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Background: Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS., Methods: In this individual patient data meta-analysis, randomised controlled trials of potential interest were identified, without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to Jan 26, 2024. All randomised trials with 6-month mortality data comparing early routine active MCS (directly in the catheterisation laboratory after randomisation) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295., Findings: Nine reports of randomised controlled trials (n=1114 patients) were evaluated in detail. Overall, four randomised controlled trials (n=611 patients) compared VA-ECMO with a control treatment and five randomised controlled trials (n=503 patients) compared left ventricular unloading devices with a control treatment. Two randomised controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with a left ventricular unloading device]). The median patient age was 65 years (IQR 57-73); 845 (79·9%) of 1058 patients with data were male and 213 (20·1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR 0·87 [95% CI 0·74-1·03]; p=0·10). No significant differences were observed for left ventricular unloading devices versus control (0·80 [0·62-1·02]; p=0·075), and loading devices also had no effect on mortality (0·93 [0·75-1·17]; p=0·55). Patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality with MCS use (0·77 [0·61-0·97]; p=0·024). Major bleeding (odds ratio 2·64 [95% CI 1·91-3·65]) and vascular complications (4·43 [2·37-8·26]) were more frequent with MCS use than with control., Interpretation: The use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications. However, patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality after MCS use. Therefore, the use of MCS should be restricted to certain patients only., Funding: The Heart Center Leipzig at Leipzig University and the Foundation Institut für Herzinfarktforschung., Competing Interests: Declaration of interests HT is the current president of the German Cardiac Society. JEM reports lecture fees from Abbott and Boehringer Ingelheim; institutional research grants from Abiomed and Novo Nordisk Foundation; travel support from Abiomed; equipment from Abiomed; and served as a data and safety monitoring board member for DanHeart. JB reports speaker fees from Resuscitec and Getinge. DB reports payment for travel expenses from Abiomed; and institutional support for steering committee membership. MF reports grants paid to their institution from the European Commission. HE reports speaker fees from Novartis; and travel expenses from Abbott paid to their institution. PO reports speaker fees from Getinge, Abiomed, Fresenius, Edwards Lifesciences, and AOP; and is the president of the Czech Society of Cardiology. PCS reports lecture fees from Abiomed and Abbott; and institutional research support from Abiomed. JP reports institutional research grants from the German Cardiac Society, Schwiete Foundation, German Heart Research Foundation, and Maquet. CH reports lecture fees from Abiomed. MH reports research support paid to their institution from the Heart Center Leipzig. AP reports lecture fees and institutional research grants from Abiomed. NM reports lecture fees from Abbott, Abiomed, AstraZeneca, B Braun, Biotronik, the British Society of Cardiovascular Imaging, Daiichi Sankyo, Edwards Lifesciences, Medtronic, Novartis, Pfizer, and Sanofi Genzyme; grants paid to their institution from Abiomed; and unrestricted educational grants from Abiomed and BSCI. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock despite the lack of evidence from adequately powered randomised clinical trials. Three trials reported so far were underpowered to detect a survival benefit; we therefore conducted an individual patient-based meta-analysis to assess the effect of VA-ECMO on 30-day death rate., Methods: Randomised clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock were identified by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomisation was reported and trial investigators agreed to collaborate (ie, providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258)., Findings: Four trials (n=567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR 0·93; 95% CI 0·66-1·29). Complication rates were higher with VA-ECMO for major bleeding (OR 2·44; 95% CI 1·55-3·84) and peripheral ischaemic vascular complications (OR 3·53; 95% CI 1·70-7·34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (p interaction ≥0·079)., Interpretation: VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted., Funding: Foundation Institut für Herzinfarktforschung., Competing Interests: Declaration of interests HT is President of the German Cardiac Society. PO reports lecture fees from Abiomed, Getinge, Edwards, and Xenios/Fresenius. JB reports lecture fees from Abiomed, Resuscitec, and Xenios. DA reports funding to support a clinical research fellow from Abbott Vascular; has received funding from AstraZeneca for unrelated research; has conducted unrelated consultancy for General Electric; holds patents for medical devices, including a cardiac assist device (EP3277337A1, PCT/GB2017/050877, UK patent application number 2211616.4); received royalties from Elsevier for The ECG Made Practical and ECG Problems books; is Chair of the ESC-ACVC SCAD Study Group and ESC-EORP SCAD Registry; and reports participation on an advisory board for Beat SCAD. MS reports consultant fees from Abbott Vascular and iVascular. AB reports that the EURO SHOCK trial received European Commission Horizons 2020 funding (reference number 754946-2), University of Leicester as beneficiary. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Before arterial cannulation for invasive blood pressure monitoring, clinical decision-making depends on non-invasive blood pressure in critically ill patients. Whether non-invasive blood pressure is comparable to invasive measurement is not clearly elucidated. We address this issue as it relates to the use of norepinephrine in patients with cardiogenic shock., Methods: We analysed invasive and non-invasive blood pressure in 85 patients admitted to the Coronary-Care Unit for cardiogenic shock. We compared initial blood pressure measurement (just after radial artery cannulation) and blood pressure taken during the first 72 hours after admission. Invasive blood pressure was used as the reference method., Results: Initial invasive mean and systolic arterial pressures were in a good agreement with oscillometric blood pressure; mean differences were -0.4 ± 8.8 and +6.1 ± 14.4 mmHg with correlation coefficients of 0.76 and 0.74. Doses of norepinephrine were significant negative determinants of invasive/oscillometric blood pressure differences. The invasive/oscillometric mean arterial pressures and SBP differences were +0.1 ± 3.4 and 7.6 ± 1.6 mmHg in patients treated with nothing or a maximum norepinephrine dose of 0.6 µg/kg/min. However, treatment with very high doses of norepinephrine was associated with a steep rise in mean arterial pressures and SBP invasive/oscillometric differences (-9.5 ± 3.3 and -8.5 ± 5.2 mmHg). In a total of 967 sets of blood pressure measurements, invasive/oscillometric differences were relatively stable across blood pressure categories, with the exception of measurements assessed after very high norepinephrine doses., Conclusions: Non-invasive BP is a sufficient substitute for invasive measurement in cardiogenic shock patients, with the exception of those receiving very high doses of norepinephrine.

