery (PDA) was too small to graft. Despite significant inotropes and an intra-aortic balloon pump, the patient deteriorated in intensive care unit with cardiogenic shock and ventricular arrhythmia. Urgent coronary angiography revealed a rupture or torn LIMA graft with extravasation of contrast into the left pleural cavity. There was no distal LIMA to LAD flow probably due to graft thrombosis. Revascularisation was performed on the severe ostial native LAD stenosis with a drug eluting stent. The rupture graft was then stented with a polytetrafluoroethylene-covered stent, which stopped the bleeding, and latter, led to total graft thrombosis. The patient improved significantly and supportive inotropes could be weaned down. At 11 month follow-up, the patient had mild left ventricular dysfunction, widely patent ostial LAD stent and thrombosed LIMA graft.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Drug-Eluting Stents; Everolimus; Humans; Male; Mammary Arteries; Middle Aged; Polytetrafluoroethylene; Prosthesis Design; Rupture; Severity of Illness Index; Shock, Cardiogenic; Sirolimus; Treatment Outcome; Vascular System Injuries

To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort.. Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization.. A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic regression.. ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09-0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002-1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04-11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73-39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1-6.2)) and peak lactate (P = 0.02).. The ability to achieve complete revascularization may be strongly associated with improved in-hospital survival in patients with cardiogenic shock.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Catheterization, Swan-Ganz; Coronary Angiography; Coronary Artery Bypass; Female; Hospital Mortality; Humans; Logistic Models; Male; Manitoba; Middle Aged; Myocardial Infarction; Odds Ratio; Patient Discharge; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Shock, Cardiogenic; Survival Analysis; Survival Rate; Time Factors; Treatment Outcome

Topics: Anti-Bacterial Agents; Bacteremia; Borrelia; Cardiopulmonary Resuscitation; Cardiovascular Agents; Ceftriaxone; Child; Combined Modality Therapy; Cytokines; Doxycycline; Endotoxins; Female; Humans; Hypotension; Positive-Pressure Respiration; Pulmonary Edema; Relapsing Fever; Shock, Cardiogenic; Tachycardia; Unconsciousness

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Female; Humans; Male; Myocardial Infarction; Shock, Cardiogenic

Topics: Adult; Antigens, Viral; Capsid; Cardiopulmonary Resuscitation; Cardiovascular Agents; Death, Sudden, Cardiac; Defibrillators, Implantable; Electric Countershock; Electrocardiography; Epstein-Barr Virus Infections; Female; Herpesvirus 4, Human; Humans; Immunoglobulin G; Immunoglobulin M; Myocarditis; Shock, Cardiogenic; Ventricular Fibrillation

In recent decades, the increased use of novel pharmacologic therapies and primary percutaneous coronary intervention has considerably improved survival in the setting of ST-segment elevation myocardial infarction. Nevertheless, optimal management and care of particular subgroups of patients such as the elderly and individuals with diabetes mellitus, renal dysfunction, or cardiogenic shock are still debated. In fact, because of their clinically relevant comorbidities, these patients are often excluded from randomized trials; thus, data are largely limited to those from retrospective cohorts or subgroup analyses of large clinical studies. These particular subgroups of patients require special management during and after prompt mechanical reperfusion because of their high risk of both thrombotic and bleeding events. Therefore, cardiologists should accurately assess the risk-benefit equation before administrating and dosing currently available antithrombotic and antiplatelets agents in these high-risk populations.

Topics: Acute Disease; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Diabetes Complications; Electrocardiography; Fibrinolytic Agents; Heart-Assist Devices; Humans; Kidney Diseases; Myocardial Infarction; Platelet Aggregation Inhibitors; Risk Assessment; Shock, Cardiogenic

Significant progress has been made over the past 60 years in defining and recognizing cardiogenic shock (CS), and there have been tremendous advances in the care of patients who have this illness. Although there are many causes of this condition, acute myocardial infarction with loss of a large amount of functioning myocardium is the most frequent cause. It was recognized early in the study of CS that prompt diagnosis and rapid initiation of therapy could improve the prognosis, and this remains true today. Although the mortality from CS remains high, especially in elderly populations, modern therapies improve the chance of survival from this critical illness.

