debates and challenges in the management of …

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Frontiers Journal of Cardiology & Cardiovascular Medicine (FJCCM)

Volume 01, Issue 01, Article ID FJCCM-20-104

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DEBATES AND CHALLENGES IN THE

MANAGEMENT OF CARDIOGENIC SHOCK DUE TO

ST ELEVATION MYOCARDIAL INFARCTION

Mody R, Max Super Specialty Hospital, India

Dash D, Zulekha Hospital, UAE

Mody B, Kasturba Medical College, India

Saholi A, Punjab Institute of Medical Sciences, India

*Corresponding Author: Mody R, Department of Cardiology, MAX Super specialty

hospital, Bathinda, Punjab, India. E-mail: [email protected]

Citation: Mody, R., Dash, D., Mody, B., & Saholi, A. (2020). Debates and Challenges in the

Management of Cardiogenic Shock Due To St Elevation Myocardial Infarction. Frontiers

Journal of Cardiology & Cardiovascular Medicine, 1(1), 1-15.

Copyright: © 2020 Mody, R., et al. This is an open-access article distributed under the terms

of the creative commons attribution license, which permits unrestricted use, distribution, and

reproduction in any medium, provided the original author and source are credited.

Received Date: 29 November 2020; Accepted Date: 15 December 2020; Published Date: 25

December 2020.

ABSTRACT

Research Article Open Access

Cardiogenic shock is a complex hemodynamically complex syndrome

characterized by reduced cardiac output that often culminates in multi-organ failure

and death. Despite recent advances, clinical outcomes remain poor, with mortality

rates exceeding 40%. Vascular remodeling, vasopressors, anticonvulsants, fluids,

mechanical circulation support, and general intensive care measures are widely used

for the management of CS. However, there is only limited evidence for any of the

treatment strategies listed above except for remodeling and the relative ineffectiveness

of intra-aortic balloon infusion. A few experiments were completed and a randomized

clinical trial focused on these patients, reflecting the challenges of conducting trials in

this severely ill population. We have little evidence to guide treatment. As a result, the

controversy surrounding treatment strategies is more common in these patients than

conclusions.

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INTRODUCTION

Recent data suggests that mortality improvement among ST-elevation myocardial

infarction (STEMI) have staggered in recent years (Shahet al., 2015). The incidence of CS

complicating AMI is still in the range of 3– 13% (Aissaoui et al., 2012; Jeger et al., 2008;

Backhaus et al., 2018; Rathod et al., 2018 ). Recent registries showed contradictory data with

a decreased, stable, or even increased incidence of CS (Aissaoui et al., 2012; Jeger et al.,

2008; Backhaus et al., 2018; Rathod et al., 2018 ). STEMI complicated by CS remains one of

the most challenging conditions to manage. Mortality rates are high with up to one half of all

patients dying before hospital discharge (Anderson et al., 2013; Babaev et al., 2005. Timely

reperfusion with primary percutaneous intervention (PCI) is a class I recommendation in the

American college of cardiology foundation/ American heart association guidelines for the

management of patients with STEMI complicated by CS (Yancy et al., 2013). Despite

continued improvement in the door-to-balloon time since the implementation of the guideline

(Menees et al, 2014); however, mortality rates remain high. We discuss different

management strategies and challenges that limit progress in the treatment of CS. Ventricular

failure subsequent to acute myocardial infarction (AMI) remains the most frequent cause of

cardiogenic shock (CS) accounting for more than 80% of cases. Mechanical complications of

AMI represent less common causes of CS (ventricular septal rupture (4%), free wall rupture

(2%), and acute coronary regurgitation (7%) (Hochman et al., 2000).

DEFINITION OF CARDIOGENIC SHOCK

In general, CS is defined as a condition of hypovolemia and hypoxia of the critical

end organ due to primary cardiac disturbances (Van Diepen et al., 2017). In practice, a

diagnosis of CS can be made on the basis of clinical criteria such as persistent hypotension

without adequate response to replace volume and clinical features associated with decreased

blood flow in the end organ such as cold extremities, oliguria or altered mental state. In

addition, biochemical features of tissue perfusion deficiency such as arterial lactate elevation

are usually present (Table 1).

SHOCK Trial (1999) IABP-SHOCK II

Trial (2012

IMPRES

S Trial

(2017

CULPRIT-SHOCK Trial

(2017

Study

design

RCT RCT RCT RCT

Study

arms

Emergent

revascularization

vs. initial medical

stabilization in AMI-

CS

IABP vs. optimal

medical therapy

in

AMI-CS treated

with early

revascularization

(PCI or CABG)

Impella

CP vs.

IABP in

mechanic

ally

ventilated

patients

with AMI

complicat

ed by

severe CS

Culprit lesion PCI (with

option of staged

revascularization) vs. Ad

hoc multivessel PCI in

AMI-CS with multivessel

CAD

Sample

size

302 600 48 786




Clinical

criteria SBP <90 mm

Hg

for $30 mins OR

vasopressors

to maintain

SBP $90 mm Hg

AND

End-organ

hypoperfusio

n

(urine output <30

ml/h

Sustained SBP

<90 mm Hg for

$30 min or

catecholamines

to maintain SBP

>90 mm Hg

AND

Clinical

pulmonary

congestion AND

Impaired end-

organ perfusion

with $1 of the

following

criteria:

a) Altered mental

status

b) Cold/clammy

skin and

extremities

c) Urine output

<30 ml/h

d) Lactate >2.0

mmol/l

Sustained

SBP #90

mm Hg

for >30

min or

need for

vasopress

ors/

inotropes

to

maintain

SBP >90

mm Hg

Sustained SBP #90 mm Hg

for

>30 min or need for

vasopressors/

inotropes to maintain SBP

>90 mm Hg

Clinical pulmonary

congestion

Impaired end-organ

perfusion

with $1 of the following

criteria:

a) Altered mental status

b) Cold/clammy skin and

extremities

c) Urine output <30 ml/h

d) Lactate >2.0

Hemody

namic

criteria

CI #2.2 l/min/m2 and

PCWP >15 mm Hg

- - -

*Data was evaluated for 686 patients.

