p.58 抽出テキスト

..........................................................................................................

analyses suggest that morphine administration is associated with a greater frequency of mechanical ventilation, prolonged hospitalization, more intensive care unit admissions, and increased mortality.488491 Thus, routine use of opiates in AHF is not recommended although they may be considered in selected patients, particularly in case of severe/intractable pain or anxiety or in the setting of palliation.

11.3.8 Digoxin Digoxin should be considered in patients with AF with a rapid ventricular rate (>110 b.p.m.) despite beta-blockers (see also section 12.1.1).151,492,493 It can be given in boluses of 0.250.5 mg i.v., if not used previously. However, in patients with comorbidities (i.e. CKD) or other factors affecting digoxin metabolism (including other drugs) and/or the elderly, the maintenance dose may be difficult to estimate theoretically and measurements of serum digoxin concentrations should be performed. Digitoxin is a potential alternative to digoxin and is currently being evaluated in a randomized placebo-controlled trial (ClinicalTrials.gov Identifier: NCT03783429).158

11.3.9 Thromboembolism prophylaxis Thromboembolism prophylaxis with heparin (e.g. low-molecularweight heparin) or another anticoagulant is recommended, unless contraindicated or unnecessary (because of existing treatment with oral anticoagulants).494,495 11.3.10 Short-term mechanical circulatory support In patients presenting with cardiogenic shock, short-term MCS may be necessary to augment cardiac output and support end-organ perfusion. Short-term MCS can be used as a BTR, BTD or BTB.450-452

The initial improvements in cardiac output, BP and arterial lactate may be counterbalanced by significant complications. High-quality evidence regarding outcomes remains scarce. Hence, the unselected use of MCS in patients with cardiogenic shock is not supported and they require specialist multidisciplinary expertise for implantation and management, similar to that outlined for advanced HF centres (Supplementary text 11.4; Supplementary Table 22, see also section 10.2.2).376,496 Recent studies show that a ‘standardized team-based approach’ using predefined algorithms for early MCS implant coupled with close monitoring (invasive haemodynamics, lactate, markers of end-organ damage) may potentially translate into improved survival.497499 The Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP- SHOCK-II) trial showed no difference in 30-day, as well as in longterm, mortality between intra-aortic balloon pump (IABP) and OMT in patients with cardiogenic shock following acute MI who underwent early revascularization.500502 According to these results, IABP is not routinely recommended in cardiogenic shock post-MI. However, it may still be considered in cardiogenic shock, especially if not due to ACS, and refractory to drug therapy, as a BTD, BTR, or BTB. Other short-term MCS were compared with IABP in small, randomized trials and propensity-matched analyses with inconclusive results.503507 Similarly, RCTs comparing extracorporeal membrane oxygenation (ECMO) with IABP or MT are lacking. A meta-analysis including only observational studies showed favourable outcomes in patients with cardiogenic shock or cardiac arrest treated with venoarterial (VA)-ECMO compared to controls.508 VA-ECMO may also be considered in fulminant myocarditis and other conditions causing severe cardiogenic shock.509 Depending on the severity of myocardial dysfunction and/or concomitant mitral or aortic regurgitation, VA-ECMO may increase LV afterload with an increase in LV end-

Inotropic agents Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of hypoperfusion who do not respond to standard treatment, including fluid challenge, to improve peripheral perfusion and maintain end-organ function.387 IIb C Inotropic agents are not recommended routinely, due to safety concerns, unless the patient has symptomatic hypotension and evidence of hypoperfusion.387,467,478 III C Vasopressors A vasopressor, preferably norepinephrine, may be considered in patients with cardiogenic shock to increase blood pressure and vital organ perfusion.485487 IIb B Other drugs Thromboembolism prophylaxis (e.g. with LMWH) is recommended in patients not already anticoagulated and with no contraindication to anticoagulation, to reduce the risk of deep venous thrombosis and pulmonary embolism.494,495 I A Routine use of opiates is not recommended, unless in selected patients with severe/intractable pain or anxiety.488,489 III C

AHF = acute heart failure; i.v. = intravenous; LMWH = low-molecular-weight heparin; PaO2 = partial pressure of oxygen; SBP = systolic blood pressure; SpO2 = transcutaneous oxygen saturation. aClass of recommendation. bLevel of evidence. ESC 2021

Recommendations for the use of short-term mechanical circulatory support in patients with cardiogenic shock

Recommendations Classa Levelb

Short-term MCS should be considered in patients with cardiogenic shock as a BTR, BTD, BTB. Further indications include treatment of the cause of cardiogenic shock or long-term MCS or transplantation. IIa C IABP may be considered in patients with cardiogenic shock as a BTR, BTD, BTB, including treatment of the cause of cardiogenic shock (i.e. mechanical complication of acute MI) or longterm MCS or transplantation.450 IIb C IABP is not routinely recommended in post-MI cardiogenic shock.500502 III B

BTB = bridge to bridge; BTD = bridge to decision; BTR = bridge to recovery; IABP = intra-aortic balloon pump; MCS = mechanical circulatory support; MI = myocardial infarction. aClass of recommendation. bLevel of evidence. ESC 2021

............................................................... Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026