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Therapeutic Advances in the Management of Cardiogenic Shock

Chioncel, Ovidiu MD, PhD, FHFA1,2,*; Collins, Sean P. MD, MSc3; Ambrosy, Andrew P. MD4,5; Pang, Peter S. MD, FACC, FAHA, FACEP6; Radu, Razvan I. MD, PhD1,2; Antohi, Elena-Laura MD1,2; Masip, Josep MD, PhD7,8; Butler, Javed MD, MPH, MBA9; Iliescu, Vlad Anton MD,PhD1,2

doi: 10.1097/MJT.0000000000000920
Systematic Reviews

Background: Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS.

Areas of Uncertainty: Many uncertainties about CS management remain in clinical practice, and these relate to the 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 are obtained from CS in the setting of acute myocardial infarction (AMI), although for non–AMI-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 meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study.

Therapeutic Advances: Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a “culprit-lesion-only” strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes.

Conclusions: Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.

1University of Medicine “Carol Davila,” Bucharest;

2Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu,” Bucharest, Romania;

3Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN;

4Division of Cardiology, Duke University Medical Center, Durham, NC;

5Duke Clinical Research Institute, Durham, NC;

6Department of Emergency Medicine and Indianapolis EMS, Indiana University School of Medicine, Indianapolis, IN;

7Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain;

8Department of Intensive Care, Consorci Sanitari Integral, Barcelona, Spain; and

9Department of Medicine, University of Mississippi School of Medicine, Jackson, MI.

Address for correspondence: Institute of Emergency for Cardiovascular Diseases “Prof. C.C. Iliescu,” sos Fundeni no 258, sect 2. Bucuresti 950474, Romania. E-mail:

O. Chioncel reports other from Servier, other from Novartis, other from Vifor, outside the submitted work; S. P. Collins reports grants from NIH, PCORI, AHA, AHRQ, BMS, Novartis, personal fees from Novartis, Trevena, outside the submitted work; A. P. Ambrosy reports grants from NHLBI T32 postdoctoral grant-5T32HL069749, outside the submitted work; P. S. Pang reports grants, personal fees and non-financial support from Baxter, BMS, Roche, Trevena, Novartis, outside the submitted work; and I am an Associate Editor for JACC-HF, and on the editorial board for the Journal of Cardiac Failure. I also receive research support from NIH/NHLBI, AHA, AHRQ, and PCORI; J. Butler reports other from Amgen, other from Array, other from Astra Zeneca, other from Bayer, other from Boehringer Ingelheim, other from Bristol Myers Squib, other from CVRx, other from G3 Pharmacautical, other from Innolife, other from Janssen, other from Luitpold, other from Medtronic, other from Merck, other from Novartis, other from Relypsa, other from StealthPeptide, other from SC Pharma, other from Vifor, other from ZS Pharma, outside the submitted work. The remaining authors have no conflicts of interest to declare.

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