AMI ¼ acute myocardial infarction; CABG ¼ coronary artery bypass grafting; CAD ¼

coronary artery disease; CI ¼ cardiac index; CS ¼ cardiogenic shock; CULPRIT-SHOCK ¼

Culprit Lesion Only PCI versus

Multi-vessel PCI in Cardiogenic Shock; IABP ¼ intra-aortic balloon pump; IABP-SHOCK II ¼

Intraaoartic Balloon Pump in Cardiogenic Shock II; IMPRESS in Severe Shock ¼ IMPella

versus IABP Reduces

mortality in STEMI patients treated with primary PCI in Severe cardiogenic SHOCK; PCI ¼

percutaneous coronary intervention; NA ¼ not applicable; PCWP ¼ pulmonary capillary wedge

pressure;

RCT ¼ randomized controlled trial; SBP ¼ systolic blood pressure; SHOCK ¼ Should We

Emergently Revascularize Occluded Arteries in Cardiogenic Shock.

In search of a common language for determining disease severity, the Society for

Cardiovascular Imaging and Interventions (SCAI) recently developed a 5-stage (A - E)

classification system for CS16 (Fig.1)




Figure 1 Cardiogenic shock pyramid according to recent proposal. Five categories of

cardiogenic shock. Stage A: At risk: Patients ‘At risk’ for cardiogenic shock development but

not currently experiencing signs/symptoms of cardiogenic shock. Stage B: Patients with

clinical evidence of relative hypotension or tachycardia without hypoperfusion being at

‘Beginning’ of cardiogenic shock. Stage C: Patients in the state of ‘Classic’ cardiogenic

shock. Stage D: Cardiogenic shock signals deteriorating or ‘Doom’. Stage E: Patients in

‘Extremis’ such those experiencing cardiac arrest with ongoing cardiopulmonary

resuscitation and/or extracorporeal membrane oxygenation cardiopulmonary resuscitation.

MANAGEMENT AND TREATMENT

a. EMERGENCY DEPARTMENT

Effective triage in the emergency department is fundamental to early recognition and

treatment of CS. In AMI-CS, this means the timely acquisition and interpretation of a 12-lead

ECG by emergency medical personnel and immediate transfer to a facility capable of

percutaneous coronary intervention. In the emergency department, the diagnosis of CS may

be facilitated by a physical examination, ECG, laboratory evaluation, and echocardiography

(when available) at the point of care (Lancellotti et al., 2014). Although patients with pre

trauma may transfer directly to the cardiac catheterization laboratory, those with SCAI in

stage C or D CS may first need initial fixation using vasocompression therapy and

mechanical ventilation, albeit without much delay in pumping blood (Levy et al., 2018; van

Diepen et al., 2020; Kochar et al., 2018). In patients with SCAI in stage E or end stage CS for

whom aggressive treatments may not be feasible, palliative care counseling and discussions

with healthcare alternatives regarding the goals of care may be warranted (Rogers et al.,

2017).

Vascular remodeling based on trauma experience, early vascular remodeling is the

most important treatment strategy in CS after myocardial infarction (Hochman et al., 1999)).

However, there was a significant reduction in mortality at longer follow-up after 6 months, 1,

and 6 years (Hochman et al., 1999; Hochman et al., 2006). Applying the current evidence-

based standards together with the failed primary study endpoint, may presently lead to a

different interpretation of the experiment. However, since the widespread use of early

revascularization, multiple records have confirmed a significant reduction in mortality from

the previous 70-80% to 40-50%. 3 Therefore, the current Category 1B recommendation in the

European Society of Cardiology (ESC) and principles American steering appears justified

(Fig. 2) (Neumann et al., 2019; Ibanez et al., 2018; Kushner et al., 2009). Recent records

indicate a detrimental effect of angiogenesis delays on outcome (Kochar et al., 2018; Scholz




et al., 2018). Therefore, efforts should be directed towards immediate transfer to specialized

24/7 PCI care centers. Evidence is lacking to support fibrinolysis in CS. However, if an early

invasive approach cannot be completed in time, then STEMI-associated fibrinolysis can be

considered (Fig.2).

Figure 2: Treatment algorithm for patients with cardiogenic shock and myocardial infarction

complication. Category recommendation and level of evidence are provided according to the

latest European Society of Cardiology guidelines if available. 15, 37, 38 Category 1

recommendations are outlined in green. Category IIa recommendations are shown in yellow.

Category IIb recommendations are shown in orange. Category 3 recommendations are shown

in red.

b. REVASCULARIZATION STRATEGIES

Although more than 70% of AMI-CS patients have multivascular coronary disease,

less than 4% undergo emerging coronary artery bypass grafting (Thiele et al., 2012).

