The golden hour in shock management: do a lot, do it quickly.

Cardiogenic shock can be defined as a state of inadequate organ perfusion linked primarily to cardiac pump dysfunction. The two predominant causes of this condition are acute myocardial infarction and acutely decompensated heart failure (ADHF). In recent years, a significant increase in cases of cardiogenic shock from ADHF has been described. Recent evidence has defined that the factors with the greatest impact on the prognosis in this context are the early clinical assessment, the definition of the aetiology, the timely application of pharmacological therapies, or individualized mechanical supports for the circulation. Haemodynamic monitoring can help in the phenotyping of cardiogenic shock and therefore guide therapeutic choices, especially if implemented with the aid of advanced monitoring tools such as the Swan-Ganz catheter. Finally, the presence of a dedicated shock team in the 'hub' centres is fundamental, which facilitates the choice of the best therapeutic strategy on a case-by-case basis.

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center.

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Acute heart failure: differential diagnosis and treatment.

Acute heart failure is a heterogeneous clinical syndrome and is the first cause of unplanned hospitalization in people >65 years. Patients with heart failure may have different clinical presentations according to clinical history, pre-existing heart disease, and pattern of intravascular congestion. A comprehensive assessment of clinical, echocardiographic, and laboratory data should aid in clinical decision-making and treatment. In some cases, a more accurate evaluation of patient haemodynamics via a pulmonary artery catheter may be necessary to undertake and guide escalation and de-escalation of therapy, especially when clinical, echo, and laboratory data are inconclusive or in the presence of right ventricular dysfunction. Similarly, a pulmonary artery catheter may be useful in patients with cardiogenic shock undergoing mechanical circulatory support. With the subsequent de-escalation of therapy and haemodynamic stabilization, the implementation of guideline-directed medical therapy should be pursued to reduce the risk of subsequent heart failure hospitalization and death, paying particular attention to the recognition and treatment of residual congestion.

CHA2DS2-VASc risk factors as predictors of stroke after acute coronary syndrome: A systematic review and meta-analysis.

BACKGROUND: Stroke is a rare but serious complication of acute coronary syndrome. At present, no specific score exists to identify patients at higher risk. The aim of the present study is to test whether each clinical variable included in the CHA2DS2-VASc score retains its predictive value in patients with recent acute coronary syndrome, irrespective of atrial fibrillation. METHODS: The meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. All clinical trials and observational studies presenting data on the association between stroke/transient ischemic attack incidence and at least one CHA2DS2-VASc item in patients with a recent acute coronary syndrome were considered in the analysis. Atrial fibrillation diagnosis was also considered. RESULTS: The whole cohort included 558,193 patients of which 7108 (1.3%) had an acute stroke and/or transient ischemic attack during follow-up (median nine months; 1st-3rd quartile 1-12 months). Age and previous stroke had the highest odds ratios (odds ratio 2.60; 95% confidence interval 2.21-3.06 and odds ratio 2.74; 95% confidence interval 2.19-3.42 respectively), in accordance with the two-point value given in the CHA2DS2-VASc score. All other factors were positively associated with stroke, although with lower odds ratios. Atrial fibrillation, while present in only 11.2% of the population, confirmed its association with an increased risk of stroke and/or transient ischemic attack (odds ratio 2.04; 95% confidence interval 1.71-2.44). CONCLUSIONS: All risk factors included in the CHA2DS2-VASc score are associated with stroke/ transient ischemic attack in patients with recent acute coronary syndrome, and retain similar odds ratios to what already seen in atrial fibrillation. The utility of CHA2DS2-VASc score for risk stratification of stroke in patients with acute coronary syndrome remains to be determined.

Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta-analysis.

AIMS: Electrical storm (ES) is a devastating and life-threatening event in clinical practice, but its real weight as a risk factor and its clinical predictors remain unclear. Our objective was to evaluate ES as a mortality and morbidity risk factor and to define the clinical variables associated with ES. METHODS AND RESULTS: The meta-analysis was performed according to the PRISMA guidelines. At the end of the selection process, 13 studies were collected and included in the quantitative analysis. Mortality and morbidity due to ES were assessed. The most acknowledged ES predictors were taken into account in separate sub-analyses. The whole cohort included 5912 patients (857 with ES). Risk of death was increased in the ES group [risk ratio (RR) 3.15; 95% confidence interval (CI) 2.22-4.48]. Electrical storm was also associated with increased composite risk of all-cause death, cardiac transplantation, and hospitalization for acute heart failure (RR 3.39; 95% CI 2.31-4.97). These results were confirmed by comparing the ES group with patients with or without previous unclustered episodes of ventricular arrhythmias. Moreover, implantable cardioverter-defibrillator (ICD) for secondary prevention, lower ejection fraction, monomorphic ventricular tachycardia as triggering arrhythmia, and class I anti-arrhythmic drugs therapy were all associated with ES. CONCLUSION: Electrical storm is a strong mortality risk factor and it is associated with an increased combined risk of death, heart transplantation, and hospitalization for heart failure. Implantable cardioverter-defibrillator for secondary prevention, monomorphic ventricular tachycardia as triggering arrhythmia, lower ejection fraction, and class I anti-arrhythmic drugs therapy are all associated with ES and could be used to define specific populations with higher risk to develop ES.

Omega-3 PUFAs and atrial fibrillation: have we made up our mind yet?

Atrial fibrillation (AF) is the most common type of arrhythmia in adults, accounting for about one third of total arrhythmia-related hospitalizations. AF impact on daily clinical practice is steadily rising, together with population aging and increased survival from underlying conditions closely associated with AF such as coronary heart disease and heart failure. Although antiarrhythmic therapy, oral anticoagulation, implanted device therapy, and ablation techniques are now all common and promptly available strategies in AF management, some of them are burdened by a low efficacy rate, while others are associated with increased proarrhythmic or hemorrhagic risk. Consequently, useful alternatives are being sought. Between those, polyunsaturated fatty acids (n-3 PUFAs) have risen from mere alternative to statins in dyslipidemia management to powerful and well-tolerated antiinflammatory, antithrombotic, and antiarrhythmogenic drugs. From the evidence collected through basic science studies, whether on in vivo myocytes, animal models, or surrogate end points in human, n-3 PUFAs seem to offer innumerable advantages. On the other hand, epidemiological and clinical trials failed to demonstrate a clear efficacy of n-3 PUFAs as antiarrhythmic drugs, although covered by an optimal safety profile. The aim of the present review is to summarize the most important evidences currently available on the role of n-3 PUFA in AF management and therapy.