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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Therapeutic Advances in the Management of Cardiogenic Shock
Ovidiu Chioncel1,2, Sean P Collins3, Andrew P Ambrosy4,5
1University of Medicine "Carol Davila," Bucharest.
Insights
Cardiogenic shock (CS) management is improving with advances in mechanical circulatory support (MCS) and regional care centers. Further research is needed to optimize pharmacological and mechanical therapies for better patient outcomes.
Area of Science:
- Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock (CS) is a critical condition characterized by tissue hypoperfusion and high mortality.
- Despite advanced monitoring and treatments, significant uncertainties persist in CS management.
Purpose of the Study:
- To review therapeutic advances in the management of cardiogenic shock.
- To highlight current uncertainties and future research directions in CS treatment.
Main Methods:
- Review of prospective multicentric acute heart failure registries focusing on CS patients.
- Inclusion of relevant clinical trials and meta-analyses on therapeutic strategies for CS, particularly post-acute myocardial infarction (AMI).
Main Results:
- Early revascularization is key for CS in AMI; "culprit-lesion-only" strategy is recommended for multivessel disease.
- Mechanical circulatory support (MCS) devices improve hemodynamics, but clinical trial outcomes are often inconclusive; new algorithms and technology show promise in selected patients.
- Establishment of regional CS centers improves care coordination and patient outcomes.
Conclusions:
- Optimal intensity and timing of pharmacological and mechanical therapies require further clarification.
- New triage algorithms are needed for effective CS management.
- Continued research is essential to address remaining uncertainties in CS treatment.
Background:
Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS.
Areas Of Uncertainty:
Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies.
Data Sources:
The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study.
Therapeutic Advances:
Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes.
Conclusions:
Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.
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