Background: Although invasively measured blood pressure (invBP) is regarded as a "gold standard" in critically ill cardiac patients, the non-invasive BP is still widely used, at least at the initiation of medical care. The erroneous interpretation of BP can lead to clinical errors. We therefore investigated the agreement of both methods with respect to some common clinical situation., Methods: We included 85 patients hospitalized for cardiogenic shock. We measured BP every 6 h for the first 72 h of hospitalization, in all patients. Each set of BP measurements included two invasive (invBP), two auscultatory (auscBP), and two oscillometric (oscBP) BP measurements. InvBP was considered as a gold standard. Mean non-invasive arterial pressure (MAP) was calculated as (diastolic pressure + (pulse pressure ÷ 3)). We used Bland-Altman analysis and we calculated concordance correlation coefficients to assess agreement between different BP methods., Results: We obtained 967 sets of BP measurements. AuscMAP and oscMAP were on average only 0.4 ± 8.2 and 1.8 ± 8.5 mmHg higher than invMAP, respectively. On the other hand, auscSBP and oscSBP were on average - 6.1 ± 11.4 and - 4.1 ± 9.8 mmHg lower than invSBP, respectively. However, the mean differences and variability for systolic and diastolic BP variability were large; the 2 standard deviation differences were ± 24 and 18 mmHg. In hypotension, non-invasive BP tended to be higher than invBP while the opposite was true for high BP values. Clinical conditions associated with hypotension generally worsened the accuracy of non-invasive MAP., Conclusions: Mean arterial pressure measured non-invasively appears to be in good agreement with invasive MAP in patients admitted for cardiogenic shock. Several clinical associated with hypotension can affect accuracy of non-invasive measurement. Auscultatory and oscillometric measurements had similar accuracy even in patients with arrhythmia.

