Cardiogenic shock (CS) is the most lethal complication of acute myocardial infarction (AMI), with a 30-day mortality of approximately 40-50% despite early revascularization. Temporary mechanical circulatory support (tMCS) devices, including the intra-aortic balloon pump (IABP), microaxial flow pumps (MAFP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), are used as adjunctive therapy in refractory shock, but evidence of a survival benefit is limited and often conflicting. The IABP-SHOCK II trial found no 30-day mortality reduction with IABP, supporting a Class III (no benefit) recommendation, whereas the DanGer Shock trial reported a 12.7% absolute mortality reduction at 180 days with the MAFP Impella CP in highly selected patients. In contrast, the ECLS-SHOCK and ECMO-CS trials showed no improvement in survival with early VA-ECMO and noted high complication rates. Real-world data reveal significant disparities between trial populations and clinical practice, highlighting limitations of current evidence, since many AMI-CS patients are older, in more advanced shock or have multiple comorbidities and would not meet typical randomized controlled trial (RCT) inclusion criteria. In clinical practice, in-hospital mortality with IABP or VA-ECMO often exceeds 50-60%. Given the heterogeneity of AMI-CS, rapid identification of appropriate tMCS candidates and personalized therapy are essential. Management guided by individual patient profile, hemodynamic stage and neurological status, supported by multidisciplinary shock teams, may improve timely triage, device selection and outcomes. This review emphasizes the need for individualized, protocol-driven care within structured shock systems to optimize tMCS use in AMI-CS.

Infective endocarditis (IE) often presents with non-specific symptoms, which may delay diagnosis and treatment. Previous studies exploring symptom duration have been limited by small cohorts or single-centre studies. We aimed to investigate patient characteristics, microbial aetiology, treatment, and all-cause mortality of patients with IE according to symptom duration prior to diagnosis. We included all patients with first-time IE from the NatIonal Danish Endocarditis StUdies (NIDUS) registry (2016–2021). Patients with left-sided IE and available symptom duration were stratified as short, intermediate, or prolonged (≤ 7, 8–29, or ≥ 30 days). The primary outcome was six-month mortality. Among 2,938 patients with left-sided IE, median symptom duration was 8 days [IQR:4–20], and 17.6

Aims The DanGer Shock trial demonstrated a mortality benefit with routine use of a microaxial flow pump (mAFP) in ST-elevation acute myocardial infarction complicated by cardiogenic shock (STEMI-CS), but at a cost of more complications. Routine use of a mAFP may, however, expose some patients to unnecessary risk, underscoring the need to identify those who stabilize rapidly and are less likely to derive benefit from device therapy. Methods and results This post hoc exploratory analysis of the DanGer Shock trial, which randomized STEMI-CS patients to mAFP plus standard care (SoC) or SoC alone, defined 'Fast Recovery' as cardiac intensive care unit (CICU) discharge alive within 3 days of randomization. Baseline variables available at catheterization lab admission associated with 'Fast Recovery' in the SoC arm were identified. Among 355 patients (SoC 176; mAFP 179), 'Fast Recovery' occurred in 29% of the SoC group vs. 15% of the mAFP group. Early CICU discharge favoured SoC through day 3 (HR 2.27, 95% CI 1.48-3.49), with no difference thereafter. Median CICU stay beyond day 3 was 13 days (SoC) vs. 12 days (mAFP), and 94 deaths occurred by day 3 (29% SoC; 24% mAFP). Compared with patients with longer CICU stays, 'Fast Recovery' patients required less inotropic support (44% vs. 85%) and mechanical ventilation (35% vs. 82%) and had lower 180-day mortality (9% vs. 46%, P < 0.001). In the SoC arm, 'Fast Recovery' was associated with lower age, initial higher LVEF, lower heart rate, and lower lactate. Model discrimination was modest (AUROC optimism-corrected 0.74). Conclusion The DanGer Shock trial showed a survival benefit of mAFP use in STEMI-CS, yet about one-third of SoC patients experienced rapid haemodynamic recovery. These 'Fast Recovery' patients were characterized by higher LVEF, younger age, and lower lactate, however discrimination between patients with and without rapid recovery was modest. Distinguishing patients who will recover rapidly remains challenging and warrants further investigation.

