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Vallabhajosyula S, Sinha SS, Kochar A, Pahuja M, Amico FJ, Kapur NK. The Price We Pay for Progression in Shock Care: Economic Burden, Accessibility, and Adoption of Shock-Teams and Mechanical Circulatory Support Devices. Curr Cardiol Rep 2024:10.1007/s11886-024-02108-4. [PMID: 39325244 DOI: 10.1007/s11886-024-02108-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these. RECENT FINDINGS In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University and Brown University Health Cardiovascular Institute, Providence, Rhode Island, USA
| | - Shashank S Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohit Pahuja
- Division of Cardiology, Department of Medicine, University of Oklahoma Health Sciences College of Medicine, Oklahoma City, OK, USA
| | - Frank J Amico
- Chesapeake Regional Healthcare Medical Center, Chesapeake, VA, USA
| | - Navin K Kapur
- The Cardiovascular Center, Section of Cardiovascular Medicine, Department of Medicine, Tufts University School of Medicine, 800 Washington Street, Box No 80, Boston, MA, 02111, USA.
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Kalapurakal G, Chau VQ, Imamura T, Tolia S, Sciamanna C, Macaluso GP, Joshi A, Pillarella J, Pauwaa S, Dia M, Kabbany T, Monaco J, Dela Cruz M, Cotts WG, Pappas P, Tatooles AJ, Narang N. Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index. ESC Heart Fail 2024. [PMID: 39294848 DOI: 10.1002/ehf2.15083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/26/2024] [Accepted: 09/04/2024] [Indexed: 09/21/2024] Open
Abstract
AIMS Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi. METHODS AND RESULTS This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72 h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72 h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59 years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72 h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12 mmHg, P < 0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5 mmHg, P = 0.001), and an increase in PAPi (1 to 1.6, P = 0.001). No significant change in cardiac index (CI; 2 to 2.1 L/min/m2, P = 0.31) was observed. The PAPi ≥2.0 group (N = 29) had no observed significant change in CVP (10 to 8 mmHg, P = 0.47), or PAPi (2.6 to 2.8, P = 0.92), but there was a significant improvement in CI (1.9 to 2.5 L/min/m2, P = 0.004) along with reduction in mPA (37 to 29 mmHg, P = 0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P = 0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P = 0.07) compared with the PAPi ≥2.0 group at 72 h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P = 0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation. CONCLUSIONS IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.
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Affiliation(s)
- George Kalapurakal
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Vinh Q Chau
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Sanika Tolia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Chris Sciamanna
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Gregory P Macaluso
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Anjali Joshi
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Jessica Pillarella
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Sunil Pauwaa
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Muhyaldeen Dia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Tarek Kabbany
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - James Monaco
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Mark Dela Cruz
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - William G Cotts
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Patroklos Pappas
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Antone J Tatooles
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
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Kyriakopoulos CP, Sideris K, Taleb I, Maneta E, Hamouche R, Tseliou E, Zhang C, Presson AP, Dranow E, Shah KS, Jones TL, Fang JC, Stehlik J, Selzman CH, Goodwin ML, Tonna JE, Hanff TC, Drakos SG. Clinical Characteristics and Outcomes of Patients Suffering Acute Decompensated Heart Failure Complicated by Cardiogenic Shock. Circ Heart Fail 2024; 17:e011358. [PMID: 39206544 DOI: 10.1161/circheartfailure.123.011358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Cardiogenic shock (CS) can stem from multiple causes and portends poor prognosis. Prior studies have focused on acute myocardial infarction-CS; however, acute decompensated heart failure (ADHF)-CS accounts for most cases. We studied patients suffering ADHF-CS to identify clinical factors, early in their trajectory, associated with a higher probability of successful outcomes. METHODS Consecutive patients with CS were evaluated (N=1162). We studied patients who developed ADHF-CS at our hospital (N=562). Primary end point was native heart survival (NHS), defined as survival to discharge without receiving advanced HF therapies. Secondary end points were adverse events, survival, major cardiac interventions, and hospital readmissions within 1 year following index hospitalization discharge. Association of clinical data with NHS was analyzed using logistic regression. RESULTS Overall, 357 (63.5%) patients achieved NHS, 165 (29.2%) died, and 41 (7.3%) were discharged post advanced HF therapies. Of 398 discharged patients (70.8%), 303 (53.9%) were alive at 1 year. Patients with NHS less commonly suffered cardiac arrest, underwent intubation or pulmonary artery catheter placement, or received temporary mechanical circulatory support, had better hemodynamic and echocardiographic profiles, and had a lower vasoactive-inotropic score at shock onset. Bleeding, hemorrhagic stroke, hemolysis in patients with mechanical circulatory support, and acute kidney injury requiring renal replacement therapy were less common compared with patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS likelihood included younger age, history of systemic hypertension, absence of cardiac arrest or acute kidney injury requiring renal replacement therapy, lower pulmonary capillary wedge pressure and vasoactive-inotropic score, and higher tricuspid annular plane systolic excursion at shock onset (all P<0.05). CONCLUSIONS By studying contemporary patients with ADHF-CS, we identified clinical factors that can inform clinical management and provide future research targets. Right ventricular function, renal function, pulmonary artery catheter placement, and type and timing of temporary mechanical circulatory support warrant further investigation to improve outcomes of this devastating condition.