Topics: Biomedical Research; Cardiovascular Agents; Catheterization, Swan-Ganz; Coronary Artery Disease; Coronary Care Units; Critical Care; History, 18th Century; History, 19th Century; History, 20th Century; Humans; Intra-Aortic Balloon Pumping; Myocardial Revascularization; Shock, Cardiogenic; United Kingdom; United States

Patients who suffer cardiogenic shock after cardiac arrest have a very poor prognosis. Left ventricular assist devices have proven to be useful in these patients to improve survival. Recently introduced percutaneous assist devices are easier to use and can be inserted quickly in the catheterization laboratory. We describe a case where intra-aortic balloon pump by itself was not enough to provide hemodynamic support in a patient with cardiogenic shock after cardiac arrest. The Impella Recover LP 2.5 system (ABIOMED, Inc., Danvers, MA) was successfully used along with the balloon pump for hemodynamic support and resulted in dramatic improvement of the patient's condition.

Topics: Adult; Cardiovascular Agents; Combined Modality Therapy; Female; Heart Arrest; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Severity of Illness Index; Shock, Cardiogenic; Treatment Outcome

Topics: Acute Disease; Cardiovascular Agents; Diagnostic Techniques, Cardiovascular; Global Health; Heart Failure; Humans; Morbidity; Myocardial Revascularization; Shock, Cardiogenic; Survival Rate

We report a possible new therapeutic strategy, using extracorporeal cardiopulmonary support (ECLS), for severe refractory cardiogenic shock (SRCS) in a patient with Tako-tsubo cardiomyopathy (TC). TC is a syndrome characterized by left ventricular wall motion abnormalities, without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. This ventricular dysfunction can be reversible; however, it can progress into refractory cardiogenic shock with limited therapeutic options available. For the first time in a Tako-tsubo patient with refractory cardiogenic shock, we used ECLS treatment in order to rest the heart, sustain circulation and end-organ perfusion, and promote potential ventricular recovery. ECLS might be the selected treatment for SRCS in patients with TC, and seems to be an effective and useful ultimate therapeutic strategy for preventing death.

Topics: Aged; Cardiovascular Agents; Echocardiography, Transesophageal; Extracorporeal Circulation; Female; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Recovery of Function; Severity of Illness Index; Shock, Cardiogenic; Stress, Psychological; Takotsubo Cardiomyopathy; Treatment Failure; Ventricular Function, Left

Topics: Cardiovascular Agents; Combined Modality Therapy; Equipment Design; Heart Arrest; Heart-Assist Devices; Hemodynamics; Humans; Intra-Aortic Balloon Pumping; Severity of Illness Index; Shock, Cardiogenic; Treatment Outcome

Although acute left main coronary artery occlusion is rare, it carries a very high mortality rate. Following the encouraging results of trials testing the effect of primary percutaneous coronary intervention, more cases of left main stenosis are treated as culprit lesion in acute myocardial infarction. Few cases of primary percutaneous intervention on left main occlusion have been published. We present the case of an elderly patient presenting with acute myocardial infarction complicated by cardiogenic shock due to left main occlusion, with concomitant chronic total occlusion of right and left anterior descending coronary arteries. Successful percutaneous intervention as a bridge to coronary artery bypass grafting was performed with stent implantation, which resulted in the relief of obstruction, the restoration of blood flow and the immediate clinical improvement of the patient. The patient left the hospital in good condition after 11 days, although she had refused the proposed coronary artery bypass grafting.

Topics: Aged, 80 and over; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Angiography; Coronary Artery Bypass; Coronary Occlusion; Electrocardiography; Female; Humans; Metals; Myocardial Infarction; Prosthesis Design; Shock, Cardiogenic; Stents; Treatment Outcome; Treatment Refusal

Poisoning caused by drugs with cardiodepressive effects is an urgent condition in medicine which is associated with high mortality rate regardless of modern therapeutic methods. Accidental or intentional poisoning whit these drugs produces heart activity depression and cardiovascular collapse as consequences. Current therapy for severe poisoning caused by beta-blockers and calcium channel blockers includes both unspecific and specific antidote therapy whit glucagon, as well as application of adrenergic drugs, calcium, phosphodiesterase inhibitors and hyperinsulinemia/euglycemia therapy. However, even whit the application of these drugs, prompt measures of unspecific detoxication therapy and cardiopulmonary reanimation are crucial for survival of patients with severe poisoning.. A 28-year-old female patient was hospitalized for cardiogenic shock and altered state of conscioussnes (Glasgow coma score = 4), caused by acute poisoning with 2 g of metoprolol (Presolol), 1.8 g of diltiazem (Cortiazem) and 50 mg of cilazapril (Zobox). Prolonged cardiopulmonary resuscitation was applied during the first 16 hours of hospitalization, including administration of crystaline solutions (8 L), 17 mg of adrenaline, 4 mg of atropine, 4 mg of glucagone and 1.6 g of dopamine, with electro-stimulation by temporary pacemaker and mechanical ventilation. In a defined time period, normalized state of consciousness was registered, mechanical ventilation was stopped and normal heart activity and hemodynamic stability were accomplished. During hospitalization the patient was treated for mild pneumonia and after ten days, completely recovered, was released and sent to home treatment.. Prompt measures of cardiopulmonary resuscitation and multidisciplinary treatment in intensive care units significantly increase the chances of complete recovery of a patient with severe poisoning caused by drugs with cardiodepressive efects.