AIMS:Obesity increases the risk of heart failure (HF), partly due to hypervolaemia and excess epicardial adipose tissue (EAT).We aimed to investigate the effect of the sodium glucose co-transporter 2 inhibitor empagliflozin on estimated extracellular volume (eECV) and ventricular EAT mass in non-diabetic patients with overweight or obesity and risk of HF to evaluate the drug's potential for HF prevention. METHODS:In this randomised, double-blind, placebo-controlled trial, we recruited non-diabetic patients with body mass index (BMI) >28kg/m2 and risk of HF. Patients were randomised 1:1 to 180-days empagliflozin 10 mg or placebo. The primary endpoints were the baseline-adjusted mean differences in change of eECV and ventricular EAT mass in the intention-to-treat population with Bonferroni-adjustment for multiplicity. RESULTS:From September 2021 to July 2024, we randomised 191 patients (empagliflozin: 94, placebo: 97) with median age 68 years and median BMI 31·9 kg/m2. Analyses of eECV and EAT included 191 and 165 patients, respectively. Compared to placebo, empagliflozin significantly reduced eECV [empagliflozin, mean change (SD): -0·154 L (0·257); placebo, mean change: -0·029 L (0·261); estimated treatment difference (ETD): -0·123 L, 97.5% CI: -0·211 to -0·035, padj=0·004] but did not affect EAT mass [empagliflozin, mean change: -2·3 g (13·4); placebo, mean change: -3·7 g (15·8); ETD: 1·5 g, 97·5% CI: -3·8 to 6·7, padj=1.00]. CONCLUSION:In high-risk patients with overweight or obesity, treatment with empagliflozin resulted in a potentially favourable reduction in eECV compared to placebo. Meanwhile, the drug did not affect EAT mass.

BACKGROUND:Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard for evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise. The aim of this observational study was to describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%. METHODS:Patients with aortic valve area ≤1.5 cm2 underwent right heart catheterization at rest and during maximal exercise, measuring pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and the PCWP/CO-slope. Patients were stratified into 3 groups: discordant LG AS (aortic valve area ≤1.0 cm2 and mean gradient <40 mm Hg); moderate AS (aortic valve area >1.0 cm2); and high-gradient (HG) severe AS (aortic valve area ≤1.0 cm2 and mean gradient ≥40 mm Hg). RESULTS:Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) HG severe AS. The median PCWP/CO-slope was significantly steeper in discordant LG (3.3 [interquartile range, 2.1-4.3] mm Hg/L/min) and HG severe AS (2.7 [1.9-3.4] mm Hg/L per minute) compared with moderate AS (1.9 [0.7-2.8] mm Hg/L per minute), P=0.004. In a regression model adjusted for age, sex, and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO-slope. Furthermore, patients with discordant LG AS had a leftward-upward shift in the PCWP/CO-curve. CONCLUSIONS:Discordant LG and HG severe AS had similar hemodynamic responses to exercise with steeper PCWP/CO-slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left upwards shift in PCWP/CO-curve for discordant LG compared with HG severe AS indicates that this group also has heart failure with preserved ejection fraction physiology. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04913870 and NCT02395107.

Background Landmark randomized controlled trials like DanGer Shock, IABP-SHOCK II, and ECLS-SHOCK guide infarct-related cardiogenic shock (CS) management with temporary mechanical circulatory support (tMCS), but strict enrollment criteria may limit real-world applicability. Objectives The objective of the study was to evaluate the eligibility overlap of patients from these three key CS trials with the contemporary CS Working Group registry. Methods In this retrospective analysis, CS patients enrolled between 2020 and 2024 in the CS Working Group registry were assessed. Using trial-specific enrollment criteria (DanGer Shock, IABP-SHOCK II, and ECLS-SHOCK), subsets of patients meeting these criteria were identified. We compared baseline characteristics and usage patterns of tMCS devices among trial-eligible and trial-ineligible patients. Results Only a small proportion of registry patients met all the key enrollment criteria: 19.3% (DanGer Shock), 28.4% (IABP-SHOCK II), and 23.6% (ECLS-SHOCK). Hypotension and elevated lactate thresholds were the most restrictive criteria across trials. Trial-eligible patients had more severe CS and end-organ damage than ineligible patients. Actual device use in real-world practice differed markedly from trial assignments; notably, only 20% of DanGer-like patients received Impella CP as their first device. Conclusions Patients meeting the landmark CS trial criteria represent a small, high-risk subset of the real-world CS population, highlighting a substantial evidence gap for the majority of CS patients receiving tMCS in clinical practice. Enhancing registry enrollment of specific CS subsets and adopting innovative analytic strategies could bridge gaps between randomized controlled trials findings and real-world applicability.

