Implementation of a Cardiogenic Shock Team in a Tertiary Academic Centre.

BACKGROUND: Observational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improve clinical outcomes. Nevertheless, these studies reflect a specific organisational setting with most patients being transfers from referring hospitals, hospitalised in cardiac intensive care units (ICU), or treated with mechanical circulatory support (MCS) devices. The purpose of this study was to document the organisation and outcomes of a CS team offering acute care in all-comer population. METHODS: A CS team was developed in a large academic tertiary institution. The team consisted of emergency care physicians, critical care cardiologists, interventional cardiologists, cardiac surgeons, ICU physicians and heart failure specialists and was supported by predefined operating protocol, dedicated communication platform and regular team meetings. RESULTS: Over 12 months, 70 CS patients (69±13 years old, 67% males) were included. Acute myocardial infarction (AMI-CS) was the most common cause (64%); 31% of the patients presented post-resuscitated cardiac arrest and 56% needed invasive mechanical ventilation (IMV). Coronary angiography was performed in 70% and 53% had percutaneous coronary intervention. MCS was used in 10% and 6% were referred for urgent cardiac surgery. The in-hospital mortality in our centre was 40% with 39% of the patients dying within 24-hours from presentation. 76% of the alive patients were discharged home. CONCLUSIONS: Across an all-comer population, AMI was the most common cause of CS. A significant number of patients presented post cardiac arrest, and the majority required IMV. Mortality was high with a significant number dying within hours of presentation.

Differences in Health-Related Quality of Life among Patients with Heart Failure.

Heart failure (HF) is characterized by a progressive clinical course marked by frequent exacerbations and repeated hospitalizations, leading to considerably high morbidity and mortality rates. Patients with HF present with a constellation of bothersome symptoms, which range from physical to psychological and mental manifestations. With the transition to more advanced HF stages, symptoms become increasingly more debilitating, interfere with activities of daily living and disrupt multiple domains of life, including physical functioning, psychological status, emotional state, cognitive function, intimate relationships, lifestyle status, usual role activities, social contact and support. By inflicting profuse limitations in numerous aspects of life, HF exerts a profoundly negative impact on health-related quality of life (HRQOL). It is therefore not surprising that patients with HF display lower levels of HRQOL compared not only to the general healthy population but also to patients suffering from other chronic diseases. On top of this, poor HRQOL in patients with HF becomes an even greater concern considering that it has been associated with unfavorable long-term outcomes and poor prognosis. Nevertheless, HRQOL may differ significantly among patients with HF. Indeed, it has consistently been reported that women with HF display poorer HRQOL compared to men, while younger patients with HF tend to exhibit lower levels of HRQOL than their older counterparts. Moreover, patients presenting with higher New York Heart Association (NYHA) functional class (III-IV) have significantly more impaired HRQOL than those in a better NYHA class (I-II). Furthermore, most studies report worse levels of HRQOL in patients suffering from HF with preserved ejection fraction (HFpEF) compared to patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF). Last, but not least, differences in HRQOL have been noted depending on geographic location, with lower HRQOL levels having been recorded in Africa and Eastern Europe and higher in Western Europe in a recent large global study. Based on the observed disparities that have been invariably reported in the literature, this review article aims to provide insight into the underlying differences in HRQOL among patients with HF. Through an overview of currently existing evidence, fundamental differences in HRQOL among patients with HF are analyzed based on sex, age, NYHA functional class, ejection fraction and geographic location or ethnicity.

Optimal use of intravenous landiolol in acute cardiac care.

INTRODUCTION: B-blockers are regarded as beneficial pharmacologic agents in cardiac care, but their role in the acute setting remains ambiguous. Increasing evidence supports the important role of landiolol in critical care, a highly cardioselective intravenous b-blocker with rapid onset of action and short elimination time. Among its most valuable properties, which may aid to overcome special reservations related to b-blocker therapy in the acute setting, landiolol has a potent negative chronotropic effect while at the same time it exhibits a mild negative inotropic effect. AREAS COVERED: This expert opinion review aims to present basic pharmacologic aspects of landiolol and provide current clinical research focused on its efficacy and safety. EXPERT OPINION: Landiolol is a valuable and safe pharmacologic agent in acute cardiac care. Japanese and European guidelines have incorporated its use for the management of atrial tachyarrhythmia in patients with cardiac dysfunction. Although emerging clinical trials have experimented its use in patients with sustained ventricular tachycardia/fibrillation, acute myocardial infarction undergoing primary percutaneous intervention and in patients with septic cardiomyopathy, more studies are needed in order to establish its value in such cardiac conditions.