Monitoring data indicate that coronary artery bypass grafting and coronary artery bypass

grafting share similar mortality rates in AMI-CS (Mehta et al., 2010). Despite the specific

benefits of complete revascularization in AMI, optimal management of artery lesions not

associated with infarction in AMI-CS remains unclear (Mehta et al., 2019). To date, the

CULPRIT-SHOCK trial (Culprit Lesion Only PCI versus Multivascular PCI in Cardiogenic

Shock) is the only study that has addressed this question, and has shown lower rates of 30-

day death or renal replacement therapy using culprit vessel PCI versus a multivascular

intervention (Thiele et al., 2017). A recent National Heart Trauma Initiative sub-study

showed similar mortality, acute renal injury, and length of hospital stay between the two

strategies when axial-flow MCSs were implanted before revascularization (Lemor et al.,

2020), suggesting that revascularization of non-induced lesions may be possible when

supported by MCS. AMI-CS custom multi-unit PCI is currently receiving a Class IIb

guidance recommendation (Levine et al., 2016).




c. CICU MANAGEMENT OF CARDIOGENIC SHOCK

The treatment of CS is complex and cardiac intensive care units are best suited to deal

with such a complication (Van Diepen et al, 2017; Rab et al, 2018). Optimal MODS intensive

care unit therapy is essential to treat patients with CS as it has a major influence on prognosis.

Although CS has not been specifically investigated, multiple measures are generally

accepted. If invasive ventilation is required, protective lung ventilation (6 mL / kg expected

tidal volume of body weight) should be performed to prevent lung injury. Non-invasive

ventilation with continuous positive airway pressure may be an option to prevent intubation

in borderline respiratory conditions (Ponikowski et al., 2016). Urinary production as well as

renal function should be measured by serial creatinine measurements and initiation of renal

replacement therapy in acute renal failure with clinical signs of hematuria, irreversible

overload, or metabolic acidosis (pH 6.0 mmol / L) . Based on these criteria, renal replacement

therapy was necessary in 14% of patients in the CULPRIT-SHOCK trial (Thiele et al., 2017).

initiation of renal replacement therapy had no effect on outcomes in ICU patients with acute

renal injury (Gaudry et al., 2016).

High liver norms often follow poor circulation as a result of RV congestion. Liver

function tests are altered in more than 50% of patients with CS (Jung et al., 2017). The

elevated transaminases can be interpreted as a direct sign of decreased blood flow to the liver,

associated with increased mortality (Jung et al., 2017). Hemodynamics must be stabilized to

achieve optimal hepatic perfusion. Furthermore, it is recommended to adjust blood sugar to

target blood glucose concentrations between 144 mg / dL and 180 mg / dL (8-10 mmol / L)

while avoiding hypoglycaemia (Jacobi et al., 2012). Prevention of thromboembolism and

stress ulcers should follow general recommendations for critically ill patients. Until recently

the available evidence was insufficient for nutritional management in relation to enteral or

parenteral administration. In a recent randomized trial including all-cause trauma (19% CS)

requiring intestinal vascular pressures or parenteral nutrition initiated within 24 hours. Early

parenteral parenteral administration compared with early parenteral parenteral nutrition did

not reduce mortality but was associated with an increased risk of gastrointestinal

complications. Therefore, no early stage feeding and possibly primary parenteral nutrition in

CS should be preferred. There is no consensus on the optimal method of hemodynamic

monitoring in the evaluation and treatment of patients in CS, including pulmonary artery

catheterization. Current scientific guidelines and data take into account the use of PAC early

in the treatment course in patients who do not respond to initial therapy or in diagnostic or

therapeutic uncertainties (Figure 2) (Van Diepen et al., 2017; Ponikowski et al., 2016). The

understanding of the etiology of CS and RV failures has changed in the past decade. With

PAC, several hemodynamic profiles were identified where the diagnosis is driven by RV

performance that can be altered with RV MCS. These variables and calculations were

recently revised (Kapur et al., 2017). Of them, the pulmonary artery pulse index (pulmonary

artery systolic pressure - diastolic pulmonary pressure / right atrial pressure) 7 g / dL (> 4.3

mmol / L) unless there is no clinical bleeding problem (Hunt, 2014). Overall CICU

management is summarized for CS in Figure 3.




Figure 3. This schematic illustrates the longitudinal and multidisciplinary care pathways for

cardiogenic shock (CS) care in a contemporary level 1 cardiac intensive care unit (CICU). CI

¼ cardiac index; CO ¼ cardiac output; CPO ¼ cardiac power output; DNR ¼ Do Not

Resuscitate order; dPAP ¼ diastolic pulmonary arterial pressure; L ¼ left; MAP ¼ mean

arterial pressure; MCS ¼ mechanical circulatory support; PAPi ¼ pulmonary arterial

pulsatility index; PCWP ¼ pulmonary capillary wedge pressure; pVAD ¼ percutaneous

ventricular assist device; R ¼ right; sPAP ¼ systolic pulmonary arterial pressure.

d. MECHANICAL CIRCULATORY SUPPORT

Mechanical circulation support devices (MCS) are increasingly used in CS to stabilize

hemodynamics (Helgestad et al., 2020), although exactly when and whether they are

incorporated into trauma care remains controversial (Van Diepen et al., 2017; Thiele et l.,

