Alexander Jobs

Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials

Aims Evidence on the impact on clinical outcome of active mechanical circulatory support (MCS) devices in cardiogenic shock (CS) is scarce. This collaborative meta-analysis of randomized trials thus aims to investigate the efficacy and safety of percutanzeous active MCS vs. control in CS. Methods and results Randomized trials comparing percutaneous active MCS to control in patients with CS were identified through searches of medical literature databases. Risk ratios (RR) and 95% confidence intervals (95% CI) were calculated to analyse the primary endpoint of 30-day mortality and device-related complications including bleeding and leg ischaemia. Mean differences (MD) were calculated for mean arterial pressure (MAP), cardiac index (CI), pulmonary capillary wedge pressure (PCWP), and arterial lactate. Four trials randomizing 148 patients to either TandemHeart™ or Impella® MCS (n = 77) vs. control (n = 71) were identified. In all four trials intra-aortic balloon pumping (IABP) served as control. There was no difference in 30-day mortality (RR 1.01, 95% CI 0.70 to 1.44, P = 0.98, I2 = 0%) for active MCS compared with control. Active MCS significantly increased MAP (MD 11.85 mmHg, 95% CI 3.39 to 20.31, P = 0.02, I2 = 32.7%) and decreased arterial lactate (MD - 1.36 mmol/L, 95% CI - 2.52 to - 0.19, I2 = 0%, P = 0.02) at comparable CI (MD 0.32, 95% CI - 0.24 to 0.87, P = 0.14, I2 = 44.1%) and PCWP (MD - 5.59, 95% -15.59 to 4.40, P = 0.14, I2 = 81.1%). No significant difference was observed in the incidence of leg ischaemia (RR 2.64, 95% CI 0.83 to 8.39, P = 0.10, I2 = 0%), whereas the rate of bleeding was significantly increased in MCS compared to IABP (RR 2.50, 95% CI 1.55 to 4.04, P < 0.001, I2 = 0%). Conclusion Results of this collaborative meta-analysis do not support the unselected use of active MCS in patients with CS complicating AMI.

Multivessel versus culprit lesion only percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis:

Background: Early revascularisation of the culprit lesion is the therapeutic cornerstone in cardiogenic shock complicating acute myocardial infarction. The optimal management of additional non-culprit lesions is unclear. This systematic review and meta-analysis aims to summarise current evidence on the comparison of immediate multivessel percutaneous coronary intervention (MV-PCI) or culprit lesion only PCI with possible staged revascularisation (C-PCI) in patients with cardiogenic shock complicating acute myocardial infarction. Methods: Medical literature databases were screened to identify analyses comparing MV-PCI with C-PCI in patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease. In absence of randomised trials, 10 cohort studies were included in the current meta-analysis. The primary outcome of short-term mortality was assessed at hospital discharge or 30 days after hospital admission. Secondary outcomes were long-term mortality as well as myocardial re-infarction, stroke, acute renal failure, and bleeding at short-term follow-up. Results: Of 6051 patients, 1194 (19.7%) received MV-PCI and 4857 (80.3%) C-PCI. Short-term mortality was 37.5% in patients undergoing MV-PCI compared with 28.8% in C-PCI patients (risk ratio 1.26, 95% confidence interval 1.12–1.41, p=0.001). Long-term mortality (p=0.77), myocardial re-infarction (p=0.77), stroke (p=0.12), acute renal failure (p=0.17) and bleeding (p=0.53) did not differ significantly between the two revascularisation groups. Conclusions: Results of this first meta-analysis on the interventional management of patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease do not support MV-PCI over C-PCI. However, possible treatment selection bias in the individual studies must be taken into account.

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials

BACKGROUND A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. METHODS We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). FINDINGS We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. INTERPRETATION An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. FUNDING None.

