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Review
. 2021 Dec;8(6):4717-4736.
doi: 10.1002/ehf2.13643. Epub 2021 Oct 19.

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature

Razvan I Radu  1 , Tuvia Ben Gal  2 , Magdy Abdelhamid  3 , Elena-Laura Antohi  1   4 , Marianna Adamo  5 , Andrew P Ambrosy  6   7 , Oliviana Geavlete  1   4 , Yuri Lopatin  8 , Alexander Lyon  9 , Oscar Miro  10 , Marco Metra  11 , John Parissis  12 , Sean P Collins  13 , Stefan D Anker  14 , Ovidiu Chioncel  1   4
Affiliations
Review

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature

Razvan I Radu et al. ESC Heart Fail. 2021 Dec.

Abstract

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.

Keywords: Anticoagulation therapy; Antiplatelet therapy; Antithrombotic therapy; Cardiogenic shock.

PubMed Disclaimer

Conflict of interest statement

RIR, TBG, MA, ELA, MA, APA, OG, YL, AL, OM, MM,JP, SPC have nothing to disclose.

SDA reports receiving fees from Abbott, Bayer, Boehringer Ingelheim, Cardiac Dimension, Cordio, Impulse Dynamics, Novartis, Occlutech, Servier, and Vifor Pharma, and grant support from Abbott and Vifor Pharma, outside the submitted work. OC reports grants from Servier, Vifor Novartis and fee from Boehringer Ingelheim, outside the submitted work.

Figures

Figure 1
Figure 1
Pathophysiology of cardiogenic shock and the balance between thrombotic and bleeding risks considering various management interventions and in‐hospital complications. AF, atrial fibrillation; MCS, mechanical circulatory support; MV, mechanical ventilation; PPIs, proton pump inhibitors; RRTs, renal replacement therapies; TTM, targeted temperature management.
Figure 2
Figure 2
Antithrombotic medication in patients with cardiogenic shock in settings of acute coronary syndrome (ACS). Technical consideration regarding primary percutaneous coronary intervention (PCI) and specific recommendations for antithrombotic therapies when different strategies are used. BMS, bare metal stent; DAPT, double antiplatelet therapy; DES, drug‐eluting stent; DTI, direct thrombin inhibitor; GPI, glycoprotein inhibitor; IV, intravenous; LWMH, low‐weight‐molecular heparin; MCS, mechanical circulatory support; MV, mechanical ventilation; TTM, targeted temperature management.
Figure 3
Figure 3
Possible options to overcome delayed onset of action of antiplatelet therapies. CS, cardiogenic shock; GPI, glycoprotein inhibitor; IV, intravenous; OHCA, out‐of‐hospital cardiac arrest; PCI, percutaneous coronary interventions; STEMI, ST‐elevation myocardial infarction.
See this image and copyright information in PMC

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