Current and Future Perspectives in Cardiogenic Shock, Reperfusion Strategies and Hemodynamic Inotropic Support for Acute Heart Failure

Cardiogenic shock continues to be one of the frustrating conditions among the acute heart syndromes that are encountered with high mortality, despite the variety of heroic interventional approaches that have been tried. Dziewierz et al (1) indentified the predictors for cardiogenic shock among an unselected cohort of acute coronary syndrome patients. Overall 4.3% of our patients are presented with cardiogenic shock and are subjected to 63% mortality rate, with the highest predictive risk factors being prior myocardial infarction, prior heart failure, age, and diabetes mellitus. Cardiogenic shock in the 21^st century is still associated with unfavorable prognosis and very high mortality. Our ability to deal with this disease more efficiently will probably involve an acute bridge intervention to a more definitive long term treatment in order to improve the clinical results in this scenario.

Reperfusion therapy for acute myocardial infarction has impacted our society and has changed the outcome of acute myocardial infarction across the globe. While thrombolysis has started as the major method of revascularization, its role was gradually replaced by primary percutaneous intervention (PCI) as the method of choise for revascularization in acute myocardial infarction. Yet, the pendulum may shift to the thrombolytic side followed by endovascular intervention. Clearly, the immediate availability of the catheterization laboratory is the major hurdle in worldwide application of the acute catheter interventions. Todt et al (2) report on the clinical results with early administration of abciximab in patients with ST elevation myocardial infarction followed by primary PCI. In a series of 133 consecutive patients TIMI 2–3 flow was observed in almost half of the patients that received abciximab versus only 20% in those that did not receive abciximab. Did these differences lead to a difference in clinical outcome? Please read it in the paper published in this cover.

Multiplex biomarkers are a widely developing field in stratifying and guiding therapy in cardiac patients in the acute settings. Introduction of multiplex arrays, developed on ELISA methodology, simultaneously measuring multiple proteins in one assay, allowed the chance to obtain patient multimarket profiles in a variety of clinical conditions. A commentary below by Ferraro et al (3) is provided to review the clinical reliability and usefulness of multiplex arrays in the Acute Coronary Syndrome (ACS) context. A criticism of the multiplex arrays approach is followed up with a suggestion to design a more hypothesis based specific arrays with a lower number of markers but with a clear link to ACS evolution.

Heart failure is becoming an increasing epidemic in the modern world. Pharmacologic inotropic methods are some of the ways to treat acute decompensate patients with heart failure. The effect of Levosimedan on hemodynamics in patients with severe heart failure with an elegant physiologic characterization of the response to the drug is provided by Despas et al (4). A decrease in the sympathetic tone was measured in patients with decompensated acute heart failure treated by the drug. This is the first study showing that Levosimedan has no direct detrimental effect on the sympathetic nervous system. Increasing sympathetic tone with inotropic stimulation is “beating a dying horse” and therefore this observation is important. This paper presents a solid physiological evidence for this advantage for Levosimedan in the heart failure setting.

Myocarditis is an entity that we all encounter in our clinical practice. It is sometimes difficult to differentiate it for an ischemic event and often diagnostic catheterization is performed in these patients. The diagnosis and management of acute eosinophilic myocarditis are reviewed by Rezaizadeh et al (5) using an interesting and well presented clinical example.

The last image presentation by Ito et al (6) describes a rare presentation of a cardiac tumor. This is a nice conclusion to this issue showing how variable are presentations of cardiac diseases and how rare diseases can mimic the common ischemic heart scenario that is the major bulk of our clinical reality.