2019). The potential benefits of MCS include reducing stroke action and filling pressure

within the heart, and enhancing perfusion of the coronary arteries and peripheral organs

(Rihal et al., 2015). Device selection should be guided by disease severity, CS phenotype,

degree of vascular and ventricular support required, vascular access or anatomy, size and

procedural expertise of the operator or center (Fig. 4). Understanding how each platform

changes ventricular pressure volume relationships is critical to implementing the optimal




strategy (Rihal et al., 2015). Although axial flow and centrifugation devices may improve

circulation compared to an intra-aortic balloon pump, no survival benefit has been

demonstrated to date (Thiele et al., 2017). In addition, recent monitoring data from CathPCI

and Chest Pain records -MI as well as the Premier Healthcare database show wide variations

in axial flow device use across the United States and raise safety concerns, particularly major

bleeding, stroke, and deaths (Dhruva et al., 2020; Amin et al., 2020). Nevertheless, data

emerging from records of dedicated trauma centers indicate that when MCSs are deployed

selectively using early invasive hemodynamics and standard multidisciplinary treatment

algorithms, improvements in survival can be achieved (Tehrani et al., 2019; Basir et al.,

2019; Taleb et al., 2019). In patients with condylar femoral angiomas, experience with

alternative access is key. The axillary artery, in particular, has been shown to be a suitable

conduit for an intra-aortic balloon pump and Impella (Abiomed, Danvers, Massachusetts) in

patients with CS, as it may also facilitate early ambulation and improve nutritional status in

patients requiring prolonged circulatory support While awaiting alternative cardiac treatment

(Tayal et al., 2019; Esposito et al., 2018). Our current practice is to selectively deploy MCS

in appropriate patients with acute or refractory CS after urgent consultation with the

multidisciplinary trauma team, which consists of an interventional cardiologist, cardiac

surgeon, cardiac intensive physician and advanced heart failure specialist. Lactate levels,

cardiac energy output, and the pulmonary arterial pulse index help facilitate both MCS and

weaning strategies. MCS may be used as a bridge to myocardial recovery, heart replacement

therapy, or as a temporary procedure to evaluate a patient's candidacy for a permanent

ventricular assist device or heart transplant. Strict adherence to best practices for vascular

access and closure, familiarity with device troubleshooting, and multidisciplinary care in

PICU Level 1 are critical components of optimal care (Rab et al., 2018).




Figure 4. The hemodynamic profiles of the various circulatory support devices available for

treatment of cardiogenic shock. ADHF ¼ acute decompensated heart failure; AMI ¼ acute

myocardial infarction; AO ¼ aorta; Bi-V ¼ biventricular; CS ¼ cardiogenic shock; FA ¼

femoral artery; FDA ¼ Food and Drug Administration; HR-PCI ¼ high risk percutaneous

coronary intervention; IABP ¼ intra-aortic balloon pump; IJ ¼ internal jugular; LA ¼ left

atrium; LV ¼ left ventricular; LVAD ¼ left ventricular assist device; PA ¼ pulmonary

artery; RA ¼ right atrium; RPM ¼ revolutions per minute; RV ¼ right ventricular; RVF ¼

right ventricular failure; VA-ECMO ¼ venoarterial extracorporeal membrane oxygenation.

Adapted with permission from Thiele et al. 39

e. CONTROVERSIES OF MECHANICAL CIRCULATORY SUPPORT

Several open problems remain in mechanical device treatment such as the optimal

timing of device insertion. Prevention of MODS could be a potential benefit of early use at

the onset of CS. However, early use may lead to complications associated with invasive

mechanical support devices, resulting in negative clinical outcomes in patients who still have

non-surgical treatment options. Moreover, adequate patient selection is important and is

currently often based on subjective criteria. Approximately 60% of CS patients will live

without any active device as described in IABP-SHOCK II (Thiele et al., 2012). There may

also be sterile situations where even the best will not be able. A device available to change

the clinical outcome. Timing and appropriate patient selection is also influenced by the

balance between the effectiveness of any device and its device-related complications. Devices

with lower complication rates may be chosen more liberally in the early stage of CS, while

more aggressive devices with higher flow rates may be reserved for more severe devices. The

optimum support has also not been identified. A randomized, multicenter Danish trial

(DanShock; Clinicaltrials.gov: NCT01633502) compares Impellaw CP with standard

treatment and may also answer if an active device implanted on a routine basis can reduce

mortality. Several other devices are currently under investigation for CE approval in Europe

such as HeartMate PHPTM (percutaneous heart pump; Thoratec, Pleasanton, CA, USA).