The current and future status of inotropes in heart failure management.

INTRODUCTION: Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED: Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION: The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.

Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done.

Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.

The role of landiolol in the management of atrial tachyarrhythmias in patients with acute heart failure and cardiogenic shock: case reports and review of literature.

Atrial tachyarrhythmias and worsening heart failure frequently coexist and potentially progress to a life threatening condition. Therapeutic approach requires simultaneous management of rapid ventricular response and heart failure symptom relief in order to improve haemodynamic stability and cardiac function. Landiolol is an ultra-short-acting b-adrenergic receptor blocker with high b1 selectivity incorporated in 2020 European Society of Cardiology guidelines for the management of atrial fibrillation. We provide a report of two cases with atrial fibrillation treated with landiolol in the acute setting of pulmonary oedema and cardiogenic shock, respectively. Additionally, we searched the international database PUBMED (MEDLINE, PubMed Central) to retrieve scientific evidence regarding its implementation in the treatment of atrial tachyarrhythmias in patients with cardiac dysfunction. Recent studies support the use of landiolol in patients with acute heart failure and atrial tachyarrhythmias. Compared to digoxin, landiolol proved to be more effective in controlling heart rate, with minimal adverse effects. Moreover, landiolol may be helpful in the conversion of atrial tachyarrhythmia to sinus rhythm. A more potent effect has been reported in patients with heart failure with preserved or mildly reduced ejection fraction, small left ventricular volume and high blood pressure. Likewise, administration of low doses of landiolol in patients with cardiogenic shock and atrial tachyarrhythmias reduced heart rate and pulmonary capillary wedge pressure and improved cardiac contractility without reducing blood pressure. Landiolol seems to be an attractive alternative in the acute management of patients with atrial tachyarrhythmias and cardiac dysfunction, though further clinical trials are needed to establish its role.

It's Not All about Echocardiography. Open the Lung Window for the Cardiac Emergencies.

In the acute cardiac care setting, undifferentiated clinical presentations such as dyspnea, chest pain, shock, and cardiac arrest are common diagnostic challenges for the clinician. Lung ultrasonography is a well-established diagnostic tool which can be integrated in simplified decision making algorithms during the initial approach of the patient, in order to differentiate accurately cardiac from non-cardiac causes and improve the management of time-sensitive cardiovascular emergencies.

Anesthetic ketamine impairs rats' recall of previous information: the nitric oxide synthase inhibitor N-nitro-L-arginine methylester antagonizes this ketamine-induced recognition memory deficit.

BACKGROUND: There is poor experimental evidence concerning the effects of anesthetic doses of the noncompetitive N-methyl-D-aspartate receptor antagonist ketamine on rodents' memory abilities. The current study was designed (1) to investigate the consequences of posttraining administration of anesthetic ketamine (100 mg/kg intraperitoneally) on rats' recognition memory and (2) to evaluate the ability of the nitric oxide synthase inhibitor N-nitro-L-arginine methylester (L-NAME; 1, 3, and 10 mg/kg intraperitoneally) to counteract the expected behavioral deficits produced by anesthetic ketamine. Finally, in an attempt to clarify if the expected memory impairments produced by anesthetic ketamine were related to the anesthesia, we also tested the effects of a subanesthetic dose of it (3 mg/kg intraperitoneally) on rats' recognition memory. METHODS: The novel object recognition test, a procedure assessing recognition memory in rats, was selected. RESULTS: Posttraining administration of anesthetic (but not of subanesthetic) ketamine disrupted rats' performance in the novel object recognition paradigm. The discrimination index (D) was decreased by ketamine from 0.415 (using saline) to 0.128, thus indicating that the anesthetic dose of ketamine impaired recognition memory. L-NAME (1-3, but not 10, mg/kg) reversed this memory deficit produced by ketamine; the D index of 0.128 using ketamine treatment was increased by 1 and 3 mg/kg L-NAME to 0.427 and 0.478, respectively. CONCLUSIONS: The current results indicate that anesthetic ketamine impaired rats' posttraining memory components (storage and/or retrieval of information) and that a nitric oxide component modulates its behavioral effects.

Effects of the nitric oxide synthase inhibitor L-NAME on recognition and spatial memory deficits produced by different NMDA receptor antagonists in the rat.

