TABLE 3.
Opportunities for Future Research in CS Care
| Clinical Realms in CS Care | Clinical Gaps in Knowledge | Study Design |
|---|---|---|
| 1. Diagnosis a) Pulmonary arterial catheters b) Classification of CS |
• Clinical utility of invasive hemodynamics in CS treatment algorithms • Prospective validation of risk stratification tools |
• Prospective multicenter registries • RCT • Prospective multicenter registries |
| 2. Tailored therapeutics a) MCS b) Revascularization in AMI-CS c) Vasopressors and inotropes in CS d) Antithrombotics in AMI-CS |
Management • Patient selection • Vascular access strategies • MCS tailored to individual CS phenotypes • Optimal strategies for anticoagulation and monitoring (TEG, aPTT, ACT) • Weaning and escalation strategies Impella in AMI-CS • Clinical benefit of LV unloading pre-PCI VA-ECMO in AMI-CS LV venting strategies with VA-ECMO 1) Pharmacologic 2) IABP 3) Impella 4) Atrial septostomy 5) Pulmonary artery cannulation 6) Surgical LV venting Decongestion in cardiorenal syndrome i. Aortix (Procyrion) ii. Reitan Catheter Pump iii. Second Heart Assist • Culprit-vessel vs. multivessel PCI • PCI vs. CABG Safety and efficacy Intravenous P2Y12 inhibition to achieve timely platelet inhibition and to mitigate bleeding risk |
• Prospective multicenter registries • RCT • Prospective multicenter registries (NCSI, cVAD) • RCT (DanGer Shock [NCT01633502]) • ECLS-SHOCK (NCT02544594) • ECMO-CS (NCT02301819) • EURO SHOCK (NCT03813134) • ANCHOR (NCT04184635) • Prospective multicenter registries • RCT • Prospective multicenter registries • RCT • RCT • RCT • Milrinone versus dobutamine in critically ill patients (NCT03207165) • Norepinephrine vs. Norepinephrine and Dobutamine in Cardiogenic Shock (SHOCK-NORDOB [NCT03340779]) • Efficacy and Safety on Heart Rate Control with Ivabradine in Cardiogenic Shock (ES-FISH [NCT03437369]) • RCT (DAPT-AMI-SHOCK [NCT03551964]) |
| 3. Care delivery models a) Regionalized systems of CS with: i) Hub-and-spoke networks ii) Multidisciplinary shock teams b) Multidisciplinary CICUs with 24/7 staffing |
• Improved clinical outcomes • Improved clinical outcomes • Reduced complications • Reduced hospital length of stay • Reduced costs |
• Prospective multicenter registries • Prospective multicenter registries |
| 4. Palliative care a) Early implementation of palliative services in multidisciplinary CS care 1) Shared decision making 2) Goals of care and health values discussions |
• Improved patient QOL, well-being • Reduced Complications • Reduced costs |
• Prospective multicenter registries • RCT |
ACT = activated clotting time; aPTT = activated partial thromboplastin time; cVAD = catheter-based ventricular assist device; DanGer Shock = Danish-German Cardiogenic Shock Trial; DAPT-AMI-SHOCK = Dual Antiplatelet Therapy for Shock Patients with Acute Myocardial Infarction; ECLS-SHOCK = extracorporeal life support in cardiogenic shock; ECMO-CS = •••; LV = left ventricular; MCS = mechanical circulatory support; NCSI = National Cardiogenic Shock Initiative; QOL = quality of life; RCT = randomized controlled trial; SHOCK-NORDOB = Norepinephrine vs Norepinephrine and Dobutamine in Cardiogenic Shock; TEG = thromboelastography; other abbreviations as in Table 2.