BACKGROUND:The microaxial flow pump (mAFP) has demonstrated improved outcomes in selected patients with ST-segment elevation acute myocardial infarction and cardiogenic shock (STEMI-CS). However, its use has been associated with bleeding events. OBJECTIVES:The authors analyzed bleeding in the international multicenter randomized DanGer Shock (Danish German Shock) trial. METHODS:A total of 355 patients with ST-segment elevation acute myocardial infarction and cardiogenic shock were randomized to either mAFP (n = 179) or standard care alone (n = 176). Bleeding events were classified according to Bleeding Academic Research Consortium (BARC) type 3-5. RESULTS:In the mAFP group, 47 patients (26.3% [95% CI: 20.3%-33.2%]) experienced BARC type 3-5 bleeding, compared with 27 (15.3% [95% CI: 10.7%-21.4%]) in the standard care group; P < 0.001. Median follow-up was 121 days (Q1-Q3: 3-180 days). Among the 210 patients treated with any mechanical circulatory support (MCS), 2 of 74 bleeding events (2.7%) occurred in the cath lab, 35 (47.3%) while on MCS, and 37 (50.0%) after the MCS was removed. Bleeding increased with complexity of MCS: OR for BARC 3-5 bleeding with mAFP was 4.94 (95% CI: 2.30-10.65); P < 0.001, with venoarterial extracorporeal membrane oxygenation (VA-ECMO) 8.06 (95% CI: 2.81-23.09); P < 0.001, and with combined mAFP+VA-ECMO 27.40 (95% CI: 9.82-76.43); P < 0.001, no device as reference. Multivariable logistic regression identified use of mAFP, renal replacement therapy, and escalation to VA-ECMO as predictors of BARC type 3-5 bleeding. CONCLUSIONS:Patients randomized to mAFP experienced more bleeding than the standard care group. Bleeding was associated with the complexity of MCS, with one-half of the bleeding events occurring after device removal. (Danish Cardiogenic Shock Trial [DanShock]; NCT01633502).

INTRODUCTION:Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and substantial long-term neurological sequelae among survivors. During postresuscitation intensive care after return of spontaneous circulation (ROSC), myocardial dysfunction, vasoplegia, and mixed shock states are often observed. Arterial blood pressure alone may not adequately reflect tissue perfusion or oxygen delivery. Advanced hemodynamic profiling has the potential to improve individualized postresuscitation management, but the overall evidence base has not been comprehensively mapped. AIMS:This scoping review will map the available evidence on advanced hemodynamic monitoring during early postresuscitation care after adult OHCA (< 72 h after ROSC). Specifically, we will characterize which hemodynamic variables are measured, when and how they are measured, and in which clinical contexts; summarize how studies report associations between these variables and outcomes or markers of organ perfusion/function; and identify methodological gaps in hemodynamic monitoring. METHODS:A scoping review will be conducted, including adult (≥ 18 years) patients hospitalized after OHCA with sustained ROSC. Eligible studies must investigate one or more predefined advanced hemodynamic parameters using invasive or non-invasive techniques beyond arterial pressure monitoring. There are no restrictions on comparators, publication year, language, setting, or publication type. Animal, pediatric, simulation, intra-arrest-only studies, microcirculatory/local perfusion studies, and echocardiography-only studies are excluded. MEDLINE (via PubMed) will be searched from inception to 31 January 2026. Two reviewers will screen and extract data independently in duplicate using Covidence. Data will be synthesized descriptively. CONCLUSIONS:This review will provide a comprehensive overview of advanced hemodynamic monitoring after OHCA and identify evidence and gaps in the research in this area.

Each year, the European Heart Journal – Acute Cardiovascular Care publishes key studies shaping contemporary understanding of CS pathophysiology, patient selection, optimal timing of intervention, and outcomes associated with CS and various MCS strategies. This review highlights the papers published in EHJ Acute Cardiovascular Care between 2024 and 2025 focusing on CS and MCS. These contributions provide essential insights for clinicians navigating the complexity of CS management and underscore the continued need for high-quality, research in the field of CS and MCS.