Despite all these uncertainties, current European and American guidelines recommend

considering the use of a percutaneous assist device to support circulation in refractory CS

without any preference for device selection (IIa / C recommendation) (Windecker et al.,

2014; Steg et al., 2012; O'Gara et al., 2013).

f. LV ASSIST DEVICES AND HEART TRANSPLANTATION

Early and ongoing evaluation of the potential need for cardiac replacement therapy,

either with permanent MCS or heart transplantation, is essential for patients with refractory

CS. Therapeutic considerations include traditional risk factors such as age, renal and hepatic

function, blood clotting, aortic valve regurgitation, RV function, and compliance with drugs

(Samsky et al., 2020). A thorough clinical and psychosocial evaluation is required. With an

updated Heart Allocation Protocol of the United Network for Organ Participation that

temporarily prioritizes patients with MCS for accelerated heart transplantation, an increasing

number of patients with CS have used this pathway (Varshney et al., 2020). More research is

needed to guide the patient's choice of such advanced therapies (Hanff et al., 2020).

g. SHORT REVIEW OF MANAGEMENT

Here are key points to remember from this recent review on cardiogenic shock

management (Mukherjee, 2020):




i. Cardiogenic shock (CS) is a dynamically complex syndrome characterized by reduced

cardiac output that often culminates in multi-organ failure and death.

ii. Despite recent advances, clinical outcomes remain poor, with mortality rates

exceeding 40%. In the absence of sufficiently powered randomized controlled trials to

guide treatment, best practices for managing trauma remain inconsistent.

iii. Data emerging from the North American records support the use of standardized

protocols that focus on rapid diagnosis, early intervention, ongoing haemodynamic

assessment, and interdisciplinary longitudinal care.

iv. Effective triage in the emergency department is fundamental to early recognition and

treatment of CS. In the case of acute myocardial infarction (AMI) -CS, this means

timely acquisition of a 12-lead EKG and interpretation by emergency medical

personnel and immediate transfer to a facility capable of percutaneous coronary

intervention.

v. Although there is no benefit from using routine pulmonary artery catheterization

(PAC) for heart failure, mounting evidence supports the benefit of evaluating invasive

hemodynamics in patients with CS. The use of PAC may lead to early and more

accurate identification of the CS phenotype so that medical and device-dependent

treatments can be applied in an ad hoc manner.

vi. Limited data support the use of norepinephrine as the preferred first-line agent, and

retrospective analyzes indicate similar results with dobutamine and melrinone.

vii. In setting the dynamic and time-dependent complications associated with AMI-CS

complex due to cardiac arrest, a multidisciplinary approach to management is

recommended with an emphasis on assessing the patient's general prognosis, potential

for meaningful neurological healing, and filtering for vascular and organ remodeling.

Approved treatments.

viii. Selective deployment of mechanical circulation support (MCS) in appropriate patients

with acute or refractory CS after urgent consultation with the multi-disciplinary

trauma team, which consists of an interventional cardiologist, cardiac surgeon,

cardiologist and advanced heart failure specialist, is reasonable

ix. In some patients with a dominant left ventricle (LV) and hypotension, pure

vasodilators such as nitroprusside may improve cardiac output by reducing

subsequent pregnancy, while the vasodilating effects of melrinone and dobutamine

can also be effective for high-pregnancy LV failure. Intravenous or inhaled

pulmonary vasodilators reduce right ventricular postload (RV) for pulmonary arterial

hypertension and RV failure.

x. There is a critical need for practical randomized clinical trials for current and

emerging therapies to be adequately evaluated to further inform clinical practice

including the optimal role of MCS.

CONCLUSION

The prognosis for ST segment elevation myocardial infarction has improved

significantly since the introduction of coronary care units, revascularization and anticoagulant

strategies, but CS remains a highly fatal condition. Despite efforts to improve results, the

prognosis has not improved in recent decades. Controversies remain over optimal

pharmacological treatments, remodeling strategies, the role of MCS, evidence-based patient

selection and interactions between these parts of the path of care (Thiele et al., 2016; Moller,

2012; Brunner, 2015). The current informed consent model for clinical trials creates

challenges in testing treatments for patients with CS who are too ill for consent and in need of




immediate treatment. Fortunately, several trials are underway comparing the remodeling

strategies and MCS options (Thiele et al, 2016).

REFERENCES

Shah, R. U., - Henry, T. D., Rutten Ramos, S., Garberich, R. F., Tighiouart, M., & Merz, C.

N. B. (2015). Increasing percutaneous coronary interventions for ST-segment

elevation myocardial infarction in the United States: progress and opportunity. JACC:

Cardiovascular Interventions, 8(1 Part B), 139-146.

Aissaoui, N., Puymirat, E., Tabone, X., Charbonnier, B., Schiele, F., Lefèvre, T., et

al.,(2012). Improved outcome of cardiogenic shock at the acute stage of myocardial

infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French

nationwide registries. European heart journal, 33(20), 2535-2543.

Jeger, R. V., Radovanovic, D., Hunziker, P. R., Pfisterer, M. E., Stauffer, J. C., Erne, P., &

Urban, P. (2008). Ten-year trends in the incidence and treatment of cardiogenic

shock. Annals of internal medicine, 149(9), 618-626.

Backhaus, T., Fach, A., Schmucker, J., Fiehn, E., Garstka, D., Stehmeier, J., et al., (2018).

Management and predictors of outcome in unselected patients with cardiogenic shock

complicating acute ST-segment elevation myocardial infarction: results from the

Bremen STEMI Registry. Clinical Research in Cardiology, 107(5), 371-379.

Rathod, K. S., Koganti, S., Iqbal, M. B., Jain, A. K., Kalra, S. S., Astroulakis, Z., et al.,

(2018). Contemporary trends in cardiogenic shock: Incidence, intra-aortic balloon

pump utilisation and outcomes from the London Heart Attack Group. European Heart

Journal: Acute Cardiovascular Care, 7(1), 16-27.

Anderson, M. L., Peterson, E. D., Peng, S. A., Wang, T. Y., Ohman, E. M., Bhatt, D. L., et

al., (2013). Differences in the profile, treatment, and prognosis of patients with

cardiogenic shock by myocardial infarction classification: a report from

NCDR. Circulation: Cardiovascular Quality and Outcomes, 6(6), 708-715.

