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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.

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Background/Objectives Frailty, characterized by decreased physiologic reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure (HF), making a distinction between these phenotypes difficult. We sought to determine if implantation of a left ventricular assist device (LVAD) would improve the frailty phenotype. Design Prospective, cohort study Setting Five academic medical centers. Participants 29 frail subjects (age 70.6±5.5 years, 72.4% male) Measurements Frailty assessed prior to LVAD and at 1, 3 and 6 months post-LVAD and was defined as ≥3 Fried Frailty phenotype criteria. Other domains assessed included quality of life using the Kansas City Cardiomyopathy Questionnaire, mood using PHQ9, and cognitive function using trail maker B test Results After 6 months, 3 subjects died and 1 underwent a heart transplant; among 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9±0.9 at baseline to 2.8±1.4 at 6 months, p=0.003. Improvements were not observed until 3–6 months of support. However, 10 (52.6%) continued to meet ≥3 Fried criteria and all subjects met at least one at 6 months. Changes in the frailty phenotype were associated with improvement in QOL but not with changes in mood or cognition. eGFR at baseline was independently associated with improvement in frailty phenotype. Conclusions The frailty phenotype was improved in approximately 50% of older adults with advanced HF after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.

The impact of left ventricular ejection fraction (EF) on outcome in patients with heart failure (HF) undergoing non-cardiac surgery has not been extensively evaluated. 174 subjects (mean age 75±12 years, 47% male, mean EF (47±18%) underwent intermediate or high risk non-cardiac surgery. Patients were stratified by EF and adverse perioperative complications were identified and compared. Adverse perioperative events occurred in 53 (30.5%) of subjects, including 14 (8.1%) deaths within 30 days, 26 (14.9%) myocardial infarctions, and 44 (25.3%) HF exacerbations. Among the factors associated with adverse perioperative outcomes in the first 30 days were advanced age (e.g. >80 years), diabetes and a severely decreased EF (e.g. <30%). Long term mortality was high and Cox proportional hazards analysis demonstrated that EF was an independent risk factor for long term mortality.

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