Background Atrial fibrillation (AF) often follows myocardial infarction (MI) and is associated with increased risks of adverse cardiovascular outcomes. Obesity is a potent risk factor for both MI and AF. Objective To understand if MI and obesity have a synergistic impact on atrial remodeling. Methods Lean (sham n=3, MI n=12) and obese (sham n=3, MI n=9)Göttingen minipigs (MI group) underwent a 120-minute balloon occlusion of the left anterior descending coronary artery. After 8 weeks, myocardial tissue was collected from four distinct left and right atrial sites for histological analysis. Results Obese animals have a significantly higher amount of atrial adipose tissue compared to lean at all four sites (RA: p = 0.0008, RAA: p = 0.002, LA: p = 0.04, LAA p = 0.0002). Obese animals also showed a higher level of intramyocardial adipose tissue in the left atrial free wall and both appendages (RAA: p = 0.03, LA: p = 0.004, LAA p = 0.001). No significant fibrotic remodeling was detected under any condition or atrial site. MI pigs exhibited a trend towards smaller epicardial adipocytes, while obesity was associated with larger adipocytes in the right atrial appendage and free wall. Finally, obesity significantly increased PR interval duration by 13.7 % in MI pigs (p=0.037). Conclusion Obesity is the primary driver of atrial adipose tissue remodeling both in and around the atria. MI had no effect on atrial remodeling at any site in either lean or obese animals.

BACKGROUND:Microaxial flow pump (mAFP) use in selected patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock improves survival. The present study aimed to assess the influence of delay from first symptoms to randomization on the benefit of an mAFP in patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock. METHODS:This was a secondary analysis of the international, multicenter, randomized, open-labeled DanGer Shock trial (Danish-German Cardiogenic Shock). A total of 345 of 355 patients with ST-segment-elevation myocardial infarction and cardiogenic shock were enrolled in this substudy. Patients were stratified into quartiles according to delay from first symptoms to randomization to either an mAFP or standard care alone. The end point was death from any cause at 180 days for treatment with an mAFP versus standard of care, according to time from onset of symptoms to randomization obtained by logistic regression analysis. RESULTS:Mortality at 180 days increased across quartiles of time from onset of symptoms to randomization: Q1 (0-140 minutes), 36%; Q2 (141-248 minutes), 53%; Q3 (249-650 minutes), 59%; and Q4 (> 651 minutes), 62%, respectively (log-rank P=0.002). However, those with longer delays were also older and more often women. Median age rose from 66 years (interquartile range, 57-73) in the earliest quartile to 71 years (interquartile range, 62-79) in the latest quartile (P=0.005), and the proportion of women increased from 15% to 34%, respectively. Combining the 3 lowest quartiles for the time from onset of symptoms to randomization, the mAFP treatment was associated with an odds ratio of 0.51 (95% CI, 0.31-0.84), whereas the odds ratio for the highest quartile was 0.92 (95% CI, 0.38-2.22; P for interaction = 0.26). CONCLUSIONS:In patients with ST-segment-elevation myocardial infarction complicated with cardiogenic shock, treatment with an mAFP was associated with reduced all-cause mortality, but the treatment benefit appeared to weaken with prolonged time from the onset of symptoms to randomization. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT01633502.

Abstract Background and Aims Aortic root abscess is a severe and diagnostically challenging complication of infective endocarditis (IE). This study aimed to examine differences between IE patients with and without aortic root abscesses in patient characteristics, treatment strategies, and clinical outcomes. Methods We conducted nationwide, unselected, registry-based cohort study using National Danish Endocarditis Studies registry. All patients with aortic valve endocarditis in Denmark from 2016 to 2021 were included. Clinical and microbiological characteristics, treatment, and mortality were compared according to status of aortic root abscess. Mortality was adjusted for clinically relevant covariates. Results The study population included 1902 patients with aortic endocarditis, of whom 316 (17%) had an aortic root abscess. Patients with an abscess versus those without were significantly younger (median 71.5 vs 75.1 years, P-value ≤.001), more often male (76.3% vs. 69.7%, P-value = .02), prosthetic valve (50.0% vs. 30.4%, P-value ≤.001), AV-block (10% vs 1.7%, P-value ≤.001), coagulase-negative staphylococci and streptococci in their blood cultures, and were surgically treated (59.5% vs 16.1%). In multivariable Cox regression, patients with abscesses had significantly higher 1-year mortality rate compared with those without (HR 1.41, 95% CI: 1.13–1.76). When stratifying for surgery, non-operated patients with an abscess had the highest 1-year mortality 55.4%, alongside a high pre-operative risk (median age 79, 38% not self-reliant, more comorbidities including 12% active cancer). Conclusions Aortic root abscess was present in 17% of patients with aortic valve endocarditis and was associated with distinct clinical and microbiological characteristics, a higher frequency of complications, greater prevalence of surgery albeit a higher mortality rate compared with those without an abscess.