There is consistent experimental evidence that noncompetitive antagonists of the N-methyl-D-aspartate (NMDA) receptor, such as ketamine, MK-801, and phencyclidine (PCP), impair cognition and produce psychotomimetic effects in rodents. Nitric oxide (NO) is considered as an intracellular messenger in the brain. The implication of NO in learning and memory is well documented. This study was designed to investigate the ability of the NO synthase inhibitor L-NAME to antagonize recognition and spatial memory deficits produced by the NMDA receptor antagonists, MK-801 and ketamine, in the rat. L-NAME (1-3 mg/kg) counteracted MK-801- (0.1 mg/kg) and ketamine (3 mg/kg)-induced performance impairments in the novel object recognition task. L-NAME (10 mg/kg) attenuated ketamine (15 mg/kg)-induced spatial working memory and retention deficits in the radial water maze paradigm. L-NAME, applied at 3 mg/kg, however, disrupted rodents' performance in this spatial memory task. The present findings indicate (1) that L-NAME is sensitive to glutamate hypofunction produced by other than PCP NMDA antagonists such as MK-801 and ketamine and (2) that L-NAME alone differentially affects rodents' spatial memory.

The nitric oxide-releasing derivative of ferulic acid NCX 2057 antagonized delay-dependent and scopolamine-induced performance deficits in a recognition memory task in the rat.

Nitric oxide (NO) is considered as an intracellular messenger in the brain. Its involvement in learning and memory processes has been proposed. The present study was designed to investigate the effects of the NO-releasing derivative of ferulic acid NCX 2057 on rats' recognition memory. For this purpose the object recognition task was selected. Post-training treatment with NCX 2057 (10 mg/kg, i.p.) and with the reference compound, the NO donor molsidomine (4 mg/kg, i.p.), antagonized extinction of recognition memory in the normal rat. Conversely, animals treated with the parent compound ferulic acid (1.9, 6.2 and 18.7 mg/kg, i.p.) failed to do so. In addition, NCX 2057 (3 and 10 mg/kg, i.p) reversed the scopolamine (0.2 mg/kg, s.c.)-induced performance deficits in this recognition memory task. These results indicate that this novel NO donor may modulate different aspects of recognition memory and suggest that an interaction between the nitrergic and cholinergic system is relevant to cognition.

Effects of the nitric oxide synthase inhibitor L-NAME on different memory components as assessed in the object recognition task in the rat.

Nitric oxide (NO) is sought to be an intracellular messenger in the central nervous system and its implication in learning and memory is well documented. Compounds that inhibit nitric oxide synthase (NOS), the key synthesizing enzyme, block cognition, though discrepant findings, in this context, have also been reported. The present study was designed to investigate in the rat: (a) the effects on recognition memory exerted by low doses of the NOS inhibitor L-NAME and (b) the ability of this compound in modulating different mnemonic processes (acquisition, storage and retrieval). For this aim, the object recognition task was selected. In a first study, pre- or post-training systemic administration of L-NAME (1, 3 and 10mg/kg, i.p.) did not disrupt animals' performance in this recognition memory paradigm. Subsequently, L-NAME (1 and 3, but not 10mg/kg, i.p.) antagonized delay-dependent deficits in the object recognition task suggesting that L-NAME affected acquisition, storage and retrieval of information. These results indicate that the NOS inhibitor L-NAME may modulate different aspects of memory.

Pre-training administration of anesthetic ketamine differentially affects rats' spatial and non-spatial recognition memory.

There is poor experimental evidence concerning the effects of anesthetic doses of the non-competitive NMDA receptor antagonist ketamine on rodents' memory abilities. The present study was designed to investigate a) the long-term consequences of anesthetic ketamine on rats' non-spatial and spatial recognition memory; b) to evaluate whether or not these effects are related to the hypothermic properties of ketamine and c) to detect when the (amnestic) effects of ketamine on recognition memory were extinguished. For this purpose, the object recognition and the object location task were selected. Pre-training administration of ketamine (100 mg/kg; i.p.) disrupted animals' performance in the object location task and to some extent also in the object recognition paradigm indicating that anesthetic ketamine impaired both spatial and non-spatial recognition memory. Hypothermia-induced by this NMDA receptor antagonist and the type (spatial vs. non-spatial) of the behavioral paradigm utilized seem to affect rats' recognition memory recovery.