Therapeutic Advances in the Management of Cardiogenic Shock

Abstract

Background: Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated to a very high risk of mortality, despite intensive monitoring and modern treatment modalities. Present review aims to describe the therapeutic advances in the management of CS. Areas of Uncertainty: Many uncertainties about CS management remain in clinical practice, and these relate to 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 is coming from CS in setting of acute myocardial infarction (AMI), while for nonAMI-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 metaanalysis providing information about benefits and risks of MCS were reviewed in the manuscript.

Effect of arterial oxygen partial pressure inflection point on Venoarterial extracorporeal membrane oxygenation for emergency cardiac support

“…Legend: The cut-off value was set at 62 h, prediction sensitivity was 92.3%, and specificity was 65.6%. tIPPaO2, time of inflection point of arterial oxygen partial pressure cautiously recommended as an alternative option for CA/RCS [1,4,10,14]. The present study showed an overall survival rate similar to that in previous studies [10,12,15].…”

“…Reportedly, traditional CPR therapy survival rate for in-hospital CA is between 35.6 and 39.7% and between 7.7 and 8.3% for out-of-hospital CA [ 7 , 11 ]. RCS mortality rate is also high at 30–60% [ 10 ] Multi-center prospective RCT studies are still lacking because multiple factors affect the VA-ECMO treatment prognosis and complex ethical issues are involved in the process. However, a few studies, such as ARREST trial [ 12 ], show that CA/RCS patients treated with VA-ECMO might improve survival compared with traditional treatment [ 5 , 7 , 11 , 13 ].…”

“…Treatment monitoring was performed using catheterization of the right radial or brachial artery, arterial blood pressure monitoring, observing pulse pressure difference and arterial waveform in real-time, analyzing arterial blood gas and activated clotting time (ACT) every 4–6 h (Fig. 1 , green fork represents monitoring point), and performing bedside cardiac ultrasound every 24 h. If the pulse pressure difference suddenly became large or the amplitude of the arterial waveform suddenly increased, blood gas analysis was performed immediately [ 9 , 10 ]. If there was an inflection point change in PaO 2 , tIPPaO 2 was recorded and bedside cardiac ultrasound was performed immediately.…”

The Prognostic Value of GRACE score for Acute Kidney injury in ST Elevation Myocardial Infarction Patients Complicated with Cardiogenic Shock

“…Although CS may be caused by a variety of cardiovascular conditions, the most common reason is STEMI (15). Although there have been great improvements in pharmacological treatment and reperfusion therapy of patients with CS in the last two decades, the mortality rate among these patients still remains to be high (16). Additionally, this condition is frequently complicated with the deterioration of renal functions that has been related with further increase in mortality rates (17,18).…”

Experimental Myocardial Infarction Elicits Time-Dependent Patterns of Vascular Hypoxia in Peripheral Organs and in the Brain

“…Despite the use of early coronary revascularization and the advances in cardiogenic shock treatment, the inability to rapidly restore regional tissular normoxia represents a critical factor impacting MI prognosis ( 2 ). Monitoring, as early as possible, organ-specific dynamics of hypoxia represents a candidate strategy to guide treatments and to timely identify high-risk patients ( 3 ). Currently, serum biomarkers like lactate are used to gauge global tissue perfusion.…”