Optimized Prognosis Assessment in ST-Segment–Elevation Myocardial Infarction Using a Cardiac Magnetic Resonance Imaging Risk ScoreCLINICAL PERSPECTIVE

Background— Cardiac magnetic resonance (CMR) demonstrated great potential for the prediction of major adverse cardiac events (MACE) in ST-segment–elevation myocardial infarction. The aim of this study was to develop and validate a CMR-based risk score for ST-segment–elevation myocardial infarction patients. Methods and Results— The scoring model was developed and validated on ST-segment–elevation myocardial infarction cohorts from 2 independent randomized controlled trials (n=738 and n=458 patients, respectively) and included left ventricular (LV) ejection fraction, infarct size, and microvascular obstruction. Primary end point was the 12-month MACE rate consisting of death, reinfarction, and new congestive heart failure. In the derivation cohort, LV ejection fraction ⩽47%, infarct size ≥19%LV, and microvascular obstruction ≥1.4%LV were identified as the best cutoff values for MACE prediction. According to the hazard ratios in multivariable regression analysis, the CMR risk score was created by attributing 1 point for LV ejection fraction ⩽47%, 1 point for infarct size ≥19%LV, and 2 points for microvascular obstruction ≥1.4%LV. In the validation cohort, the score showed a good prediction of MACE (area under the curve: 0.76). Stratification into a low (0/1 point) and high-risk group (≥2 points) resulted in significantly higher MACE rates in high-risk patients (9.0% versus 2.2%; P=0.001). Inclusion of the CMR score in addition to a model of clinical risk factors led to a significant increase of C statistics from 0.74 to 0.83 (P=0.037), a net reclassification improvement of 0.18 (P=0.009), and an integrated discriminative improvement of 0.04 (P=0.010). Conclusions— Our approach integrates the prognostic information of CMR imaging into a simple risk score that showed incremental prognostic value over clinical risk factors in ST-segment–elevation myocardial infarction patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00712101 and NCT02158468.

Pneumonia and inflammation in acute decompensated heart failure: a registry-based analysis of 1939 patients:

Background: The prognostic impact of pneumonia and signs of systemic inflammation in patients with acute decompensated heart failure (ADHF) has not been fully elucidated yet. The aim of the present study was thus to investigate the association of pneumonia and the inflammation surrogate C-reactive protein with all-cause mortality in patients admitted for ADHF. Methods: We analysed data of 1939 patients admitted for ADHF. Patients were dichotomised according to the presence or absence of pneumonia. The primary endpoint of all-cause mortality was determined by death registry linkage. Results: In total, 412 (21.2%) patients had concomitant pneumonia. Median C-reactive protein levels were higher in patients with compared to patients without pneumonia (24.9 versus 9.8 mg/l, respectively; P<0.001). All-cause mortality was significantly higher in patients with pneumonia (P<0.001). In adjusted Cox regression models, pneumonia as well as C-reactive protein were independently associated with in-hospital mortality. Only C-reactive protein remained as independent predictor for long-term mortality. Conclusion: Pneumonia is relatively common in ADHF and a predictor for in-hospital mortality. However, inflammation in general seems to be more important than pneumonia itself for long-term prognosis. Compared to community-acquired pneumonia studies, C-reactive protein levels were rather low and therefore pneumonia might be over-diagnosed in ADHF patients.

Interventional therapies in acute myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock remains the most common cause of death in patients with acute myocardial infarction. Early revascularization of the infarct-related artery has been shown to reduce mortality and is the therapeutic cornerstone. The optimal revascularization strategy of additional non-culprit lesions remains yet to be determined. Further, uncertainties exist with respect to access site choice, antiplatelet regimen as well as mechanical support devices. This review outlines current evidence on the interventional management of cardiogenic shock complicating acute myocardial infarction.ZusammenfassungDer kardiogene Schock ist die häufigste Todesursache bei Patienten mit akutem Myokardinfarkt. Eine frühe Revaskularisation des Infarktgefäßes führt zu einer Mortalitätsreduktion und stellt somit den therapeutischen Grundpfeiler dar. Die optimale Therapiestrategie bei zusätzlichen Stenosen der Koronarien ist bisher allerdings unklar. Des Weiteren bestehen weiterhin Unsicherheiten bezüglich des optimalen interventionellen Zugangswegs, der begleitenden plättchenhemmenden Therapie sowie des Gebrauchs mechanischer Unterstützungssysteme. In dieser Übersichtsarbeit wird die aktuelle Evidenz zur interventionellen Therapie des kardiogenen Schocks bei akutem Myokardinfarkt erörtert.