Topics: Adult; Cardiovascular Agents; Cilazapril; Diltiazem; Electrocardiography; Female; Humans; Metoprolol; Shock, Cardiogenic

Topics: Cardiovascular Agents; Diltiazem; Drug Therapy, Combination; Humans; Male; Middle Aged; Shock, Cardiogenic; Sotalol; Treatment Outcome

In patients with acute myocardial infarction (MI), cardiogenic shock (CS) remains associated with a high mortality (close to 50%) despite optimal therapeutic strategy. For those patients who are unlikely to survive, mechanical circulatory support (MCS) might be an additional life saving strategy.. To evaluate the efficacy of circulatory assistance in myocardial infarction complicated by cardiogenic shock.. We retrospectively studied the characteristics and clinical outcome of 10 patients hospitalized with acute MI and CS who required MCS. Mean age was 52+/-8 years; location of MI was anterior in 80% of cases. Immediate coronary angiography was performed in all cases 5.8+/-7.0 hours from the onset of symptoms. Intra-aortic balloon pumping was used in 70% of patients and 30% received thrombolysis. Angioplasty with stent implantation was performed in 8 patients.. In all patients MCS was placed within a mean of 57+/-92 hours after admission for hemodynamic instability (systolic aortic pressure: 85+/-13 mmHg; mean: 64+/-10 mmHg). Extracorporeal membrane oxygenation (ECMO) was implanted in 8 patients followed by Thoratec in one. The other 2 patients received a Thoratec and a Heartmate II system respectively. Survival rate was 40% (4 patients): 3 patients underwent heart transplantation at a mean of 93+/-97 days and one patient is alive with definitive implantable Heartmate. The other six patients died in hospital.. Mechanical circulatory support appeared life saving in 4 out of 10 patients with acute MI and cardiogenic shock refractory to optimal treatment. In this situation, circulatory assistance deserves discussion and the choice of optimal device should be further evaluated.

Topics: Adult; Angioplasty; Blood Pressure; Cardiovascular Agents; Coronary Angiography; Extracorporeal Membrane Oxygenation; Female; France; Hospital Mortality; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Myocardial Infarction; Patient Selection; Retrospective Studies; Shock, Cardiogenic; Stents; Thrombolytic Therapy; Time Factors; Treatment Failure

Acute cardiogenic shock is a lethal condition that results in death from myocardial failure, arrhythmia, or combinations of both. Aggressive medical, surgical, and interventional maneuvers have helped reduce the mortality. For the most advanced cases, ventricular assist devices have been used for persistent shock states. The purpose of this report is to describe the collaboration between cardiac surgery and cardiology subspecialty in an effort to promote native heart recovery in a complex case of cardiogenic shock requiring coronary artery bypass surgery, percutaneous coronary intervention, ventricular ablative therapy, and mechanical cardiac support.

Topics: Aged; Angioplasty, Balloon, Coronary; Arrhythmias, Cardiac; Cardiology; Cardiovascular Agents; Catheter Ablation; Coronary Artery Bypass; Heart-Assist Devices; Humans; Male; Myocardial Infarction; Patient Care Team; Shock, Cardiogenic; Stents; Thoracic Surgery

A case of a 62-year-old female with acute inferior myocardial infarction with right ventricular involvement is presented. The patient developed cardiogenic shock due to interventricular septum rupture. Pharmacological agents and intraaortic balloon counterpulsation restored normal circulation which enabled elective surgical treatment 14 days after the onset of symptoms.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Echocardiography; Electrocardiography; Female; Heart Septum; Humans; Intra-Aortic Balloon Pumping; Middle Aged; Myocardial Infarction; Shock, Cardiogenic; Treatment Outcome; Ventricular Septal Rupture