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Affiliation(s)
- Christos P Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Konstantinos Sideris
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Eleni Maneta
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Rana Hamouche
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Eleni Tseliou
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine (C.Z., A.P.P.), University of Utah Health and School of Medicine, Salt Lake City
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine (C.Z., A.P.P.), University of Utah Health and School of Medicine, Salt Lake City
| | - Elizabeth Dranow
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Kevin S Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Tara L Jones
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
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Estep JD, Nicoara A, Cavalcante J, Chang SM, Cole SP, Cowger J, Daneshmand MA, Hoit BD, Kapur NK, Kruse E, Mackensen GB, Murthy VL, Stainback RF, Xu B. Recommendations for Multimodality Imaging of Patients With Left Ventricular Assist Devices and Temporary Mechanical Support: Updated Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:820-871. [PMID: 39237244 DOI: 10.1016/j.echo.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Affiliation(s)
| | | | - Joao Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | | | | | - Brian D Hoit
- Case Western Reserve University, Cleveland, Ohio
| | | | - Eric Kruse
- University of Chicago, Chicago, Illinois
| | | | | | | | - Bo Xu
- Cleveland Clinic, Cleveland, Ohio
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Vadlakonda A, Curry J, Vela RJ, Cho NY, Hadaya J, Sakowitz S, Mallick S, Benharash P. Defining the Cross-Volume Effect of Extracorporeal Life Support on Outcomes of Cardiogenic Shock. Ann Thorac Surg 2024:S0003-4975(24)00639-8. [PMID: 39117259 DOI: 10.1016/j.athoracsur.2024.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/15/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Cardiogenic shock (CS) remains a leading cause of mortality despite advancements in mechanical circulatory support and other management strategies. In particular, venoarterial extracorporeal membrane oxygenation (ECMO) requires expertise in cardiac surgery, cardiology, and critical care. The benefits of such expertise may extend beyond patients undergoing ECMO. METHODS Hospitalizations in adults (aged ≥18 years) with a primary diagnosis of CS who were not undergoing ECMO, cardiac operations, durable left ventricular assist device therapy, or heart transplantation were abstracted from the 2016-2020 Nationwide Readmissions Database. Multivariable regression models were developed to assess the association of cardiac surgical and ECMO institutional caseload with clinical and financial outcomes. RESULTS Of an estimated 70,339 patients with CS identified for study, 33,643 (47.8%) were treated at a high-volume hospital for ECMO (HVH-ECMO). HVH-ECMO was associated with decreased odds of in-hospital mortality (adjusted odds ratio [aOR], 0.85; 95% CI, 0.75-0.95), respiratory complications (aOR, 0.86; 95% CI, 0.79-0.94), and nonhome discharge (aOR, 0.86; 95% CI, 0.79-0.94). However, HVH-ECMO was associated with a longer length of stay by 1.7 days (95% CI, 1.3-2.1) and higher inpatient costs by $9170 (95% CI, $6,490-$12,060). Although ECMO volume was inversely associated with the predicted risk of in-hospital mortality, institutional volume of cardiac operations was not significantly associated with mortality. CONCLUSIONS Our findings suggest improved outcomes for patients with CS who were treated at an HVH-ECMO. Multidisciplinary care pathways, including those among surgery, cardiology, and critical care, may influence CS management. Further studies are needed to characterize long-term outcomes of regionalization and ensure equitable access for all populations.
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Affiliation(s)
- Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ryan J Vela
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
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Augustin KJ, Wieruszewski PM, McLean L, Leiendecker E, Ramakrishna H. Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit. J Cardiothorac Vasc Anesth 2024; 38:1786-1801. [PMID: 38862282 DOI: 10.1053/j.jvca.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Katrina Joy Augustin
- Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Lewis McLean
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Dennis M, Burrell A, Lal S, Ferguson C, French J, Bowcock E, Kruit N, Burns B, Jain P. Cardiogenic Shock Challenges and Priorities: A Clinician Survey. Heart Lung Circ 2024; 33:1227-1231. [PMID: 38744603 DOI: 10.1016/j.hlc.2024.04.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia's geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described. METHOD We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities. RESULTS There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required. CONCLUSIONS Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value.
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Affiliation(s)
- Mark Dennis
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Aidan Burrell
- Australia and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Intensive Care, Alfred Health, Melbourne, Vic, Australia
| | - Sean Lal
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Caleb Ferguson
- Centre for Chronic & Complex Care Research, Blacktown Hospital, Blacktown, Sydney, and Western Sydney Local Health, Sydney, NSW, Australia; School of Nursing, University of Wollongong, NSW, Australia
| | - John French
- University of New South Wales, Sydney, NSW, Australia; Department of Cardiology, Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Emma Bowcock
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Intensive Care Medicine, Nepean Hospital, Nepean, Sydney, NSW, Australia
| | - Natalie Kruit
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Aeromedical Operations, New South Wales Ambulance, Sydney, NSW, Australia; Department of Anaesthesia, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - Brian Burns
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthesia, Westmead Hospital, Westmead, Sydney, NSW, Australia; Department of Emergency Medicine, Northern Beaches Hospital, Sydney, NSW, Australia
| | - Pankaj Jain
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Varma B, Katz JN, Alviar CL. Building a cardiogenic shock response team: key considerations necessary to improve outcomes. Curr Opin Crit Care 2024; 30:354-361. [PMID: 38872365 DOI: 10.1097/mcc.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
PURPOSE OF REVIEW This review provides key information about cardiogenic shock (CS) teams, including published evidence and practical recommendations to create a CS team and program. RECENT FINDINGS CS is a complex disease process with a high in-hospital mortality rate ranging from 30% to 70% according to recent registries and randomized studies. The explanation for the elevated rates is likely multifactorial, including the various etiologies of cardiogenic shock as well as delays in recognition and deployment of appropriate therapies. Accordingly, the use of cardiogenic shock team has been implemented with the aim of improving outcomes in these patients. The CS team typically consists of members with critical care or cardiac critical care expertise, heart failure, cardiothoracic surgery, and interventional cardiology. A number of retrospective studies have now supported the benefits of a CS team, particularly in selecting the appropriate candidates for tailored mechanical circulatory support therapies and providing interventions in a timely manner, which have translated into improved outcomes. SUMMARY CS teams provides a platform for expedited recognition of CS and timely, standardized, and multidisciplinary discussions regarding appropriate management and care.
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Affiliation(s)
- Bhavya Varma
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
| | - Jason N Katz
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
- Bellevue Hospital Center, New York, New York, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NYU Langone Medical Center
- Bellevue Hospital Center, New York, New York, USA
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Pyrpyris N, Dimitriadis K, Theofilis P, Iliakis P, Beneki E, Pitsiori D, Tsioufis P, Shuvy M, Aznaouridis K, Tsioufis K. Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication. J Clin Med 2024; 13:3528. [PMID: 38930057 PMCID: PMC11204700 DOI: 10.3390/jcm13123528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/09/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Structural heart disease is increasingly prevalent in the general population, especially in patients of increased age. Recent advances in transcatheter structural heart interventions have gained a significant following and are now considered a mainstay option for managing stable valvular disease. However, the concept of transcatheter interventions has also been tested in acute settings by several investigators, especially in cases where valvular disease comes as a result of acute ischemia or in the context of acute decompensated heart failure. Tested interventions include both the mitral and aortic valve, mostly evaluating mitral transcatheter edge-to-edge repair and transcatheter aortic valve implantation, respectively. This review is going to focus on the use of acute structural heart interventions in the emergent setting, and it will delineate the available data and provide a meaningful discussion on the optimal patient phenotype and future directions of the field.
