AIMS:Out-of-hospital cardiac arrest (OHCA) represents a major public health challenge, with high mortality and significant neurological impairments among survivors. Haemodynamic instability, particularly hypotension (a mean arterial blood pressure <65 mmHg), may be a key contributor to post-resuscitation morbidity and mortality. METHODS AND RESULTS:After return of spontaneous circulation, hypotension can result from various causes, including arrhythmias, mechanical complications, thromboembolism, or different types of shock, as well as sedation, temperature control and positive pressure ventilation. Differentiating between hypotension with vs. without hypoperfusion is critical to avoid unnecessary interventions while ensuring adequate cerebral and myocardial perfusion. Clinical assessment and repeated echocardiography should be routine in all patients. Therapeutic targets should include evidence of preserved end-organ function, including urine output, and normal or decreasing lactate. In selected cases, advanced haemodynamic monitoring with pulmonary artery catheters may be necessary to diagnose the shock-type and monitor treatment effects. Causal treatment of the precipitating cause of hypotension is crucial as well as symptomatic treatment with fluids, vasopressors and inotropes if needed. Mechanical circulatory support may be employed for refractory shock unresponsive to other treatment. CONCLUSION:This clinical consensus statement by the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology (ESC) provides clinical guidance for the haemodynamic monitoring and management of hypotension in OHCA patients in intensive care. The document advocates for a multidisciplinary approach that integrates clinical assessment, imaging, and haemodynamic parameters to guide treatment, with the overarching goal of improving survival rates and neurological outcomes.

Despite a strong pathophysiological rationale for the use of intravenous vasodilators (IVV) in acute heart failure (AHF), previous studies have yielded controversial results and international guidelines provide weak recommendations. This survey aimed to gather real-world data and physician perspectives on the management of IVV in AHF. An online survey was designed and distributed to assess the use of IVV in AHF. A total of 170 cardiologists experienced in AHF care from 32 countries participated (67% male, mostly aged 30-50 years) with the majority (62%) reporting using IVV in fewer than 10 patients per month, and nitroglycerin being the preferred agent for 48% of respondents, followed by sodium nitroprusside (29%). Nearly half (48%) administer IVV also out of the intensive care setting, and 58% consider serial non-invasive blood pressure monitoring adequate. The main indications for IVV are acute decompensated heart failure (88%) while right ventricular failure (24%) cardiogenic shock (25%) and advanced decompensated heart failure (42%) are also potential indications. The main contraindication (51%) is low blood pressure, although the reported thresholds for blood pressure vary widely. IVV are used more frequently in heart failure with reduced (55%) rather than preserved (17%) ejection fraction. Huge differences exist among the cardiologists regarding the maintenance or withdrawal of oral neurohormonal drugs during the IVV infusion. This survey shows that IVV are adopted in a limited number of AHF patients with considerable variability in practice patterns. Further well-designed studies focusing on patients’ characteristics associated with potential favourable response are needed.

Percutaneous ventricular assist devices (pVADs) are increasingly being used because of improved experience and availability. The Impella (Abiomed), a percutaneous microaxial, continuous-flow, short-term ventricular assist device, requires meticulous postimplantation management to avoid the 2 most frequent complications, namely, bleeding and hemolysis. A standardized approach to the prevention, detection, and treatment of these complications is mandatory to improve outcomes. The risk for hemolysis is mostly influenced by pump instability, resulting from patient- or device-related factors. Upfront echocardiographic assessment, frequent monitoring, and prompt intervention are essential. The precarious hemostatic balance during pVAD support results from the combination of a procoagulant state, due to critical illness and contact pathway activation, together with a variety of factors aggravating bleeding risk. Preventive strategies and appropriate management, adapted to the impact of the bleeding, are crucial. This review offers a guide to physicians to tackle these device-related complications in this critically ill pVAD-supported patient population.