Aims: Extracorporeal membrane oxygenation (ECMO) in veno-arterial configuration represents an increasingly used method for circulatory support. ECMO in cardiogenic shock offers rapid improvement of circulatory status and significant increase in tissue perfusion. Current evidence on the use of ECMO in cardiogenic shock remains insufficient. The aim of the ECMO-CS trial is to compare two recognized therapeutic approaches in the management of severe cardiogenic shock: early conservative therapy and early implantation of veno-arterial ECMO on the background of standard care., Methods: Eligible patients have either rapidly deteriorating or severe cardiogenic shock, defined using echocardiography, hemodynamic and metabolic criteria. Patients are randomized to the one of two arms: immediate veno-arterial ECMO therapy or early conservative therapy. All other diagnostic and therapeutic procedures are performed as per current standard of care, including other cardiovascular interventions (i.e. percutaneous coronary intervention or cardiac surgery). Follow-up includes visits at 30 days, 6 months and 12 months. Primary endpoint is a composite of death from any cause, resuscitated circulatory arrest, and implantation of another mechanical circulatory support device at 30 days. The sample size of 120 individuals (60 in each arm) provides 80% power to detect 50% reduction of primary endpoint, at alpha = 0.05. Patient recruitment started in October 2014., Conclusion: The results of the ECMO-CS trial may significantly influence current practice in the management of patients with severe and rapidly deteriorating cardiogenic shock. ECMO-CS trial registration number is NCT02301819., (© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.)

Acute heart failure (AHF) is a clinical syndrome of different etiology and several clinical presentations. Cardiogenic shock patients have highest long-term mortality. In contrast to chronic heart failure, we have no evidence of therapeutic benefit for any treatment strategy from randomized clinical trials. Search for new pharmacologic and non-pharmacologic therapies is ongoing. Both causal and symptomatic treatment of AHF episode should be initiated as soon as possible. This review is focused on trends in acute heart failure therapy at the beginning of 21st century.

Objectives: To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS)., Design: Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction., Results: CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%)., Conclusions: RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.

Background: Although radial approach is increasingly used in percutaneous coronary interventions (PCIs) including in acute myocardial infarction (MI), patients with cardiogenic shock have been excluded from comparisons with femoral approach. The aim of our study was to compare clinical outcomes in patients undergoing primary PCI with cardiogenic shock by radial and femoral approach., Methods and Results: From 2,663 patients presenting with ST-elevation MI in 2 large volume radial centers, we identified 197 patients (7.4%) with signs of cardiogenic shock immediately before undergoing primary PCI. Radial approach was used in 55% of cases when at least 1 radial artery was weakly palpable, either spontaneously or after intravenous noradrenaline bolus. Patients in the radial group were older (69 ± 12 vs 64 ± 12 years, P = .010), had less diabetes (13% vs 26%, P = .028), and required less often intubation prior PCI (42% vs 66%, P = .0006) or intraaortic balloon pump (36% vs 55%, P = .0096). Mortality at 1 year was 44% in the radial group and 64% in the femoral group (P = .0044). Independent predictors of late mortality included radial approach (hazard ratio [HR] 0.65, 95% CI 0.42-0.98, P = .041), the use of glycoprotein IIb-IIIa receptor inhibitors (HR 0.63, 95% CI 0.40-0.96, P = .032), baseline creatinine ≥110 μmol/L (HR 3.34, 95% CI 2.20-5.12, P < .0001), initial glycemia >200 mg/dL (HR 2.02, 95% CI 1.34-3.11, P = .0008), and age >65 years (HR 1.80, 95% CI 1.18-2.79, P = .006)., Conclusion: Radial approach was safe and feasible in more than half of the patients with ST-elevation MI and cardiogenic shock treated by primary PCI. After adjustment for baseline and procedural characteristics, radial approach remained associated with better survival. However, prognosis of patients undergoing primary PCI in cardiogenic shock remains poor., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: The outcome of acute myocardial infarction (AMI) complicated with cardiogenic shock is poor. The aim of this study was to analyse, whether upfront abciximab administration could improve the outcomes of cardiogenic shock., Methods: This multicentre open trial randomized 80 patients with AMI complicated by cardiogenic shock expected to undergo primary PCI into group A (routine upfront-pre-procedural-abciximab bolus followed by 12-h abciximab infusion) and group B (standard therapy). The study primary objective was 30-day combined outcome (death/reinfarction/stroke/new severe renal failure)., Results: PCI was technically successful in 90% (A) versus 87.5% (B) patients. Abciximab was used in 100% (A) versus 35% (B). The primary endpoint occurred in 17 group A patients (42.5%) and 11 group B patients (27.5%, P = 0.24). Ejection fraction among survivors after 30 days was 44 ± 11% (A) versus 41 ± 12% (B, P = 0.205). Major bleeding occurred in 17.5% (A) versus 7.5% (B, P = 0.310). No differences (A versus B) were found in TIMI-flow and MBG after PCI., Conclusions: This study did not show any benefit from routine pre-procedural abciximab when compared with a selective abciximab use during the intervention in patients with cardiogenic shock undergoing primary PCI. However, small sample size of the trial preclude any definitive conclusion, a larger prospective, randomized, multicentered trial is needed.

