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Published on: June 12, 2021
Mechanical Circulatory Support Devices in Acute Myocardial Infarction-Cardiogenic Shock: Current Studies and Future
Jacob C Jentzer1, Srihari S Naidu2, Deepak L Bhatt3
1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Insights
Temporary mechanical circulatory support (MCS) for cardiogenic shock (CS) after acute myocardial infarction (AMI) has not improved survival in trials. Future studies need better patient selection and study designs for effective MCS use.
Area of Science:
- Cardiology
- Critical Care Medicine
- Medical Devices
Background:
- Cardiogenic shock (CS) following acute myocardial infarction (AMI) has high mortality.
- Temporary mechanical circulatory support (MCS) devices are used for AMI-CS.
- Previous randomized controlled trials (RCTs) have not shown survival benefits for temporary MCS in AMI-CS.
Purpose of the Study:
- To review the existing literature on temporary MCS for AMI-CS.
- To discuss challenges in current research and clinical practice.
- To inform the design of future studies for improved evidence-based guidelines.
Main Methods:
- Review of randomized controlled trials (RCTs) and observational studies.
- Analysis of limitations in study designs, including selection bias and confounding variables.
- Discussion of population heterogeneity and device-matching strategies.
Main Results:
- No RCTs have demonstrated improved survival with temporary MCS in AMI-CS.
- Observational studies show conflicting results, sometimes contradicting RCT findings.
- Significant limitations in both RCTs and observational studies hinder strong inferences.
Conclusions:
- Current evidence on temporary MCS for AMI-CS is limited by study design flaws.
- Addressing selection bias, confounding, and patient heterogeneity is crucial.
- Personalized device selection for AMI-CS patients may improve outcomes.
Abstract:
Cardiogenic shock (CS) caused by acute myocardial infarction (AMI) accounts for most deaths in the population with AMI and continues to be associated with high short-term mortality. Several temporary mechanical circulatory support (MCS) devices have been developed to treat CS and studied in randomized controlled trials (RCTs) of patients with AMI-CS. Unfortunately, none of these RCTs has demonstrated an improvement in survival with temporary MCS in AMI-CS. Potential reasons for these negative results in RCTs are numerous and reflect the challenges of enrolling critically ill patients with CS. Researchers have used observational study designs to provide insights about outcomes associated with the use of temporary MCS in AMI-CS. These observational studies have yielded conflicting results, in some cases contrary to the results of RCTs. Several limitations pertinent to both RCTs and observational analyses, mostly relating to selection bias and failure to consider unmeasured confounding variables and population heterogeneity, preclude drawing strong inferences regarding the effects of temporary MCS on survival in populations with AMI-CS. Understanding these limitations is essential to correctly interpreting the literature regarding temporary MCS to treat AMI-CS and is necessary to inform the design of future studies that will potentially provide stronger evidence. Optimally matching temporary MCS devices to the needs of individual patients with AMI-CS will presumably be more successful than indiscriminate application in unselected patients. In this review, we discuss the existing literature on temporary MCS to treat AMI-CS and describe the specific challenges that must be overcome to develop an improved evidence base for guiding clinical practice.
