Optimal Antithrombotic Strategies in Cardiogenic Shock

Abstract

Cardiogenic shock (CS) represents a critical condition with a high mortality rate. The most common cause of CS is coronary artery disease, and patients typically present with myocardial infarction, necessitating immediate treatment through percutaneous coronary intervention (PCI) and often requiring mechanical circulatory support. CS is associated with a prothrombotic situation, while on the other hand, there is often a significant risk of bleeding. This dual challenge complicates the selection of an optimal antithrombotic strategy. The choice of antithrombotic agents must be personalized, taking into consideration all relevant conditions. Repeated risk assessment, therapeutic monitoring, and adjusting antithrombotic therapy are mandatory in these patients. This review article aims to provide an overview of the current evidence and practical guidance on antithrombotic strategies in the context of CS.

Keywords: antithrombotic treatment; bleeding; cardiogenic shock; mechanical circulatory support; thrombosis.

Figure 2

Cardiogenic shock—Aspects of Antithrombotic Therapy in Special Situations. # Calculate total UFH dose, including UFH purge concentration. * Contraindicated in liver failure and lactate acidosis. AF—atrial fibrillation; aPTT—activated partial thromboplastin time; CS—cardiogenic shock; DAPT—dual antiplatelet therapy; ECMO—extracorporeal membrane oxygenation; GPI—glycoprotein IIb/IIIa inhibitors; HBR—high bleeding risk; HIT—heparin-induced thrombocytopenia; MCS—mechanical circulatory support; NG—nasogastric tube; PCI—percutaneous coronary intervention; OAC—oral anticoagulation; RCA—regional citrate anticoagulation; TTM—targeted temperature management; UHF—unfractionated heparin.

Figure 1

SCAI SHOCK Stage Classification according to [1]. AMI—acute myocardial infarction; CA—cardiac arrest; CS—cardiogenic shock; HF—heart failure; SCAI—Society for Cardiovascular Angiography and Interventions.