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Affiliation(s)
- Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Theofilis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Daphne Pitsiori
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
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10
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Colombo CN, Tavazzi G, Zanetti M, Dore F, Finazzi S. Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey. Minerva Anestesiol 2024; 90:530-538. [PMID: 38551614 DOI: 10.23736/s0375-9393.24.17908-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units. METHODS A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1st-2nd versus 3rd). RESULTS Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. Among the ICUs, 94.2% routinely use a cardiac output monitoring device (pulmonary artery catheter more frequently in 3rd level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%). CONCLUSIONS According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.
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Affiliation(s)
- Costanza N Colombo
- University of Pavia, Pavia, Italy -
- Department of Anesthesia and Intensive Care, IRCCS Foundation Policlinico San Matteo, Pavia, Italy -
| | - Guido Tavazzi
- Department of Anesthesia and Intensive Care, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
- Department of Surgical, Pediatric, and Diagnostic Sciences, University of Pavia, Pavia, Italy
| | - Michele Zanetti
- Unit of Computer Science for Clinical Knowledge Sharing, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Francesca Dore
- Laboratory of Clinical Data Science, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Stefano Finazzi
- Laboratory of Clinical Data Science, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
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11
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Warren A, McCall P, Proudfoot A, Gillon S, Abu-Arafeh A, McKnight AJ, Mudie R, Armstrong D, Tzolos E, Livesey JA, Sinclair A, Baston V, Dalzell J, Owen D, Fleming L, Scott I, Puxty A, Lee MMY, Walker F, Hobson S, Campbell E, Kinsella M, McGinnigle E, Docking R, Price G, Ramsay A, Bauld R, Herron S, Lone NI, Mills NL, Hartley L. EPidemiology Of Cardiogenic sHock in Scotland (EPOCHS): A multicentre, prospective observational study of the prevalence, management and outcomes of cardiogenic shock in Scotland. J Intensive Care Soc 2024; 25:147-155. [PMID: 38737313 PMCID: PMC11086715 DOI: 10.1177/17511437231217877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background Despite high rates of cardiovascular disease in Scotland, the prevalence and outcomes of patients with cardiogenic shock are unknown. Methods We undertook a prospective observational cohort study of consecutive patients with cardiogenic shock admitted to the intensive care unit (ICU) or coronary care unit at 13 hospitals in Scotland for a 6-month period. Denominator data from the Scottish Intensive Care Society Audit Group were used to estimate ICU prevalence; data for coronary care units were unavailable. We undertook multivariable logistic regression to identify factors associated with in-hospital mortality. Results In total, 247 patients with cardiogenic shock were included. After exclusion of coronary care unit admissions, this comprised 3.0% of all ICU admissions during the study period (95% confidence interval [CI] 2.6%-3.5%). Aetiology was acute myocardial infarction (AMI) in 48%. The commonest vasoactive treatment was noradrenaline (56%) followed by adrenaline (46%) and dobutamine (40%). Mechanical circulatory support was used in 30%. Overall in-hospital mortality was 55%. After multivariable logistic regression, age (odds ratio [OR] 1.04, 95% CI 1.02-1.06), admission lactate (OR 1.10, 95% CI 1.05-1.19), Society for Cardiovascular Angiographic Intervention stage D or E at presentation (OR 2.16, 95% CI 1.10-4.29) and use of adrenaline (OR 2.73, 95% CI 1.40-5.40) were associated with mortality. Conclusions In Scotland the prevalence of cardiogenic shock was 3% of all ICU admissions; more than half died prior to discharge. There was significant variation in treatment approaches, particularly with respect to vasoactive support strategy.
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Affiliation(s)
- Alex Warren
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Anaesthesia, Critical Care & Pain, University of Edinburgh, Edinburgh, UK
- Barts Heart Centre, London, UK
| | - Philip McCall
- Golden Jubilee National Hospital, Clydebank, UK
- Anaesthesia, Critical Care & Peri-Operative Medicine, University of Glasgow, Glasgow, UK
| | - Alastair Proudfoot
- Barts Heart Centre, London, UK
- Queen Mary University of London, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ian Scott
- Aberdeen Royal Infirmary, Aberdeen, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Nazir I Lone
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Anaesthesia, Critical Care & Pain, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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12
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Zapata L, Gómez-López R, Llanos-Jorge C, Duerto J, Martin-Villen L. Cardiogenic shock as a health issue. Physiology, classification, and detection. Med Intensiva 2024; 48:282-295. [PMID: 38458914 DOI: 10.1016/j.medine.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024]
Abstract
Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.
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Affiliation(s)
- Luis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Rocío Gómez-López
- Servicio de Medicina Intensiva, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Celina Llanos-Jorge
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Jorge Duerto
- Servicio de Medicina Intensiva, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Luis Martin-Villen
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Seville, Spain
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13
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Gillespie LE, Lane BH, Shaw CR, Gorder K, Grisoli A, Lavallee M, Gobble O, Vidosh J, Deimling D, Ahmad S, Hinckley WR, Brent CM, Lauria MJ, Gottula AL. The Intra-aortic Balloon Pump: A Focused Review of Physiology, Transport Logistics, Mechanics, and Complications. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101337. [PMID: 39132456 PMCID: PMC11307388 DOI: 10.1016/j.jscai.2024.101337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 08/13/2024]
Abstract
Critical care transport medicine (CCTM) teams are playing an increasing role in the care of patients in cardiogenic shock requiring mechanical circulatory support devices. Hence, it is important that CCTM providers are familiar with the pathophysiology of cardiogenic shock, the role of mechanical circulatory support, and the management of these devices in the transport environment. The intra-aortic balloon pump is a widely used and accessible cardiac support device capable of increasing cardiac output and reducing work on the left ventricle through diastolic augmentation and counterpulsation. This article reviews essential CCTM-based considerations for patients supported by intra-aortic balloon pump, including indications for placement, mechanics and physiology, potential issues during transport, and associated complications.
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Affiliation(s)
- Lauren E. Gillespie
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Bennett H. Lane
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Christopher R. Shaw
- Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kari Gorder
- The Christ Hospital Heart & Vascular Center, Cincinnati, Ohio
| | - Anne Grisoli
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Matthew Lavallee
- Department of Anesthesiology, Division of Cardiovascular Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Olivia Gobble
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jacqueline Vidosh
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Diana Deimling
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Saad Ahmad
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - William R. Hinckley
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
- Division of Air Care & Mobile Care, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Christine M. Brent
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael J. Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Adam L. Gottula
- Texas IPS at San Antonio Methodist Hospital, San Antonio, Texas
- Institute for Extracorporeal Life Support, San Antonio, Texas
- The Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
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14
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Belfioretti L, Francioni M, Battistoni I, Angelini L, Matassini MV, Pongetti G, Shkoza M, Piangerelli L, Piva T, Nicolini E, Maolo A, Muçaj A, Compagnucci P, Munch C, Dello Russo A, Di Eusanio M, Marini M. Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center. J Clin Med 2024; 13:2101. [PMID: 38610866 PMCID: PMC11012883 DOI: 10.3390/jcm13072101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.
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Affiliation(s)
- Leonardo Belfioretti
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Matteo Francioni
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Ilaria Battistoni
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Luca Angelini
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Maria Vittoria Matassini
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Giulia Pongetti
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Matilda Shkoza
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Luca Piangerelli
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
| | - Tommaso Piva
- Intervention Cardiology, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (T.P.); (E.N.)
| | - Elisa Nicolini
- Intervention Cardiology, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (T.P.); (E.N.)
| | - Alessandro Maolo
- Intervention Cardiology, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (T.P.); (E.N.)
| | - Andi Muçaj
- Intervention Cardiology, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (T.P.); (E.N.)
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (P.C.); (A.D.R.)
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy;
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (P.C.); (A.D.R.)
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy;
| | - Marco Marini
- Intensive Care Unit, Cardiology Department, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy; (M.F.); (I.B.); (M.V.M.); (M.M.)
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15
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Garan AR, Kataria R, Li B, Sinha S, Kanwar MK, Hernandez-Montfort J, Li S, Ton VANK, Blumer V, Grandin EW, Harwani N, Zazzali P, Walec KD, Hickey G, Abraham J, Mahr C, Nathan S, Vorovich E, Guglin M, Hall S, Khalife W, Sangal P, Zhang Y, Kim JH, Schwartzman A, Vishnevsky A, Burkhoff D, Kapur NK. Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis. J Card Fail 2024; 30:564-575. [PMID: 37820897 DOI: 10.1016/j.cardfail.2023.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of "spoke" centers to tertiary/"hub" centers with higher capabilities. However, outcomes associated with such transfers are largely unknown beyond those reported in individual health networks. OBJECTIVES To analyze a contemporary, multicenter CS cohort with the aim of comparing characteristics and outcomes of patients between transfer (between spoke and hub centers) and nontransfer cohorts (those primarily admitted to a hub center) for both acute myocardial infarction (AMI-CS) and heart failure-related HF-CS. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality. METHODS The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high-volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020. RESULTS Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these patients, 528 (58.1%) had heart failure-related CS (HF-CS), and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stages C and D, when compared to nontransfer patients. Transfer patients had higher mortality rates (37% vs 29%, < 0.001) than nontransfer patients; the differences were driven primarily by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer or within 24 hours of arrival was associated with decreased mortality rates. Among transfer AMI-CS patients, BMI > 28 kg/m2, worsening renal failure, lactate > 3 mg/dL, and increasing numbers of vasoactive drugs were associated with increased mortality rates. CONCLUSION More than half of patients with CS managed at high-volume CS centers were transferred from another hospital. Although transfer patients had higher mortality rates than those who were admitted primarily to hub centers, the outcomes and their predictors varied significantly when classified by HF-CS vs AMI-CS.
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Affiliation(s)
| | - Rachna Kataria
- Brown University, Lifespan Cardiovascular Center, Providence, RI
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Shashank Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | | | - Song Li
- University of Washington Medical Center, Seattle, WA
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Neil Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Karol D Walec
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | | | | | - Maya Guglin
- Indiana University Health Advanced Heart and Lung Care, Indianapolis, IN
| | - Shelley Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, TX
| | | | - Paavni Sangal
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | | | | | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA.
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16
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Choi KH, Kang D, Lee J, Park H, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Gwon HC, Cho J, Yang JH. Association between intensive care unit nursing grade and mortality in patients with cardiogenic shock and its cost-effectiveness. Crit Care 2024; 28:99. [PMID: 38523296 PMCID: PMC10962168 DOI: 10.1186/s13054-024-04880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Despite the high workload of cardiac intensive care unit (ICU), there is a paucity of evidence on the association between nurse workforce and mortality in patients with cardiogenic shock (CS). This study aimed to evaluate the prognostic impact of the ICU nursing grade on mortality and cost-effectiveness in CS. METHODS A nationwide analysis was performed using the K-NHIS database. Patients diagnosed with CS and admitted to the ICU at tertiary hospitals were enrolled. ICU nursing grade was defined according to the bed-to-nurse ratio: grade1 (bed-to-nurse ratio < 0.5), grade2 (0.5 ≤ bed-to-nurse ratio < 0.63), and grade3 (0.63 ≤ bed-to-nurse ratio < 0.77) or above. The primary endpoint was in-hospital mortality. Cost-effective analysis was also performed. RESULTS Of the 72,950 patients with CS, 27,216 (37.3%) were in ICU nursing grade 1, 29,710 (40.7%) in grade 2, and 16,024 (22.0%) in grade ≥ 3. The adjusted-OR for in-hospital mortality was significantly higher in patients with grade 2 (grade 1 vs. grade 2, 30.6% vs. 37.5%, adjusted-OR 1.14, 95% CI1.09-1.19) and grade ≥ 3 (40.6%) with an adjusted-OR of 1.29 (95% CI 1.23-1.36) than those with grade 1. The incremental cost-effectiveness ratio of grade1 compared with grade 2 and ≥ 3 was $25,047/year and $42,888/year for hospitalization and $5151/year and $5269/year for 1-year follow-up, suggesting that grade 1 was cost-effective. In subgroup analysis, the beneficial effects of the high-intensity nursing grade on mortality were more prominent in patients who received CPR or multiple vasopressors usage. CONCLUSIONS For patients with CS, ICU grade 1 with a high-intensity nursing staff was associated with reduced mortality and more cost-effectiveness during hospitalization compared to grade 2 and grade ≥ 3, and its beneficial effects were more pronounced in subjects at high risk of CS.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Lee
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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17
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Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
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Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
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18
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Barrionuevo-Sánchez MI, Ariza-Solé A, Viana-Tejedor A, Del Prado N, Rosillo N, Jorge-Pérez P, Sánchez-Salado JC, Lorente V, Alegre O, Llaó I, Martín-Asenjo R, Bernal JL, Fernández-Pérez C, Corbí-Pascual M, Pascual J, Marcos M, de la Cuerda F, Carmona J, Comin-Colet J, Elola FJ. Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:226-233. [PMID: 37925017 DOI: 10.1016/j.rec.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/11/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting. METHODS This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality. RESULTS A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047). CONCLUSIONS The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.
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Affiliation(s)
- M Isabel Barrionuevo-Sánchez
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Náyade Del Prado
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Nicolás Rosillo
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pablo Jorge-Pérez
- Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - José Carlos Sánchez-Salado
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Victòria Lorente
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Alegre
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Isaac Llaó
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - José Luis Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Área Sanitaria de Santiago y Barbanza, Instituto de Investigaciones Sanitarias de Santiago, Santiago de Compostela, A Coruña, Spain
| | | | - Júlia Pascual
- Servicio de Cardiología, Hospital Universitari Josep Trueta, Girona, Spain
| | - Marta Marcos
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco de la Cuerda
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jesús Carmona
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep Comin-Colet
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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19
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Baran DA, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Kanwar MK. Consensus statements from the International Society for Heart and Lung Transplantation consensus conference: Heart failure-related cardiogenic shock. J Heart Lung Transplant 2024; 43:204-216. [PMID: 38069919 DOI: 10.1016/j.healun.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
The last decade has brought tremendous interest in the problem of cardiogenic shock. However, the mortality rate of this syndrome approaches 50%, and other than prompt myocardial revascularization, there have been no treatments proven to improve the survival of these patients. The bulk of studies have been in patients with acute myocardial infarction, and there is little evidence to guide the clinician in those patients with heart failure cardiogenic shock (HF-CS). An International Society for Heart and Lung Transplant consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals) with vast clinical and published experience in CS, representing 42 centers worldwide. This consensus report summarizes the results of a premeeting survey answered by participants and the breakout sessions where predefined clinical issues were discussed to achieve consensus in the absence of robust data. Key issues discussed include systems for CS management, including the "hub-and-spoke" model vs a tier-based network, minimum levels of data to communicate when considering transfer, disciplines that should be involved in a "shock team," goals for mechanical circulatory support device selection, and optimal flow on such devices. Overall, the document provides expert consensus on some important issues facing practitioners managing HF-CS. It is hoped that this will clarify areas where consensus has been reached and stimulate future research and registries to provide insight regarding other crucial knowledge gaps.
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Affiliation(s)
| | | | | | | | | | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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20
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Kanwar MK, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Baran DA. Heart failure related cardiogenic shock: An ISHLT consensus conference content summary. J Heart Lung Transplant 2024; 43:189-203. [PMID: 38069920 DOI: 10.1016/j.healun.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varinder Randhawa
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Cowger
- Department of Cardiology, Henry Ford Health Heart and Vascular Institute, Detroit, Michigan
| | - Christopher M Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Hoong S Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center, New York, New York
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Maria F Renedo
- Department of Heart Failure and Thoracic Transplantation, Fundacion Favaloro, Buenos Aires, Argentina
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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21
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Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.
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Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
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22
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Bloom JE, Wong N, Nehme E, Dawson LP, Ball J, Anderson D, Cox S, Chan W, Kaye DM, Nehme Z, Stub D. Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:89-98. [PMID: 36808236 DOI: 10.1093/ehjqcco/qcad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023]
Abstract
AIMS The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). METHODS AND RESULTS This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. CONCLUSION This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shelley Cox
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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23
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Truesdell AG, Rosner C, Fordyce CB. None of us alone is as effective as all of us together. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:831-833. [PMID: 37798086 DOI: 10.1093/ehjacc/zuad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, 2901 Telestar Court, Falls Church, VA 22042, USA
- Inova Schar Heart and Vascular Institute, 2901 Telestar Court, Falls Church, VA 22042, USA
| | - Carolyn Rosner
- Inova Schar Heart and Vascular Institute, 2901 Telestar Court, Falls Church, VA 22042, USA
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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24
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Khalil M, Maraey A, Wahadneh OA, Elzanaty AM, Brilakis ES, Alaswad K, Basir MB, Megaly M. Use of a Multidisciplinary Shock Team and Inhospital Mortality in Patients With Cardiogenic Shock. Am J Cardiol 2023; 206:200-201. [PMID: 37708751 DOI: 10.1016/j.amjcard.2023.08.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Mahmoud Khalil
- Cardiology Department, University of Connecticut, Farmington, Connecticut
| | - Ahmed Maraey
- Cardiology Department, University of Toledo, Toledo, Ohio
| | - Omar Al Wahadneh
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, Illinois
| | | | | | | | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Michael Megaly
- Division of Cardiology, Willis Knighton Heart Institute, Shreveport, Louisiana.
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25
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Gillespie L, Diaz M, Gorder K, Shaw C, Ahmad S, Hinckley W, Chuko J, Gottula A. The Successful Rotor Wing Transport of 2 Patients Requiring Biventricular Impella Support: A Case Series and Review. Air Med J 2023; 42:499-503. [PMID: 37996190 DOI: 10.1016/j.amj.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/20/2023] [Accepted: 07/31/2023] [Indexed: 11/25/2023]
Abstract
Despite many advances in care, the mortality rate for cardiogenic shock remains high. Because the medical management of patients with cardiogenic shock is limited, many patients often require mechanical circulatory support. As such, cardiogenic shock patients requiring percutaneous ventricular support devices such as the Impella (Abiomed, Danvers, MA) may be encountered by critical care transport crews with increasing frequency. Recently, biventricular Impella support has been described as a mechanical support strategy for biventricular failure. This case series describes the successful rotor wing transport of 2 patients with severe cardiogenic shock requiring biventricular Impella support and presents a review of Impella RP (Abiomed) and biventricular Impella support devices for the critical care transport medicine clinician.
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Affiliation(s)
- Lauren Gillespie
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH.
| | - Martina Diaz
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Kari Gorder
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH
| | - Chris Shaw
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Saad Ahmad
- Department of Internal Medicine, Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - William Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Jonathan Chuko
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Adam Gottula
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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26
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Kruit N, Hambly J, Ong A, French J, Bowcock E, Kushwaha V, Jain P, Dennis M. Protocolised Management of Cardiogenic Shock and Shock Teams: A Narrative Review. Heart Lung Circ 2023; 32:1148-1157. [PMID: 37813747 DOI: 10.1016/j.hlc.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/30/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023]
Abstract
Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume-dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches.
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Affiliation(s)
- Natalie Kruit
- Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - James Hambly
- Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew Ong
- Westmead Hospital, Sydney, NSW, Australia
| | - John French
- Liverpool Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - Emma Bowcock
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Nepean Hospital, Sydney, NSW, Australia
| | - Virag Kushwaha
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia
| | - Pankaj Jain
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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27
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Seoane LA, Burgos L, Vila RB, Furmento JF, Costabel JP, Vrancic M, Villagra M, Ramírez-Hoyos OD, Navia D, Diez M. [Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:132-140. [PMID: 38298412 PMCID: PMC10824746 DOI: 10.47487/apcyccv.v4i4.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/05/2023] [Indexed: 02/02/2024]
Abstract
Objectives Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. Objective We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. Materials and methods . We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Results Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. Conclusions After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.
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Affiliation(s)
- Leonardo A. Seoane
- Servicio de Cardiología Crítica, Departamento de Cardiología, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Servicio de Cardiología CríticaDepartamento de CardiologíaICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Lucrecia Burgos
- Sección de Insuficiencia Cardíaca, Departamento de Cardiología, ICBA Instituto Cardiovascular, Buenos Aires, Argentina.Sección de Insuficiencia CardíacaDepartamento de CardiologíaICBA Instituto CardiovascularBuenos AiresArgentina
| | - Rocío Baro Vila
- Sección de Insuficiencia Cardíaca, Departamento de Cardiología, ICBA Instituto Cardiovascular, Buenos Aires, Argentina.Sección de Insuficiencia CardíacaDepartamento de CardiologíaICBA Instituto CardiovascularBuenos AiresArgentina
| | - Juan F. Furmento
- Servicio de Cardiología Crítica, Departamento de Cardiología, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Servicio de Cardiología CríticaDepartamento de CardiologíaICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Juan P. Costabel
- Servicio de Cardiología Crítica, Departamento de Cardiología, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Servicio de Cardiología CríticaDepartamento de CardiologíaICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Mariano Vrancic
- Servicio de Cirugía cardiovascular, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Servicio de Cirugía cardiovascularICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Maximiliano Villagra
- Servicio de Ultrasonido, Departamento de Diagnóstico por Imagen. ICBA Instituto Cardiovascular de Buenos Aires Buenos AiresArgentina.Servicio de UltrasonidoDepartamento de Diagnóstico por ImagenICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Olga D Ramírez-Hoyos
- Sección de Perfusión, Servicio de Cirugía Cardiovascular, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Sección de PerfusiónServicio de Cirugía CardiovascularICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Daniel Navia
- Servicio de Cirugía cardiovascular, ICBA Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.Servicio de Cirugía cardiovascularICBA Instituto Cardiovascular de Buenos AiresBuenos AiresArgentina
| | - Mirta Diez
- Sección de Insuficiencia Cardíaca, Departamento de Cardiología, ICBA Instituto Cardiovascular, Buenos Aires, Argentina.Sección de Insuficiencia CardíacaDepartamento de CardiologíaICBA Instituto CardiovascularBuenos AiresArgentina
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Dalia T, Pothuru S, Chan WC, Mehta H, Goyal A, Farhoud H, Boda I, Malhotra A, Vidic A, Rali AS, Hanff TC, Gupta K, Fang JC, Shah Z. Trends and Outcomes of Cardiogenic Shock in Patients With End-Stage Renal Disease: Insights From USRDS Database. Circ Heart Fail 2023; 16:e010462. [PMID: 37503601 PMCID: PMC11270562 DOI: 10.1161/circheartfailure.122.010462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis). METHODS This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients. RESULTS A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients (Ptrend<0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 (Ptrend=0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 (Ptrend=0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 (Ptrend<0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 (Ptrend<0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients (Ptrend<0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P=0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality. CONCLUSIONS The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support.
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Affiliation(s)
- Tarun Dalia
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Suveenkrishna Pothuru
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Harsh Mehta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Amandeep Goyal
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Hassan Farhoud
- Medical Student, Class of 2023, University of Kansas Medical Center (H.F.)
| | - Ilham Boda
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Anureet Malhotra
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Andrija Vidic
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.S.R.)
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
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29
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Kirigaya J, Iwahashi N, Terasaka K, Takeuchi I. Prevention and management of critical care complications in cardiogenic shock: a narrative review. J Intensive Care 2023; 11:31. [PMID: 37408036 PMCID: PMC10324237 DOI: 10.1186/s40560-023-00675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era. MAIN TEXT Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies. CONCLUSIONS This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.
