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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThe rate of mortality after cardiogenic shock remains high. However, mortality is not reduced with the currently available devices that provide hemodynamic support. The benefit with inotropic drug therapy is also limited. As the technology evolves, it is anticipated the management of cardiogenic shock will improve, but better identification of patients to benefit is needed.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiogenic shock\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eacute myocardial infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eintra-aortic balloon pump\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epercutaneous coronary intervention\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eextracorporeal membrane oxygenation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eventricular assist device\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ehemodynamic\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIABP SHOCK II\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimpella\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETRIS trial\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine clinical trials\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003ECardiogenic shock (CS) develops in about 6% of patients who suffer an acute myocardial infarction (AMI), with a relative incidence of 1 in 40 AMI patients [American Heart Association. \u003Cem\u003EHeart Disease and Stroke Statistics\u20132011 Update\u003C\/em\u003E. 2011]. The rate of mortality associated with CS after AMI continues to remain at about 45% to 50%, unchanged from 1997 to 2006, despite the increased use of an intra-aortic balloon pump (IABP) and percutaneous coronary intervention (PCI) and the decreased use of thrombolysis and coronary bypass surgery [Jeger RV et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe time to intervene is within 90 minutes to reverse CS or the opportunity to repair the heart is lost, based on physiological responses to CS, stated Ramesh Daggubati, MD, East Carolina Heart Institute at Vidant Medical Center, East Carolina University, Greenville, North Carolina, USA. A device for hemodynamic (HD) support should be considered when a moderate dose of inotropes is needed, said Dr Daggubati. None of the most commonly used devices (eg, IABP, TandemHeart, and Impella), however, have been shown to reduce mortality, despite their ability to improve hemodynamics. The limited beneficial effects and the increased side effects associated with the current drugs and devices to treat CS are summarized in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16899\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16899\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16899\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EThe Advantages and Limitations of Current Drug and Device Treatments for Cardiogenic Shock\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EThe lack of a mortality benefit with IABP was shown in the IABP SHOCK II study [Thiele H et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2013] and in a meta-analysis of studies conducted in the 1990s comparing it to no IABP [Sjauw KD et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2009], which also showed that mortality was about 6% higher with IABP in patients who underwent PCI, based on pooled data from the National Registry of Myocardial Infarction 2 and the Amsterdam Medical Center Cardiogenic Shock registries. IABP increased the risk of stroke by 2% (95% CI, 0 to 4; \u003Cem\u003EP\u003C\/em\u003E = .03) and bleeding by 6% (95% CI, 1 to 11; \u003Cem\u003EP\u003C\/em\u003E = .02), according to this meta-analysis.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EHD support with IABP remains controversial and is being challenged because of the lack of evidence of benefit, stated Dr Daggubati, and the new percutaneous left-ventricular assist devices (TandemHeart, Impella) provide better HD support than IABP but do not improve mortality. In the ISAR-SHOCK study, the Impella LP 2.5 device versus IABP significantly improved the primary end point of cardiac index (0.49 vs 0.11 L\/min\/m\u003Csup\u003E2\u003C\/sup\u003E, respectively; \u003Cem\u003EP\u003C\/em\u003E = .01), but mortality was similar (log-rank \u003Cem\u003EP\u003C\/em\u003E = .97) [Seyfarth M et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe timing of mechanical support, however, may lead to improved outcomes. The preintervention placement of an IABP compared with no IABP or an IABP placed after the intervention in the CS group significantly reduced the incidence of ventricular fibrillation (\u003Cem\u003EP\u003C\/em\u003E = .02), cardiopulmonary arrest (\u003Cem\u003EP\u003C\/em\u003E = .01), and total events in the catheterization laboratory (\u003Cem\u003EP\u003C\/em\u003E = .0009) [Brodie BR et al. \u003Cem\u003EAm J Cardiol.\u003C\/em\u003E 1999]. A similar result was found in the Impella registry, stated Dr Daggubati, and the pre-intervention approach is being studied in the upcoming TandemHeart to Reduce Infarct Size Trial [TRIS Trial; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT02164058\u0026amp;atom=%2Fspmdc%2F14%2F16%2F12.atom\u0022\u003ENCT02164058\u003C\/a\u003E]. Implementation of a CS protocol with quick escalation of percutaneous ventricular assist devices has been shown to reduce mortality of in-hospital CS in a small registry of 32 patients from 44% to 24%. Dr Daggubati presented these data at the Society of Cardiovascular and Angiography Interventions national meeting in May 2014.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe management of CS with circulatory support will evolve with new paradigm shifts and treatment protocols as technology evolves, but better identification of the patients most likely to benefit based on stronger clinical evidence is needed.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/16\/12.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlk2q\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlk2q\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}