Risk stratification in cardiogenic shock: a focus on the available evidence

Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients

Approach to the diagnosis and management of patients with cardiac amyloidosis. A consensus document by the Tuscan section of the Italian Association of Hospital Cardiologists (ANMCO) and the Tusco-Umbrian section of the Italian Society of Cardiology (SIC)

The diagnosis of cardiac amyloidosis (CA) is challenging because of its phenotypic heterogeneity, multi-organ involvement often requiring the interaction among experts in different specialties and subspecialties, the lack of a single non-invasive diagnostic tool, and limited awareness in the medical community. Recent studies have challenged the dogma of CA as a rare, incurable disease, and have redefined the epidemiology and therapeutic options for this condition. Missing or delaying the diagnosis may have a profound impact on patient outcome, as potentially life-saving treatments may be omitted or delayed, particularly chemotherapy in the case of amyloid light-chain amyloidosis. For a timely identification, clinical cardiologists should be able to recognize the "red flags" prompting a dedicated diagnostic work-up. Cardiologists could also face the challenge of making decisions about drug and device therapies for patients with known CA. The present consensus document aims to provide a practical guide and an organizational framework for professionals belonging to the Tuscan network of hospital cardiologists

Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients\u2019 condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01\u201318.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival

Intravascular lithotripsy in calcified-coronary lesions: A real-world observational, European multicenter study.

BACKGROUND The recently introduced intravascular lithotripsy (IVL) appears promising and relatively safer than conventional approaches when dealing with calcified lesions. Although there are published reports on this novel technology, data from the real world are limited. In this study, we aim to report on the experience of IVL from a real-world population derived from six European centers that undertake high-volume complex coronary interventions. METHODS AND RESULTS We enrolled all patients treated with IVL between November 2018 and February 2020 at six centers. Procedural success and complications were assessed along with clinical outcomes, which included: cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR), and major adverse cardiac event (MACE) (composite of cardiac death, TVMI, and TLR). Hundred and ninety patients (200 lesions) with a mean age of 72 years were treated using IVL. Diabetes and chronic kidney disease were present in 50% (n = 95) and 16% (n = 30) of cases, respectively. Acute-coronary syndromes accounted for 91 (48%) of the cases. Most were de-novo lesions (77%; n = 154). Upfront use of IVL occurred in 26% of cases, while the rest were bail-out procedures due to inadequate predilatation with conventional balloons. Adjuvant rotational atherectomy was needed in 17% of cases. Procedural success was achieved in 99% of cases with a complication rate of 3%. During the median follow-up of 222 days, there was two cardiac deaths (1%), one case of TVMI (0.5%), 3 TLR (1.5%) taking the MACE rate to 2.6%. CONCLUSION Use of IVL appears to be safe and effective in dealing with calcified-coronary lesions. A high success rate was observed with low procedural complications and event rates

Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients\u2019 condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01\u201318.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival