Herz
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Treatment of patients in cardiogenic shock (CS) presenting with acute myocardial infarction (AMI) is still a challenge and mortality rates remain high, approaching 50 %. Hemodynamic stabilization before and/or after early revascularization remains the primary goal in these patients. In addition to hemodynamic support by inotropes and vasopressors, support with mechanical devices such as intra-aortic balloon pumping (IABP), percutaneous left ventricular assist devices (LVAD) and complete extracorporeal life support (ECLS) with extracorporeal membrane oxygenation (ECMO) may be considered. ⋯ Another important open question to be answered is which subgroups of patients may have a benefit from LVAD therapy. Guidelines discourage the routine use of mechanical support as a first-line treatment in CS patients and emphasize that the application should be restricted to those patients with refractory shock. This article gives an overview of the different devices for percutaneous mechanical support in CS and describes the available evidence and guideline recommendations.
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The new oral anticoagulants (NOAC) dabigatran etexilate, rivaroxaban, and apixaban show similar efficacy for stroke prevention in patients with atrial fibrillation (AF) as the vitamin K antagonist warfarin. Absorption of NOACs is dependent on the intestinal P-glycoprotein (P-gp) system and P-gp activity is modulated by a variety of drugs and food components. ⋯ There is an urgent need to investigate the role of P-gp-modulating substances as potential sources of drug-drug and drug-food interactions. A thorough analysis of the data accumulated in the three large NOAC trials regarding the role of P-gp-modulating drugs in bleeding and embolic events is desirable. Pharmacological studies should investigate the influence of P-gp-modulating drugs and food on NOAC plasma concentrations and coagulation parameters. When prescribing NOACs, patients should be informed about the potential interactions with drugs and herbal drugs. Patients who develop bleeding or embolic events under treatment with NOACs should be investigated for co-medications as well as for over-the-counter drugs and dietary habits. In post-marketing surveillance of NOACs, the association with drug or food intake with complications, bleeding, and embolic events should be registered.