Topics: Algorithms; Bradycardia; Cardiovascular Agents; France; Heart Arrest; Hospital Units; Humans; Myocardial Infarction; Myocardial Reperfusion; Patient Transfer; Shock, Cardiogenic; Tachycardia

Perfusion of the abdomen is determined by cardiac function and circulation. Intestinal ischemia can be caused by Non occlusive bowel ischemia (NOD) that is important in internal as well as surgical intensive care medicine. Cardiac medication can influence perfusion of the bowel: 1) digitalis increases muscular tonus and decreases perfusion regulation b) diuretics lead to hypovolemia, hypotonia and malperfusion, c) antihypertensive medication can cause intraoperative hypotension that demands catecholamines, d) catecholamines can reduce perfusion by pathologic vasoconstriction in the splanchnicus area. Preoperative medication should respect 1) preoperatively taken ACE-inhibitors should be given postoperatively, as they have protective influence on the microcirculation of the bowel, 2) beta-blockers stabilize the myogenic tonus of the abdominal vessels, reduce an overshot of the parasympatheticus and diminish the risk of neurogenic abdominal shock, 3) catecholamines should be used with respect to ischemia of the bowel. Therapy of NOD should be focused on the primary vascular and hemodynamic causes and also take care for bacterial translocation and consecutive sepsis.

Topics: Aged; Cardiovascular Agents; Coronary Circulation; Hemodynamics; Humans; Intestines; Ischemia; Male; Mesenteric Vascular Occlusion; Risk Factors; Shock, Cardiogenic; Splanchnic Circulation; Systemic Inflammatory Response Syndrome; Thrombosis

We describe a patient who developed severe ventricular dysfunction and cardiogenic shock after intense emotional stress. Her subsequent course was favorable, with complete recovery of left ventricular systolic function. The coronary arteries were normal and no specific etiologic agent was demonstrated. Her clinical picture was compatible with transient left ventricular apical ballooning. [I123]metaiodobenzyl guanidine cardiac scintigraphy showed a marked decrease in cardiac sympathetic nerve activity. We discuss the pathophysiologic mechanisms of this syndrome.

Topics: Aged; Cardiovascular Agents; Echocardiography, Doppler; Electrocardiography; Female; Heart Ventricles; Humans; Shock, Cardiogenic; Stress, Psychological; Tomography, Emission-Computed, Single-Photon; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left

Topics: Angina, Unstable; Cardiovascular Agents; Female; Heart Ventricles; Humans; Hypertrophy, Left Ventricular; Middle Aged; Shock, Cardiogenic; Ventricular Outflow Obstruction

The authors report the case of a man with a laryngeal neoplasm treated by chemotherapy including 5 FU who presented a severe cardiogenic shock responding to medical therapy with a favourable outcome. This classical clinical presentation is commented by the authors. Based on the electrocardiogram, the echocardiography and a review of literature, they favour as first underlying hypothesis the secondary metabolic pathway linked to ribonucleic acid (RNA), rather than a possible coronary spasm.

Topics: Adenocarcinoma; Antineoplastic Combined Chemotherapy Protocols; Cardiovascular Agents; Fluorouracil; Humans; Laryngeal Neoplasms; Male; Middle Aged; Shock, Cardiogenic

Topics: Cardiac Output, Low; Cardiovascular Agents; Education, Nursing, Continuing; Humans; Nursing Assessment; Pulmonary Wedge Pressure; Shock, Cardiogenic

Topics: Cardiac Glycosides; Cardiovascular Agents; Heart Failure; Humans; Shock, Cardiogenic

Topics: Angina Pectoris; Assisted Circulation; Cardiovascular Agents; Diagnosis, Differential; Drug Therapy, Combination; First Aid; Humans; Plasma Substitutes; Shock, Cardiogenic

Topics: Cardiovascular Agents; Heart Failure; Humans; Kinetics; Lidocaine; Liver; Metabolic Clearance Rate; Shock, Cardiogenic

Topics: Blood Transfusion; Cardiovascular Agents; Dopamine; Droperidol; Humans; Shock, Cardiogenic

Topics: Cardiovascular Agents; Heart Failure; Humans; Myocardial Infarction; Pulmonary Edema; Shock, Cardiogenic

Topics: Cardiovascular Agents; Critical Care; Humans; Male; Middle Aged; Myocardial Infarction; Nursing Assessment; Shock, Cardiogenic