Bright days, critical decisions: evolving strategies in cardiogenic shock and OMI

Abstract

Welcome to the July issue of the European Heart Journal-Acute Cardiovascular Care, in which we spotlight the evolving and high-stakes landscape of cardiogenic shock (CS). This lethal and complex syndrome is increasingly shaped by precision diagnostics and physiologically guided therapies. 1-4 Despite advances, complications like bleeding and acute kidney injury (AKI) continue to drive poor outcomes. 5-8 As frontline teams face a continued drumbeat of acute myocardial infarction complicated by cardiogenic shock (AMI-CS), this issue highlights the critical role of individualized, physiology-based care, advanced diagnostics, and harm-reduction strategies-including optimal access site selection 9,10 and antithrombotic use 11-in improving survival. In parallel, the timely recognition of occluded myocardial infarction (OMI) has emerged as a key factor in determining the success of early intervention and long-term prognosis. Traditional STEMI criteria too often miss acute coronary occlusions, delaying life-saving reperfusion. Mounting evidence , including new data featured in this issue, calls for a shift towards an OMI/non-OMI model in frontline ECG interpretation, potentially facilitating earlier diagnosis and better patient outcomes. 12 This important investigation highlights the long-term association between AKI and poor outcomes in patients with acute myo-cardial infarction complicated by cardiogenic shock (AMI-CS). Among 1473 patients, 44% developed AKI, with 25% requiring renal replacement therapy (RRT). Mortality was more than 30% higher at 10 years among those who developed AKI (P < 0.001), positioning AKI as a major prognostic determinant in AMI-CS. Bjørn's findings resonate with concerns raised in the DanGer Shock trial, where improved survival from micro-axial pump support was shadowed by increased AKI incidence-reinforcing the urgent need for renal-protective strategies in shock management. 5,14 This manuscript is put into perspective by an editorial from Kevin Damman and Jozine Ter Maaten. 15 From the Mayo Clinic, Fazzini et al. 16 contribute a powerful retrospective study assessing the prognostic utility of ventricular-arterial coupling (VAC) in 4685 critically ill cardiac intensive care patients. Using a simple, non-invasive ratio (left ventricle end-systolic volume/ stroke volume), the study finds that a VAC ratio >2 was independently associated with increased in-hospital and 1-year mortality. This work positions VAC as an emerging bedside risk stratification tool based on non-invasive imaging, with strong potential to guide therapy in a wide range of critically ill cardiac patients. Also featured is Zeymer et al. 11 retrospective analysis of cangrelor use in patients with out-of-hospital cardiac arrest undergoing PCI. In a cohort of 414 patients, cangrelor was shown to provide potent plate-let inhibition without increasing major bleeding risk, even in the high-risk subgroup treated with extracorporeal CPR. These data support the tolerability of cangrelor as a bridging antiplatelet agent when oral drug absorption may be compromised-a pragmatic insight for inter-ventionalists managing complex resuscitated patients. Timely recognition of an occluded vessel is a defining moment in the trajectory of myocardial infarction. Yet, traditional tools are too often inadequate. In a compelling substudy from the DOMI-ARIGATO trial, Meyers et al. 17 reveal that 38% of patients with a confirmed LAD occlu-sion (TIMI 0 flow) failed to meet STEMI criteria on ECG. Crucially, both expert readers and an AI algorithm (PMCardio Queen of Hearts) achieved 100% sensitivity for occlusion detection on the first ECG. These findings raise attention to potential a paradigm shift-from STEMI/Non-STEMI to the more clinically accurate OMI/Non-OMI model-and signal a transformative future in which AI augments front-line diagnostic accuracy when every second counts. In a clinically grounded and practical contribution, François Roubille 18 present an educational review on the early management of acute myocarditis (AM). Addressing ten real-world clinical questions , from imaging selection to timing of physical activity resumption, the authors emphasize that despite progress in diagnostic capabilities, no disease-specific therapies exist. Their call for a multidisciplinary myocarditis response team is a timely reminder that coordination and clinical intuition remain cornerstones in the face of therapeutic uncertainty. We are also proud to debut a new section: The Physiopathological Page. In this inaugural feature, Dr. Johannes Grand from Copenhagen University Hospital 19 explores the metabolic signatures of CS, examining lactate dynamics and context-specific variations across shock phenotypes. His analysis bridges mechanistic insight and bedside relevance, laying the groundwork for more tailored resuscitation strategies.