One-Year Outcomes after PCI Strategies in Cardiogenic Shock

Background Among patients with acute myocardial infarction, cardiogenic shock, and multivessel coronary artery disease, the risk of a composite of death from any cause or severe renal failure leading to renal‐replacement therapy at 30 days was found to be lower with percutaneous coronary intervention (PCI) of the culprit lesion only than with immediate multivessel PCI. We evaluated clinical outcomes at 1 year. Methods We randomly assigned 706 patients to either culprit‐lesion‐only PCI or immediate multivessel PCI. The results for the primary end point of death or renal‐replacement therapy at 30 days have been reported previously. Prespecified secondary end points at 1 year included death from any cause, recurrent myocardial infarction, repeat revascularization, rehospitalization for congestive heart failure, the composite of death or recurrent infarction, and the composite of death, recurrent infarction, or rehospitalization for heart failure. Results As reported previously, at 30 days, the primary end point had occurred in 45.9% of the patients in the culprit‐lesion‐only PCI group and in 55.4% in the multivessel PCI group (P=0.01). At 1 year, death had occurred in 172 of 344 patients (50.0%) in the culprit‐lesion‐only PCI group and in 194 of 341 patients (56.9%) in the multivessel PCI group (relative risk, 0.88; 95% confidence interval [CI], 0.76 to 1.01). The rate of recurrent infarction was 1.7% with culprit‐lesion‐only PCI and 2.1% with multivessel PCI (relative risk, 0.85; 95% CI, 0.29 to 2.50), and the rate of a composite of death or recurrent infarction was 50.9% and 58.4%, respectively (relative risk, 0.87; 95% CI, 0.76 to 1.00). Repeat revascularization occurred more frequently with culprit‐lesion‐only PCI than with multivessel PCI (in 32.3% of the patients vs. 9.4%; relative risk, 3.44; 95% CI, 2.39 to 4.95), as did rehospitalization for heart failure (5.2% vs. 1.2%; relative risk, 4.46; 95% CI, 1.53 to 13.04). Conclusions Among patients with acute myocardial infarction and cardiogenic shock, the risk of death or renal‐replacement therapy at 30 days was lower with culprit‐lesion‐only PCI than with immediate multivessel PCI, and mortality did not differ significantly between the two groups at 1 year of follow‐up. (Funded by the European Union Seventh Framework Program and others; CULPRIT‐SHOCK ClinicalTrials.gov number, NCT01927549.)

Antithrombozytäre oder antikoagulative Strategie nach chirurgischer/interventioneller Klappenbehandlung

At the end of August 2017 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published new joint guidelines for the treatment of valvular heart disease. These guidelines incorporate the scientific progress since the last version of the guidelines published in 2012. This article reviews current guideline recommendations for antiplatelet and anticoagulative therapy after surgical/interventional treatment of the aortic and mitral valves and discusses the underlying scientific evidence.ZusammenfassungEnde August 2017 publizierte die europäische kardiologische Gesellschaft (European Society of Cardiology, ESC) gemeinsam mit der europäischen Gesellschaft für Herz- und thorakale Gefäßchirurgie (European Association for Cardio-Thoracic Surgery, EACTS) neue Leitlinien zur Behandlung von Klappenerkrankungen. Diese Leitlinien berücksichtigen neue wissenschaftliche Erkenntnisse, die seit der letzten Leitlinienversion 2012 verfügbar sind. Diese Übersichtsarbeit berichtet über die aktuellen Empfehlungen zur antithrombozytären und antikoagulativen Therapie nach chirurgischer/interventioneller Behandlung der Aorten- und Mitralklappe und diskutiert die zugrunde liegende wissenschaftliche Evidenz.AbstractAt the end of August 2017 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published new joint guidelines for the treatment of valvular heart disease. These guidelines incorporate the scientific progress since the last version of the guidelines published in 2012. This article reviews current guideline recommendations for antiplatelet and anticoagulative therapy after surgical/interventional treatment of the aortic and mitral valves and discusses the underlying scientific evidence.

German contribution to development and innovations in the management of acute myocardial infarction and cardiogenic shock

Treatment of acute coronary syndromes has evolved over time leading to a significantly reduced mortality. Multiple major trials have been performed in Germany leading to new treatment strategies in acute coronary syndromes including cardiogenic shock. This review article will summarize major trials and their impact on guideline recommendations in acute myocardial infarction highlighting reperfusion strategies, antiplatelet regimens, prognosis assessment and also mechanical circulatory support in stable infarction patients and in cardiogenic shock.