Unlabelled: Levosimendan may improve the outcome of acute heart failure patients with preserved arterial blood pressure. However, the data on its use in critically ill patients are scarce., Objectives: The aim of this study was to assess the effects of levosimendan on global haemodynamics in patients with cardiogenic shock., Materials and Methods: Fourteen adult patients in cardiogenic shock were studied prospectively. One patient died after 10 hours and was excluded from final analysis. Haemodynamic monitoring included arterial and pulmonary arterial thermodilution catheters. Before levosimendan administration, 12 patients required norepinephrine, 6 patients dobutamine and 4 patients intraaortic balloon pump. Levosimendan was given as a bolus (12 microg x kg(-1) x 10 min(-1)) followed by 24 hrs infusion (0.1 microg x kg(-1) x min(-1)). Baseline data had been collected before levosimendan administration. Following data sets were obtained after 1, 8, 16 and 24 hours. Positive haemodynamic response was defined as an increase of > or = 30% in cardiac output., Results: Eleven patients met the criterion for the positive haemodynamic response. During levosimendan infusion systemic vascular resistance decreased (p<0.05) whereas cardiac output (p<0,001) and urine output increased (p<0.01). Mean arterial pressure and heart rate remained unchanged. No severe arrhythmias occurred and norepinephrine-dose did not change. Two patients were classified as non-responders., Conclusions: Our results suggest that levosimendan infusion given as adjunctive therapy in patients with cardiogenic shock may be safe with beneficial effects on global haemodynamics.

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used for circulatory support in cardiogenic shock patients, although the evidence supporting its use in this context remains insufficient. The aim of the Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock (ECMO-CS) trial was to compare immediate implementation of VA-ECMO vs. an initially conservative therapy (allowing downstream use of VA-ECMO) in patients with rapidly deteriorating or severe cardiogenic shock. Methods: This multicenter, randomized, investigator-initiated, academic clinical trial included patients with either rapidly deteriorating or severe cardiogenic shock. Patients were randomly assigned to immediate VA-ECMO or no immediate VA-ECMO. Other diagnostic and therapeutic procedures were performed as per current standard(s) of care. In the early conservative group, VA-ECMO could be used downstream in case of worsening hemodynamic status. The primary endpoint was the composite of death from any cause, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days. Results: A total of 122 patients were randomized; after excluding 5 patients due to the absence of informed consent, 117 subjects were included in the analysis, of whom 58 randomized to immediate VA-ECMO and 59 to no immediate VA-ECMO. The composite primary endpoint occurred in 37 (63.8%) and 42 (71.2%) of patients in the immediate VA-ECMO and the no early VA-ECMO groups, respectively (hazard ratio, 0.72; 95% confidence intervals [CI], 0.46 to 1.12; P=0.21). VA-ECMO was used in 23 (39%) of no early VA-ECMO patients. The 30-day incidence of resuscitated cardiac arrest (10.3. % vs. 13.6%; risk difference [RD], -3.2; 95% CI, -15.0 to 8.5), all-cause mortality (50.0% versus 47.5%; RD, 2.5; 95% CI, -15.6 to 20.7), serious adverse events (60.3% vs. 61.0%; RD, -0.7; 95% CI, -18.4 to 17.0), sepsis, pneumonia, stroke, leg ischemia, and bleeding was not statistically different between the immediate VA-ECMO and the no immediate VA-ECMO groups. Conclusions: Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status. Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT02301819. [ABSTRACT FROM AUTHOR]