Babaev, A., Frederick, P. D., Pasta, D. J., Every, N., Sichrovsky, T., Hochman, J. S., &

NRMI Investigators. (2005). Trends in management and outcomes of patients with

acute myocardial infarction complicated by cardiogenic shock. Jama, 294(4), 448

454.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey Jr, D. E., Drazner, M. H., et al.,

(2013). 2013 ACCF/AHA guideline for the management of heart failure: executive

summary: a report of the American College of Cardiology Foundation/American

Heart Association Task Force on practice guidelines. Circulation, 128(16), 1810

1852.

Menees, D. S., Peterson, E. D., Wang, Y., Curtis, J. P., Messenger, J. C., Rumsfeld, J. S., &

Burm, H. S. (2014). Door-to-Balloon Time and Mortality Among Patients

Undergoing Primary PCI. Survey of Anesthesiology, 58(4), 162-163.

Hochman, J. S., Buller, C. E., Sleeper, L. A., Boland, J., Dzavik, V., Sanborn, T. A., et al.,

(2000). Cardiogenic shock complicating acute myocardial infarction—etiologies,

management and outcome: a report from the SHOCK Trial Registry. Journal of the

American College of Cardiology, 36(3 Supplement 1), 1063-1070.

Van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., et al.,

(2017). Contemporary management of cardiogenic shock: a scientific statement from

the American Heart Association. Circulation, 136(16), e232-e268.




Hochman, J. S., Sleeper, L. A., Webb, J. G., Sanborn, T. A., White, H. D., Talley, J. D., et al.,

(1999). Early revascularization in acute myocardial infarction complicated by

cardiogenic shock. New England Journal of Medicine, 341(9), 625-634.

Thiele, H., Zeymer, U., Neumann, F. J., Ferenc, M., Olbrich, H. G., Hausleiter, J., et al.,

(2012). Intraaortic balloon support for myocardial infarction with cardiogenic

shock. New England Journal of Medicine, 367(14), 1287-1296.

Ouweneel, D. M., Eriksen, E., Sjauw, K. D., van Dongen, I. M., Hirsch, A., Packer, E. J., et

al., (2017). Percutaneous mechanical circulatory support versus intra-aortic balloon

pump in cardiogenic shock after acute myocardial infarction. Journal of the American

College of Cardiology, 69(3), 278-287.

Thiele, H., Akin, I., Sandri, M., Fuernau, G., de Waha, S., Meyer-Saraei, R., et al., (2017).

PCI strategies in patients with acute myocardial infarction and cardiogenic

shock. New England Journal of Medicine, 377(25), 2419-2432.

Baran, D. A., Grines, C. L., Bailey, S., Burkhoff, D., Hall, S. A., Henry, T. D., et al.,

(2019). SCAI clinical expert consensus statement on the classification of cardiogenic

shock: This document was endorsed by the American College of Cardiology (ACC),

the American Heart Association (AHA), the Society of Critical Care Medicine

(SCCM), nd the Society of Thoracic Surgeons (STS) in April 2019. Catheterization

and Cardiovascular Interventions, 94(1), 29-37.

Lancellotti, P., Price, S., Edvardsen, T., Cosyns, B., Neskovic, A. N., Dulgheru, R., et al.,

(2014). The use of echocardiography in acute cardiovascular care: Recommendations

of the European Association of Cardiovascular Imaging and the Acute Cardiovascular

Care Association. European Heart Journal: Acute Cardiovascular Care,

2048872614549739.

Levy, B., Clere-Jehl, R., Legras, A., Morichau-Beauchant, T., Leone, M., Frederique, G., et

al., (2018). Epinephrine versus norepinephrine for cardiogenic shock after acute

myocardial infarction. Journal of the American College of Cardiology, 72(2), 173

182.

van Diepen, S., Hochman, J. S., Stebbins, A., Alviar, C. L., Alexander, J. H., & Lopes, R. D.

(2020). Association Between Delays in Mechanical Ventilation Initiation and

Mortality in Patients With Refractory Cardiogenic Shock. JAMA Cardiology.

Kochar, A., Al-Khalidi, H. R., Hansen, S. M., Shavadia, J. S., Roettig, M. L., Fordyce, C. B.,

et al., (2018). Delays in primary percutaneous coronary intervention in ST-segment

elevation myocardial infarction patients presenting with cardiogenic shock. JACC:

Cardiovascular Interventions, 11(18), 1824-1833.

Rogers, J. G., Patel, C. B., Mentz, R. J., Granger, B. B., Steinhauser, K. E., Fiuzat, M., et al.,

(2017). Palliative care in heart failure: the PAL-HF randomized, controlled clinical

trial. Journal of the American College of Cardiology, 70(3), 331-341.

Hochman, J. S., Sleeper, L. A., Webb, J. G., Dzavik, V., Buller, C. E., Aylward, P., et al.,

(2006). Early revascularization and long-term survival in cardiogenic shock

complicating acute myocardial infarction. Jama, 295(21), 2511-2515.

Neumann, F. J., Sousa-Uva, M., Ahlsson, A., Alfonso, F., Banning, A. P., Benedetto, U., et

al., (2019). 2018 ESC/EACTS guidelines on myocardial revascularization. European

heart journal, 40(2), 87-165.

Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., et al.,

(2018). 2017 ESC Guidelines for the management of acute myocardial infarction in

patients presenting with ST-segment elevation: The Task Force for the management

of acute myocardial infarction in patients presenting with ST-segment elevation of the

European Society of Cardiology (ESC). European heart journal, 39(2), 119-177.




Kushner, F. G., Hand, M., Smith Jr, S. C., King III, S. B., Anderson, J. L., Antman, E. M., et

al., (2009). 2009 focused updates: ACC/AHA guidelines for the management of

patients with ST-elevation myocardial infarction (updating the 2004 guideline and

2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary

intervention (updating the 2005 guideline and 2007 focused update) a report of the

American College of Cardiology Foundation/American Heart Association Task Force

on Practice Guidelines. Circulation, 120(22), 2271-2306.

Scholz, K. H., Maier, S. K., Maier, L. S., Lengenfelder, B., Jacobshagen, C., Jung, J., et al.,

(2018). Impact of treatment delay on mortality in ST-segment elevation myocardial

infarction (STEMI) patients presenting with and without haemodynamic instability:

results from the German prospective, multicentre FITT-STEMI trial. European heart

journal, 39(13), 1065-1074.

Mehta, R. H., Lopes, R. D., Ballotta, A., Frigiola, A., Sketch Jr, M. H., Bossone, E., & Bates,

E. R. (2010). Percutaneous coronary intervention or coronary artery bypass surgery

for cardiogenic shock and multivessel coronary artery disease?. American heart

journal, 159(1), 141-147.

Mehta, S. R., Wood, D. A., Storey, R. F., Mehran, R., Bainey, K. R., Nguyen, H., et al.,

(2019). Complete revascularization with multivessel PCI for myocardial

infarction. New England Journal of Medicine, 381(15), 1411-1421.

Lemor, A., Basir, M. B., Patel, K., Kolski, B., Kaki, A., Kapur, N., et al., (2020). Multivessel

versus culprit-vessel percutaneous coronary intervention in cardiogenic shock. JACC:

Cardiovascular Interventions, 13(10), 1171-1178.

Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., et al.,

(2016). 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary

intervention for patients with ST-elevation myocardial infarction: an update of the

2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the

2013 ACCF/AHA guideline for the management of ST-elevation myocardial

infarction. Journal of the American College of Cardiology, 67(10), 1235-1250.

Rab, T., Ratanapo, S., Kern, K. B., Basir, M. B., McDaniel, M., Meraj, P., et al., (2018).

Cardiac shock care centers: JACC review topic of the week. Journal of the American


Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., et al.,

(2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic

heart failure: The Task Force for the diagnosis and treatment of acute and chronic

heart failure of the European Society of Cardiology (ESC) Developed with the special

contribution of the Heart Failure Association (HFA) of the ESC. European heart

journal, 37(27), 2129-2200.

Gaudry, S., Hajage, D., Schortgen, F., Martin-Lefevre, L., Pons, B., Boulet, E., et al., (2016).

Initiation strategies for renal-replacement therapy in the intensive care unit. New

England Journal of Medicine, 375(2), 122-133.

Jung, C., Fuernau, G., Eitel, I., Desch, S., Schuler, G., Kelm, M., et al., (2017). Incidence,

laboratory detection and prognostic relevance of hypoxic hepatitis in cardiogenic

shock. Clinical Research in Cardiology, 106(5), 341-349.

Jacobi, J., Bircher, N., Krinsley, J., Agus, M., Braithwaite, S. S., Deutschman, C., et al.,

(2012). Guidelines for the use of an insulin infusion for the management of

hyperglycemia in critically ill patients. Critical care medicine, 40(12), 3251-3276.

Kapur, N. K., Esposito, M. L., Bader, Y., Morine, K. J., Kiernan, M. S., Pham, D. T., &

Burkhoff, D. (2017). Mechanical circulatory support devices for acute right

ventricular failure. Circulation, 136(3), 314-326.




Hunt, B. J. (2014). Bleeding and coagulopathies in critical care. New England Journal of

Medicine, 370(9), 847-859.

Helgestad, O. K. L., Josiassen, J., Hassager, C., Jensen, L. O., Holmvang, L., Udesen, N. L.

J., et al., (2020). Contemporary trends in use of mechanical circulatory support in

patients with acute MI and cardiogenic shock. Open heart, 7(1), e001214.

Thiele, H., Ohman, E. M., de Waha-Thiele, S., Zeymer, U., & Desch, S. (2019). Management

of cardiogenic shock complicating myocardial infarction: an update 2019. European

Heart Journal, 40(32), 2671-2683.

Rihal, C. S., Naidu, S. S., Givertz, M. M., Szeto, W. Y., Burke, J. A., Kapur, N. K., et al.,

(2015). 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of

percutaneous mechanical circulatory support devices in cardiovascular care: endorsed

by the American Heart Assocation, the Cardiological Society of India, and Sociedad

Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian

Association of Interventional Cardiology-Association Canadienne de Cardiologie

d’intervention. Journal of the American College of Cardiology, 65(19), e7-e26.

Thiele, H., Jobs, A., Ouweneel, D. M., Henriques, J. P., Seyfarth, M., Desch, S., et al.,

(2017). Percutaneous short-term active mechanical support devices in cardiogenic

shock: a systematic review and collaborative meta-analysis of randomized

trials. European heart journal, 38(47), 3523-3531.