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Affiliation(s)
- Jin Kirigaya
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Terasaka
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
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30
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Araki T, Kondo T, Imaizumi T, Sumita Y, Nakai M, Tanaka A, Okumura T, Yang M, Butt JH, Petrie MC, Murohara T. Relationship between the volume of cases and in-hospital mortality in patients with cardiogenic shock receiving short-term mechanical circulatory support. Am Heart J 2023; 261:109-123. [PMID: 37031832 DOI: 10.1016/j.ahj.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND We examined the relationship between annual case volume at each hospital and outcome in cardiogenic shock (CS) patients receiving mechanical circulatory support (MCS) devices. METHODS This cross-sectional study used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients, 3 subcohorts were created; the intra-aortic balloon pump (IABP) alone (n = 48,643), the extracorporeal membrane oxygenation (ECMO) (n = 16,871), and the Impella cohorts (n = 696). RESULTS The median annual case volume was 13.5 (7.4-22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0-10.7) in the Impella cohort. The highest quintile for the volume of cases in the IABP alone and ECMO had the lowest in-hospital mortality (IABP alone, 25.1% in quintile 1 vs 15.2% in quintile 5; ECMO, 73.7% in quintile 1 in 67.4% in quintile 5). Adjusted ORs for in-hospital mortality decreased as case volume increased (IABP alone, 0.63 [0.58-0.68] in quintile 5; ECMO, 0.73 [0.65-0.82] in quintile 5, with the lowest quintile as reference) but did not decrease significantly in the Impella (0.90 [0.58-1.39] in tertile 3, with the lowest tertile as reference). In the continuous models with the case volume as a continuous variable, adjusted ORs for in-hospital mortality decreased to 28 IABP cases/year and 12 ECMO cases/year. They did not decrease or became almost flat above that. CONCLUSIONS Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline. Centralizing patients with refractory CS in a particular hospital might improve patient outcomes in each region.
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Affiliation(s)
- Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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31
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Kochan A, Lee T, Moghaddam N, Milley G, Singer J, Cairns JA, Wong GC, Jentzer JC, van Diepen S, Alviar C, Fordyce CB. Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock. Circ Cardiovasc Interv 2023; 16:e012810. [PMID: 37339233 DOI: 10.1161/circinterventions.122.012810] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. METHODS We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. RESULTS 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. CONCLUSIONS Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.
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Affiliation(s)
- Andrew Kochan
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - Nima Moghaddam
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Grace Milley
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - John A Cairns
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (J.C.J.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Canada (S.v.D.)
| | - Carlos Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY (C.A.)
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
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Hill KL, Rustin MA, Asche MA, Bennett CE, Patel PC, Jentzer JC. Cardiogenic Shock Classification and Associated Mortality Risk. Mayo Clin Proc 2023; 98:771-783. [PMID: 37028976 DOI: 10.1016/j.mayocp.2022.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/30/2022] [Accepted: 12/16/2022] [Indexed: 04/09/2023]
Abstract
The Society for Cardiovascular Angiography and Interventions (SCAI) Shock Classification was developed to create standardized language describing the severity of cardiogenic shock (CS). The purposes of this review were to evaluate short-term and long-term mortality rates at each SCAI shock stage for patients with or at risk for CS, which has not been studied previously, and to propose using the SCAI Shock Classification to develop algorithms for clinical status monitoring. A detailed literature search was conducted for articles published from 2019 through 2022 in which the SCAI shock stages were used to assess the mortality risk. In total, 30 articles were reviewed. The SCAI Shock Classification at hospital admission revealed a consistent and reproducible graded association between shock severity and mortality risk. Furthermore, shock severity correlated incrementally with mortality risk even after patients were stratified for diagnosis, treatment modalities, risk modifiers, shock phenotype, and underlying cause. The SCAI Shock Classification system can be used to evaluate mortality across populations of patients with or at risk for CS including those with different causes, shock phenotypes, and comorbid conditions. We propose an algorithm that uses clinical parameters incorporating the SCAI Shock Classification into the electronic health record to continually reassess and reclassify the presence and severity of CS across time throughout hospitalization. The algorithm has the potential to alert the care team and a CS team, leading to earlier recognition and stabilization of the patient, and may facilitate the use of treatment algorithms and prevent CS deterioration, leading to improved outcomes.
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Affiliation(s)
- Katherine L Hill
- Department of Nursing, Mayo Clinic, Rochester, MN; Doctor of Nursing Program, Winona State University, Winona, MN
| | - Mark A Rustin
- Department of Nursing, Mayo Clinic, Rochester, MN; Doctor of Nursing Program, Winona State University, Winona, MN
| | | | | | - Parag C Patel
- Division of Heart Failure and Transplant, Mayo Clinic, Jacksonville, FL
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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The Utility of Invasive Hemodynamics in the Management of Cardiogenic Shock. Can J Cardiol 2023; 39:420-422. [PMID: 36764653 DOI: 10.1016/j.cjca.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
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Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction. Can J Cardiol 2023; 39:406-419. [PMID: 36731605 DOI: 10.1016/j.cjca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/01/2023] Open
Abstract
Cardiogenic shock is an extreme manifestation of acute decompensated heart failure. Cardiogenic shock is often caused by-and has traditionally been studied in the setting of-acute myocardial infarction (AMI CS); however, there is increasing incidence and recognition of cardiogenic shock not associated with acute myocardial infarction (non-AMI CS) as a distinct entity. Despite decades of study and technologic advancements, cardiogenic shock mortality remains as high as 50%, regardless of etiology. New approaches to shock phenotyping and classification have emerged, with a focus on appropriately matching patient physiology to a growing list of available interventions. Further study is needed to determine whether these efforts will lead to more nuanced use of mechanical circulatory support and improved patient outcomes, especially in non-AMI CS. In the meantime, models of care incorporating multidisciplinary decision making, such as shock teams, may improve patient selection and outcomes.
