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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Acute heart failure and cardiogenic shock


Cardiovascular disease accounts for one quarter of all deaths, and once cancer mortality is excluded, cardiac disease alone accounts for more deaths than all other causes put together. Heart failure (defined as the inability of the heart to pump enough blood to meet the demands of the body) is common, being the primary cause of hospital admission in >1million patients per year in the USA, with 25% readmitted within 1 month, and a 10-20% mortality at 6 months after discharge. In newly diagnosed patients there is a >20% mortality at one year, rising to 50% at two years and >66% at ten years – proving as malignant as many common cancers. The underlying causes include coronary artery disease, hypertension, valve dysfunction, cardiomyopathies (inherited and acquired), congenital heart disease, arrhythmia, toxins (either ‘recreational’ – cocaine and alcohol, or therapeutic – some chemotherapeutic agents), pulmonary embolism and sepsis. Acute heart failure (AHF) may be a new diagnosis in patients with no history of cardiac disease, or occur as a result of acute decompensation in patients with known heart failure. It is the leading cause of hospital admission in people >65 years in the UK. European-wide, approximately 50% of these patients will be readmitted within 12 months, and 30% deceased at the 1-year follow-up.

Key words: cardiogenic shock, heart failure, mechanical circulatory support

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Palliative care in heart failure


Chronic heart failure is a progressive disease with serious symptoms, which reduce patient functionality and increasingly interfere with basic daily activities. Therefore, palliative care should be incorporated relatively early in the management of the disease as supportive treatment. With its progression, the role of palliation becomes more and more important. Principles of palliative care in heart patients cannot be simply transferred from the oncology. The prognosis in patients with chronic heart failure is less reliable than in oncology. Furthermore, in cardiac patients, active treatment of the heart failure is preserved or even intensified in the advanced stage of the disease, because it can control the severity of the symptoms.

Nevertheless, when ICU treatment in the terminal stage is recognized and confirmed as futile, the duty of intensivist is to provide care so that the patient can die with preserved dignity and without any additional harm.

Key words: palliative care, heart failure

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Intensive care management of patients with left ventricular assist device


Mechanical circulatory support devices, especially left ventricular assist devices (LVADs) represent an important treatment modality for patients with end-stage heart failure (HF). In a 1-year period (from January to December 2017) in our intensive care unit (ICU) we had a total of 8 patients with LVAD implantation. LVADs are devices with unique physiology which restore tissue circulation by increasing blood supply, nevertheless, they can be challenging to manage and are associated with significant complications.

Keywords: Critical Care, Heart-Assist Devices, Heart Failure, Hemodynamics, Hemodynamic Monitoring, Cardiac surgery, Postoperative Complications

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Percutaneous mechanical support in acute coronary syndromes


Despite advances in interventional cardiology, persistently disappointing outcomes in patients with cardiogenic shock complicating myocardial infarction, together with the lack of evidence the that intra-aortic balloon pump improves outcomes in this patient population have led to a re-evaluation of other types of mechanical circulatory support. The increase in extracorporeal membrane oxygenation (ECMO) prompted by the H1N1 pandemic led to an increase in experience in using this technique in critically ill adult patients, and its use is now expanding in both respiratory and cardiac failure. Despite enthusiasm for the technique, high-quality evidence is lacking for its benefit. Nonetheless, ECMO and other types of percutaneous mechanical circulatory support do provide critical care clinicians with new supportive therapies that may prove to benefit patients, both from the high level of support that can be offered, and also minimising the use of potentially toxic inotropic agents.

Key words: cardiogenic shock, heart failure, mechanical circulatory support, extracorporeal membrane oxygenation, ECMO, myocardial infarction, acute coronary syndromes

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Inotropes and vasopressors


Inotropic agents are used to increase myocardial contraction while vasopressors are used to increase vascular tone. They are often used for treatment of patients whose tissue perfusion is insufficient to meet metabolic requirements. Therefore, these agents are usually administered in intensive care units where continuous and invasive monitoring of cardiac function can be applied.

Inotropic agents can be divided into those that increase cAMP levels and those that do not. Adrenergic receptor agonists and phosphodiesterase inhibitors (PDEi) increase cAMP levels and are currently the mainstay of positive inotropic therapy. Levosimendan acts as calcium sensitizer and increases myocardial contraction force without increasing intracellular calcium levels. In addition to existing inotropic agents, new promising inotropes are being developed. These include sarcoplasmic reticulum calcium pump (istaroxime), cardiac myosin activators (omecamtivmecarbil), gene therapy, nitroxyl donors and ryanodine receptor stabilizers.

Current treatments of heart failure are aimed at prolonging survival and not just alleviating symptoms. This review provides a short description of the physiology of myocardial contraction and adrenergic receptors. We also provide a short description of commonly used inotropic agents and vasopressor drugs as well as a short review of agents that are expected are in use in the future.

Inotropes are agents used to increase myocardial contractility, while vasopressors are administered to increase vascular tone(1).Their use ismostly confined to critically ill patients whose hemodynamic impairment is such that tissue perfusion is insufficient to meet metabolic requirements(2). Patients in need of inotropic or vasopressor support are often presented with septic or cardiogenic shock and severe heart failure, and are victims of major trauma or undergoing major surgery.These drugs are therefore administered usually to patients treated in intensive care settings where continuous monitoring of cardiac rhythm, arterial oxygenation, urine output and other invasive hemodynamic monitoring can be applied.Inotropic and vasopressor drugs should be administered through a central venous catheter via infusion pumps that can deliver precise flow rates. These agents are mostly short acting with rapid onset and offset of action. Therefore, they can be used without an initial bolus and can be titrated frequently. Abrupt discontinuation should be avoided because of possible hypotension.

Key words: Inotropes, Vasopressor Agents, Intensive Care, Heart Failure

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