Dhruva, S. S., Ross, J. S., Mortazavi, B. J., Hurley, N. C., Krumholz, H. M., Curtis, J. P., et

al., (2020). Association of use of an intravascular microaxial left ventricular assist

device vs intra-aortic balloon pump with in-hospital mortality and major bleeding

among patients with acute myocardial infarction complicated by cardiogenic

shock. Jama, 323(8), 734-745.

Amin, A. P., Spertus, J. A., Curtis, J. P., Desai, N., Masoudi, F. A., Bach, R. G., et al.,

(2020). The evolving landscape of Impella use in the United States among patients

undergoing percutaneous coronary intervention with mechanical circulatory

support. Circulation, 141(4), 273-284.

Tehrani, B. N., Truesdell, A. G., Sherwood, M. W., Desai, S., Tran, H. A., Epps, K. C., et al.,

(2019). Standardized team-based care for cardiogenic shock. Journal of the American

college of cardiology, 73(13), 1659-1669.

Basir, M. B., Kapur, N. K., Patel, K., Salam, M. A., Schreiber, T., Kaki, A., et al., (2019).

Improved outcomes associated with the use of shock protocols: updates from the

National Cardiogenic Shock Initiative. Catheterization and Cardiovascular

Interventions, 93(7), 1173-1183.

Taleb, I., Koliopoulou, A. G., Tandar, A., McKellar, S. H., Tonna, J. E., Nativi-Nicolau, J., et

al., (2019). Shock team approach in refractory cardiogenic shock requiring short-term

mechanical circulatory support: a proof of concept. Circulation, 140(1), 98-100.

Tayal, R., Hirst, C. S., Garg, A., & Kapur, N. K. (2019). Deployment of acute mechanical

circulatory support devices via the axillary artery. Expert review of cardiovascular

therapy, 17(5), 353-360.

Esposito, M. L., Jablonski, J., Kras, A., Krasney, S., & Kapur, N. K. (2018). Maximum level

of mobility with axillary deployment of the Impella 5.0 is associated with improved

survival. The International journal of artificial organs, 41(4), 236-239.

Rab, T., Ratanapo, S., Kern, K. B., Basir, M. B., McDaniel, M., Meraj, P., et al., (2018).

Cardiac shock care centers: JACC review topic of the week. Journal of the American


Samsky, M., Krucoff, M., Althouse, A. D., Abraham, W. T., Adamson, P., Aguel, F., et al.,

(2020). Clinical and regulatory landscape for cardiogenic shock: a report from the




Cardiac Safety Research Consortium ThinkTank on cardiogenic shock. American

heart journal, 219, 1–8.

Varshney, A. S., Berg, D. D., Katz, J. N., Baird-Zars, V. M., Bohula, E. A., Carnicelli, A. P.,

et al., (2020). Use of Temporary Mechanical Circulatory Support for Management of

Cardiogenic Shock Before and After the United Network for Organ Sharing Donor

Heart Allocation System Changes. JAMA cardiology, 703–708.

Hanff, T. C., Harhay, M. O., Kimmel, S. E., Birati, E. Y., & Acker, M. A. (2020). Update to

an early investigation of outcomes with the new 2018 donor heart allocation system in

the United States. The Journal of Heart and Lung Transplantation, 1–4.

Authors/Task Force members, Windecker, S., Kolh, P., Alfonso, F., Collet, J. P., Cremer, J.,

et al., (2014). 2014 ESC/EACTS guidelines on myocardial revascularization: the Task

Force on Myocardial Revascularization of the European Society of Cardiology (ESC)

and the European Association for Cardio-Thoracic Surgery (EACTS) developed with

the special contribution of the European Association of Percutaneous Cardiovascular

Interventions (EAPCI). European heart journal, 35(37), 2541-2619.

Authors/Task Force Members, Steg, P. G., James, S. K., Atar, D., Badano, L. P., Lundqvist,

C. B., et al., (2012). ESC Guidelines for the management of acute myocardial

infarction in patients presenting with ST-segment elevation: The Task Force on the

management of ST-segment elevation acute myocardial infarction of the European

Society of Cardiology (ESC). European heart journal, 33(20), 2569-2619.

O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A.,

et al., (2013). 2013 ACCF/AHA guideline for the management of ST-elevation

myocardial infarction: a report of the American College of Cardiology

Foundation/American Heart Association Task Force on Practice Guidelines. Journal

of the American college of cardiology, 61(4), e78-e140.

Thiele, H., Desch, S., Piek, J. J., Stepinska, J., Oldroyd, K., Serpytis, P., et al., (2016).

Multivessel versus culprit lesion only percutaneous revascularization plus potential

staged revascularization in patients with acute myocardial infarction complicated by

cardiogenic shock: design and rationale of CULPRIT-SHOCK trial. American heart

journal, 172, 160-169.

Moller, J., (2012), Danish cardiogenic SHOCK trial (DANSHOCK). Clinical trials.gov

identifier: NCT01633502.

Brunner, S., (2015), Clinical study of extra-corporeal life support in cardiogenic shock

complicating acute myocardial infarction (ECLS-SHOCK). Clinicaltrials.gov

identifier: Nct02544594

Debabrata Mukherjee, MD, FACC. Review on Management of Cardiogenic Shock. Oct 26,

2020 – Journal of American College of Cardiology.


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