Key Points:

• ECMO has been used as a salvage strategy in severe cardiogenic shock. However, it is unclear whether immediate ECMO initiation is superior to an initial trial of medical therapy with subsequent MCS utilization as needed if no improvement occurs.
• In the ECMO-CS study, patients presenting with severe cardiogenic shock (SCAI stage D-E) were randomized to either immediate ECMO or medical therapy (with downstream MCS as needed) The primary outcome of interest was a 30-day composite of death from any cause, resuscitated circulatory arrest, and implementation of any other MCS device.
• Immediate ECMO initiation was not associated with a significant reduction in the primary outcome relative to medical therapy with downstream as-needed MCS. There was a 40% crossover in the conservative arm to eventual downstream ECMO.

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It goes without saying that refractory out of hospital cardiac arrest (OHCA) is associated with very poor outcomes. In recent decades, E-CPR, or the combination of veno-arterial ECMO and mechanical CPR, has emerged as a potential mitigator of refractory OHCA to improve survival. Given the difficulties in design and enrollment of randomized trials in the OHCA space, however, definitive data favoring the use of E-CPR had yet to be established.

In a Late Breaking Clinical Trials Session at the 2021 American College of Cardiology Scientific Sessions, Dr. J. Belohlavek of the Charles University in Prague presented the results of Prague OHCA, a 7-year trial comparing E-CPR to standard ACLS in refractory OHCA. Patients with a presumed cardiac cause of their OHCA were electronically randomized to a hyperinvasive or standard approach to ACLS during bystander chest compressions. The hyperinvasive approach consisted of a rapid transfer to a hospital center with mechanical CPR and/or the implantation of veno-arterial ECMO could be implemented. Standard of care remained at the discretion of the responders but would include manual chest compressions and progression of ACLS.
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A recent study by Dr. Kilic, published in the American Heart Association Journal, showed similar adverse outcomes in the 1-year survival, rejection rates, and complications of patients who received a heart transplant using hepatitis C-positive (HCV+) donors whereas those using hepatitis C-negative donors.

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Hypertrophic cardiomyopathy (HCM) is the most common inherited genetic disorder of the myocardium, and the number one culprit of sudden cardiac death in athletes, particularly African Americans.

“Is race associated with differential disease expression, inequitable care provision, or disparate clinical outcomes among patients with hypertrophic cardiomyopathy?”

In order to answer the above question, Lauren A. Eberly, et al. studied 2,467 patients with hypertrophic cardiomyopathy. In a retrospective cohort study, black and white patients with hypertrophic cardiomyopathy from the US-based sites of the Sarcomeric Human Cardiomyopathy Registry from 1989 through 2018 compared in terms of baseline characteristics; genetic architecture; adverse outcomes such as cardiac arrest, cardiac transplantation or left ventricular assist device implantation, cardioverter-defibrillator implantation, all-cause mortality, atrial fibrillation, stroke,  prevalence and likelihood of developing heart failure; and receiving septal reduction therapies.

According to the results of this study (8.3 percent black; 91.7 percent white), published in the JAMA CARDIOLOGY (December 2019), compared with white patients, black patients with HCM were younger (mean age, 36.5 versus 41.9 years), were less likely to have sarcomere mutations (26.1 versus 40.5 percent), had a higher prevalence of New York Heart Association (NYHA) class III or IV heart failure at presentation (22.6 versus 15.8 percent) and were more prone to developing heart failure (hazard ratio, 1.45). Lower rates of genetic testing (26.1 versus 40.5 percent) have been observed in black patients. Although there were no racial differences in implantation of implantable cardioverter-defibrillators, the invasive septal reduction was less common among African Americans (14.6 versus 23 percent). Nevertheless, Black patients had fewer incidents of atrial fibrillation (35 [17.1 percent] versus 608 [26.9 percent].

The results of this study were in accordance with the previous studies that mentioned a higher prevalence of complicated hypertrophic cardiomyopathy in African Americans in contrast to the lower prevalence of HCM in this community.  Eberly, et al. believe that racial differences in disease expression and adverse clinical outcomes are not only because of different characteristics of the disease in African Americans but also inequities in clinical care provision might be responsible for these observed differences.

A study by Gabriel Riva and his colleagues published in Circulation assessed the rates of different forms of cardiopulmonary resuscitation (CPR) during three different guideline periods. They showed that there was almost a two-fold increase in the rates of CPR before the arrival of emergency medical services (EMS) as well as a 6-fold higher rate of compression-only CPR (CO-CPR) over time. Additionally, any form of CPR was associated with doubled survival rates when compared to no CPR. These findings support the use of CO-CPR as an option in future CPR guidelines as it is associated with higher CPR rates and higher overall survival in out-of-hospital cardiac arrest when compared to no CPR. Continue reading →

COAPT trial

This prospective, multicenter, open-label, randomized trial aimed to assess the use of transcatheter mitral valve repair in heart failure (HF) patients with mitral regurgitation due to left ventricular dysfunction. A total of 614 patients were randomized to either receiving guideline-directed medical therapy (GDMT) alone or GDMT in addition to transcatheter mitral-valve repair. The primary efficacy endpoint was all hospitalizations due to heart failure at 24 months of follow-up, while the primary safety endpoint was freedom from device-related complications at 12 months of follow-up. The study showed that the device group had a lower risk of hospitalization for HF (HR 0.53, 95% CI 0.4-0.7) and all-cause mortality (HR 0.62, 95% CI 0.46-0.82) at 24 months. Moreover, the rate of freedom from device complications at 12 months was 96.6% which exceeded the prespecified safety threshold. Continue reading →

Cardiogenic shock (CS) is not a rare complication in patients with Takotsubo syndrome (TTS). Moreover, it is associated with an increased risk of adverse outcomes in the short- and long-term follow-up, according to a new study published in the Journal of the American College of Cardiology. Continue reading →

The use of Proton Pump Inhibitors (PPIs) for prophylaxis against gastrointestinal (GI) bleeding due to stress ulceration in critically ill patients admitted to the Intensive Care Unit (ICU) was not associated with improved mortality rate or fewer clinically important events, according to a new study published in the New England Journal of Medicine. Continue reading →

 In a randomized multi-center clinical trial that enrolled more than 700 patients with multi-vessel coronary artery disease and acute myocardial infarction (MI) with cardiogenic shock, it was shown that percutaneous coronary intervention (PCI) of the culprit lesion only (with the option of staged revascularization of nonculprit lesions) was associated with better clinical outcomes compared to immediate multi-vessel PCI. It was found that at 30 days, there was a 9.5% absolute reduction in the rate of the primary endpoint of death or renal replacement therapy in patients randomized to culprit-lesion only revascularization. Previously DANAMI-3-PRIMULTI, PRAMI, and CvLPRIT trials have suggested that there may be a benefit to complete revascularization but those studies did not enroll patients with hemodynamic instability or cardiogenic shock. Consequently, this led to the inclusion of immediate multi-vessel PCI in the 2015 ACC/AHA/SCAI STEMI guidelines as a Class II-b recommendation (can be considered). Continue reading →

A non-randomized study published in the American Heart Journal showed increased survival rates in patients with Impella device being used as the first support strategy for patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) when invasive hemodynamic monitoring was used, and at centers with higher Impella implantation volume. Continue reading →