BACKGROUND:Informed consent is a fundamental part of clinical research involving human participants. However, in certain emergency medical situations, participants are unable to provide prospective informed consent before inclusion, or the urgency of the situation deems it non-futile to await consent before the intervention. This has led to the introduction of legal guardians who can provide proxy consent initially, where the legal guardian, next-of-kin, and the participant themselves later can give or withdraw consent regarding continued follow-up. Prior to the initiation of an emergency trial in Denmark, it has been accepted and approved by national or regional research ethics committees, as well as The Danish Medicines Agency if it is a drug study. OBJECTIVE:The objective of this systematic review is to first identify all conducted emergency trials in Denmark and then contact the researchers of those trials through a national survey. This will serve as the basis for providing a systematic evaluation of the consent procedures and how they are utilized in emergency setting trials in Denmark through both quantitative and qualitative data. METHODS:This protocol describes a two-phase study, consisting of a systematic review identifying all emergency trials in Denmark throughout the different iterations of legislation, and a national survey regarding the use of proxy consent in the trials identified in the systematic review. An information specialist will generate the search string to identify all relevant trials by searching relevant databases. These trials will have data extracted, and the corresponding authors of the trials will be contacted and invited to conduct a survey. This survey will contain quantitative questions about the amount of included participants and to what extent consent was either denied or not obtained. Furthermore, an anonymized section of the questionnaire will investigate qualitatively the opinions, suggestions, and beliefs of the emergency researchers regarding the consent procedures.

Background:Atrial fibrillation often follows myocardial infarction (MI) and is associated with increased risks of adverse cardiovascular outcomes. Obesity is a potent risk factor for both MI and atrial fibrillation. Objective:This study aimed to understand whether MI and obesity have a synergistic impact on atrial remodeling. Methods:Lean (sham n = 3; MI n = 12) and obese (sham n = 3; MI n = 9) Göttingen minipigs (MI group) underwent a 120-minute balloon occlusion of the left anterior descending coronary artery. After 8 weeks, myocardial tissue was collected from 4 distinct left and right atrial sites for histologic analysis. Results:Obese animals have a significantly higher amount of atrial adipose tissue than lean animals at all 4 sites (right atrium [RA] P = .0008; RA appendage [RAA] P = .002; left atrium [LA] P = .04; LA appendage [LAA] P = .0002). Obese animals also showed a higher level of intramyocardial adipose tissue in the LA and both appendages (RAA P = .03; LA P = .004; LAA P = .001). No significant fibrotic remodeling was detected under any condition or atrial site. MI pigs exhibited a trend toward smaller epicardial adipocytes, whereas obesity was associated with larger adipocytes in the RAA and free wall. Finally, obesity significantly increased PR interval duration by 13.7% in MI pigs (P = .037). Conclusion:Obesity is the primary driver of atrial adipose tissue remodeling both in and around the atria. MI had no effect on atrial remodeling at any site in either lean or obese animals.

Aims:Right ventricular (RV) dysfunction is a key prognostic factor in pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Evaluation by cardiac magnetic resonance imaging (cMRI) is preferred, but it is expensive and time-consuming. We therefore tested whether semiautomated, three-dimensional transthoracic echocardiography and RV free-wall strain could discriminate between clinical risk groups. Methods and results:We studied 49 patients with PAH or CTEPH. Study participants underwent cMRI and 2D and 3D echocardiography with the assessment of measures of RV size and function. Patients were categorized into low and non-low clinical risk groups based on a modified version of the ESC/ERS four-strata risk-assessment model. Among the non-low-risk patients, cMRI found an elevated RV end-diastolic and end-systolic volume, and a reduced RV ejection fraction, after adjustment for disease subtype, age, sex, BMI, and smoking status, compared to the low-risk group; 3D echocardiography confirmed a higher end-diastolic and end-systolic volume in the non-low-risk group (191 ± 61 mL vs. 151 ± 44 mL, P = 0.001 and 121 ± 42 mL vs. 97 ± 38 mL, P = 0.007), and free-wall strain was reduced (-15.0 ± 4.1% vs. -17.3 ± 3.4%, P = 0.029). No significant difference was observed in RV ejection fraction between groups (37.2 ± 6.4% vs. 38.7 ± 7.7%, P = 0.223). Traditional 2D echocardiographic measures of RV function, including tricuspid annular plane systolic excursion and RV fractional area change, did not differ between the groups. Conclusion:Larger 3D-echocardiographic RV volumes and reduced free-wall strain were associated with a worse clinical risk profile in PAH and CTEPH, whereas RV ejection fraction and traditional 2D measures were not. These parameters offer a practical alternative to cMRI for evaluating RV remodeling.