Improving Survival in Cardiogenic Shock by Adopting a Uniform Approach to Systems of Care
Reference: J Am Coll Cardiol 2018; 72:1972-80
Cardiogenic shock continues to be the leading cause of death in patients with acute myocardial infarction (AMI).1 Despite implementation of guideline-recommended early revascularization, mortality rates in AMI complicated by cardiogenic shock (AMICS) remains constant at about 50%. Given that about 60,000 patients with AMI develop CS every year,2 there is an urgent need for treatment strategies that might improve outcomes in AMICS.
Mechanical circulatory support (MCS) devices such as Impella® heart pumps have emerged as an attractive treatment option in cardiogenic shock, owing to its ability to maintain vital organ perfusion, prevent irreversible end-organ damage, and reduce workload of the heart.3 However, according to the 2016 report based on the analysis of National Cardiovascular Data Registry, only 3.1% of percutaneous coronary intervention (PCI) cases involved the use of MCS with support provided by advanced MCS devices accounting for only 0.7%.4 Even among those receiving advanced MCS, there was heterogeneity in the timing of support with initiation during or prior to PCI in 77.6%, and after PCI in 22.4%. Hence, the lack of standardized algorithms for use of MCS devices have hampered their widespread use.
Rab T et al. in the Journal of the American College of Cardiology suggest a care pathway emphasizing 3 key steps to improve survival outcomes in AMICS.5
- Early recognition and rapid triage of patients with cardiogenic shock to cardiac catheterization laboratory
- Initiation of MCS device prior to PCI with “door to support” time of ≤ 90 minutes
- Consistent use of invasive hemodynamic monitoring to guide weaning and/or escalation of care
The National Cardiogenic Shock Initiative (NCSI) is based on uniform adoption of the above 3 key steps with Impella as the advanced MCS device. As of September 2018, 104 patients with AMICS have been treated at 56 NCSI sites with survival to hospital discharge at 77%. Overall, preliminary results suggest that uniform adoption of these best practices to treat AMICS is associated with improved survival in real world cohorts.
In accordance with the currently available best practices, Rab et al. suggest a care pathway for management of AMICS (Figure 1):
- Early emergency medical services recognition of cardiogenic shock to enable transfer of patients to a shock care center with first medical contact-to-support time of ≤ 90 minutes.
- Bypassing Level II and III shock care centers to transfer patients directly to a Level I cardiogenic shock center with PCI facilities, availability of advanced MCS 24/7, and multidisciplinary cardiogenic shock team including on-site cardiothoracic surgery.
- Although inotropic support may be used initially, escalating doses of inotropes are detrimental to cardiac recovery, instead rapid initiation of MCS devices should be favored.
- Hypothermia with targeted temperature management in patients with out of hospital cardiac arrest and cardiogenic shock who have achieved return of spontaneous circulation.
- Initiation of hemodynamic support with an Impella CP® prior to PCI of the culprit lesion only with goals of achieving both in 90 minutes. This is an important measure especially since the recent FITT-STEMI trial showed that every 10 minute of treatment delay in AMICS resulted in 3.3 additional deaths per 100 patients.6
- Hemodynamic assessment with right heart cardiac catheterization after PCI.
- Escalation and de-escalation of hemodynamic support based on the clinical course of the patient to escalate or de-escalate care.
The authors concluded that “cardiac shock care centers are necessary to improve outcomes in cardiogenic shock and early recognition and transportation of patients with AMICS to Level I cardiac shock care centers may help improve survival in this difficult group of patients.”
- Kolte D, Khera S, Aronow WS, et al. Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States. J Am Heart Assoc. 2014;3(1):e000590.
- Benjamin E.J., Blaha M.J., Chiuve S.E., et al.Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017; 135:e146–e603.
- Truesdell AG, Tehrani B, Singh R, et al. 'Combat' Approach to Cardiogenic Shock. Interv Cardiol. 2018;13(2):81-86.
- Masoudi F.A., Ponirakis A., de Lemos J.A., et al. (2017) Trends in U.S. cardiovascular care. 2016 report from 4 ACC National Cardiovascular Data Registries. J Am Coll Cardiol. 2016; 69:1427–1450.
- Rab T, Ratanapo S, Kern KB, et al. Cardiac Shock Care Centers. J Am Coll Cardiol 2018; 72:1972-80.
- Scholz KH, Maier SKG, Maier LS, et al. Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial. Eur Heart J 2018; 39:1065-74.