Kazuya Tateishi

Vasospastic angina (VSA) is an important and potentially treatable cause of cardiac arrest (CA) and may account for approximately 2–10% of otherwise unexplained cases of out-of-hospital CA. VSA can sometimes be diagnosed by spontaneous coronary spasm during emergency coronary angiography or by transient ST-segment elevation during a spontaneous attack after resuscitation. However, because coronary spasm is transient and may not be evident during the initial evaluation, provocation testing after clinical stabilization may be required to establish the diagnosis in otherwise unexplained cases. Once VSA is diagnosed, vasodilator therapy, particularly calcium-channel blockers, is the mainstay of treatment. Nevertheless, survivors of VSA-related CA may remain at risk of recurrent lethal ventricular arrhythmias despite medical therapy. Evaluation for alternative or overlapping arrhythmogenic disorders, including cardiomyopathies and channelopathies, should therefore be considered even after a diagnosis of VSA, and implantable cardioverter-defibrillator implantation may be considered in selected patients according to the risk of recurrence and response to medical therapy. Further prospective studies, including randomized controlled trials, are needed to determine whether systematic provocation testing followed by targeted therapy reduces recurrent ventricular arrhythmias and CA and improves long-term outcomes.

Extracorporeal membrane oxygenation (ECMO) delivers powerful mechanical circulatory support while simultaneously offering respiratory support; however, it can increase afterload and is associated with potential device-related vascular complications. To date, several randomized controlled trials have failed to demonstrate a prognostic benefit of routine use of ECMO in patients with cardiogenic shock secondary to acute myocardial infarction or in those with out-of-hospital cardiac arrest. Therefore, the routine use of ECMO is not a guideline-recommended therapeutic strategy. However, in real-world clinical practice, a considerable proportion of patients with cardiogenic shock and cardiac arrest have no other therapeutic options besides ECMO to save their life. Additionally, a combination of ECMO with other mechanical circulatory support devices, such as an intra-aortic balloon pump and percutaneous ventricular assist device, may help reduce the limitations of ECMO and improve patient outcomes. The results of ongoing randomized trials will shape our understanding of the role of ECMO itself and the combination strategies in patients with cardiogenic shock and out-of-hospital cardiac arrest.

Background: Given that insulin resistance and lower levels of high-density lipoprotein cholesterol are reportedly associated with the development of coronary vasospasm, metabolic disorders may play a significant role in the underlying mechanisms of vasospastic angina (VSA). In this context, however, the impact of serum uric acid (SUA) levels on the diagnosis of VSA remains unclear. Methods: From May 2012 to March 2025, a total of 947 patients undergoing intracoronary acetylcholine (ACh) provocation tests for diagnosing VSA were included. Positive diagnosis of ACh provocation testing was defined as angiographic coronary spasm accompanied by chest symptoms and/or ischemic electrocardiographic changes. The primary interest of this study was to evaluate the potential relationship between SUA levels and ACh provocation test results. Results: Of the 947 patients, 497 (52.5%) had positive ACh provocation testing (i.e., VSA). Patients with positive ACh tests had significantly higher SUA levels than their counterparts (5.4 ± 1.6 vs. 5.2 ± 1.5 mg/dL, p = 0.039). The receiver operating characteristics curve analysis showed that SUA levels were predictive of positive ACh test results (area under the curve 0.538, best cut-off value 5.4 mg/dL, p = 0.040). In the multivariable logistic regression analysis, male sex and current smoking were identified as predictors of positive ACh testing, while SUA levels were not. Conclusions: Patients diagnosed with VSA had a higher SUA level than patients without VSA. However, this association was confounded with other factors, such as male sex and current smoking.

Background: In patients with cardiogenic shock (CS), a percutaneous microaxial ventricular assist device (Impella, Abiomed, Danvers, MA) is a choice for temporary mechanical circulatory support. Given the high morbidity and mortality in this patient population, early risk stratification is relevant when making treatment decisions. Methods: Using nationwide registry data between February 2020 and December 2022 in Japan, we included a total of 4122 patients with cardiogenic shock treated with the Impella devices. Using logistic regression analysis, we incorporated patient characteristics and biomarkers to develop a risk‐stratifying model for in‐hospital mortality. The model was also tested if applicable to composite outcomes of in‐hospital death and major complications. Results: Of the 4122 patients with cardiogenic shock, the Impella was indicated for acute myocardial infarction in 2575 (62.5%). Multivariable analysis identified 4 patient characteristics (age, body mass index, out‐of‐hospital cardiac arrest, and blood pressure) and 6 biomarkers (lactate, lactate dehydrogenase, creatinine, total bilirubin, albumin, and creatinine kinase) with cutoff values as factors significantly associated with in‐hospital mortality. We developed a risk‐stratifying model using the 10 variables, which was predictive of in‐hospital death (area under the curve, 0.711; P P P <0.001). Conclusions: In patients with cardiogenic shock treated with the Impella devices, our risk‐stratifying system, consisting of 4 patient characteristics and 6 biomarkers, strongly correlated with in‐hospital mortality, potentially facilitating clinical decision‐making.