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Xiao X, Bloom JE, Andrew E, Dawson LP, Nehme Z, Stephenson M, Anderson D, Fernando H, Noaman S, Cox S, Chan W, Kaye DM, Smith K, Stub D. Age as a predictor of clinical outcomes and determinant of therapeutic measures for emergency medical services treated cardiogenic shock. J Geriatr Cardiol 2023; 20:1-10. [PMID: 36875161 PMCID: PMC9975487 DOI: 10.26599/1671-5411.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The impact of age on outcomes in cardiogenic shock (CS) is poorly described in the pre-hospital setting. We assessed the impact of age on outcomes of patients treated by emergency medical services (EMS). METHODS This population-based cohort study included consecutive adult patients with CS transported to hospital by EMS. Successfully linked patients were stratified into tertiles by age (18-63, 64-77, and > 77 years). Predictors of 30-day mortality were assessed through regression analyses. The primary outcome was 30-day all-cause mortality. RESULTS A total of 3523 patients with CS were successfully linked to state health records. The average age was 68 ± 16 years and 1398 (40%) were female. Older patients were more likely to have comorbidities including pre-existing coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, and cerebrovascular disease. The incidence of CS was significantly greater with increasing age (incidence rate per 100,000 person years 6.47 [95% CI: 6.1-6.8] in age 18-63 years, 34.34 [32.4-36.4] in age 64-77 years, 74.87 [70.6-79.3] in age > 77 years, P < 0.001). There was a step-wise increase in the rate of 30-day mortality with increasing age tertile. After adjustment, compared to the lowest age tertile, patients aged > 77 years had increased risk of 30-day mortality (adjusted hazard ratio = 2.26 [95% CI: 1.96-2.60]). Older patients were less likely to receive inpatient coronary angiography. CONCLUSION Older patients with EMS-treated CS have significantly higher rates of short-term mortality. The reduced rates of invasive interventions in older patients underscore the need for further development of systems of care to improve outcomes for this patient group.
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Affiliation(s)
- Xiaoman Xiao
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia
| | - Emily Andrew
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - Michael Stephenson
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - David Anderson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia
| | - Shelley Cox
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Australia
| | - Karen Smith
- Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.,Department of Paramedicine, Monash University, McMahons Road, Frankston, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia
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Martínez-Sellés M, Hernández-Pérez FJ, Uribarri A, Martín Villén L, Zapata L, Alonso JJ, Amat-Santos IJ, Ariza-Solé A, Barrabés JA, Barrio JM, Canteli Á, Alonso-Fernández-Gatta M, Corbí Pascual MJ, Díaz D, Crespo-Leiro MG, de la Torre-Hernández JM, Ferrera C, García González MJ, García-Carreño J, García-Guereta L, García Quintana A, Jorge Pérez P, González-Juanatey JR, López de Sá E, Sánchez PL, Monteagudo M, Palomo López N, Reyes G, Rosell F, Solla Buceta MA, Segovia-Cubero J, Sionis Green A, Stepanenko A, Iglesias Álvarez D, Viana Tejedor A, Voces R, Fuset Cabanes MP, Gimeno Costa JR, Díaz J, Fernández-Avilés F. Cardiogenic shock code 2023. Expert document for a multidisciplinary organization that allows quality care. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 76:261-269. [PMID: 36565750 DOI: 10.1016/j.rec.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/14/2022] [Indexed: 12/24/2022]
Abstract
Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Universidad Europea, Madrid, Spain; Universidad Complutense, Madrid, Spain.
| | | | - Aitor Uribarri
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Luis Martín Villén
- Unidad de Gestión Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Luis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Joaquín J Alonso
- Universidad Europea, Madrid, Spain; Servicio Cardiología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Ignacio J Amat-Santos
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Albert Ariza-Solé
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José A Barrabés
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - José María Barrio
- Sección de Anestesia Cardiaca-Unidad de Cuidados Posquirúrgicos Cardiacos, Servicio de Anestesiología, Hospital General Universitario Gregorio Marañón, CIBERES, Madrid, Spain
| | - Ángela Canteli
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Marta Alonso-Fernández-Gatta
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Miguel J Corbí Pascual
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital General de Albacete, Albacete, Spain
| | - Domingo Díaz
- Servicio de Cuidados Intensivos, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - María G Crespo-Leiro
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Universidad de A Coruña (UDC), A Coruña, Spain
| | | | - Carlos Ferrera
- Unidad de Cuidados Agudos Cardiológicos, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Martín J García González
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Jorge García-Carreño
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Luis García-Guereta
- Servicio de Cardiología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | - Antonio García Quintana
- Servicio de Cardiología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Pablo Jorge Pérez
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | | | - Pedro Luis Sánchez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - María Monteagudo
- Servicio de Cirugía Cardiaca, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Nora Palomo López
- Unidad de Gestión Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Guillermo Reyes
- Servicio de Cirugía Cardiaca, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Fernando Rosell
- Servicio de Emergencias Sanitarias (061), La Rioja Salud, La Rioja, Spain
| | - Miguel Antonio Solla Buceta
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - Javier Segovia-Cubero
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Alessandro Sionis Green
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Cuidados Agudos Cardiológicos, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alexander Stepanenko
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Diego Iglesias Álvarez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Ana Viana Tejedor
- Universidad Complutense, Madrid, Spain; Unidad de Cuidados Agudos Cardiológicos, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Roberto Voces
- Grupo ECMO, Hospital Universitario de Cruces, Bilbao, Vizcaya, Spain
| | - María Paz Fuset Cabanes
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, Servicio de Emergencias Sanitarias de Cataluña, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - José Díaz
- Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Francisco Fernández-Avilés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain; Universidad Complutense, Madrid, Spain
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Bruno RR, Wolff G, Kelm M, Jung C. Pharmacological treatment of cardiogenic shock - A state of the art review. Pharmacol Ther 2022; 240:108230. [PMID: 35697151 DOI: 10.1016/j.pharmthera.2022.108230] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.
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Affiliation(s)
- Raphael Romano Bruno
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Georg Wolff
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Duesseldorf, Germany
| | - Christian Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany.
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Zhao N, Pan Z, Yang Q, Chen J, Ruan D, Huang M, Lu P, Chen X, Huang X, Lin X, Mo P. Effect of sex on the association between arterial partial pressure of oxygen and in-hospital mortality in ICU patients with cardiogenic shock: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1313. [PMID: 36660698 PMCID: PMC9843427 DOI: 10.21037/atm-22-5141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022]
Abstract
Background Maintaining tissue perfusion and oxygen supply are essential for cardiogenic shock (CS) treatment. Sex has been reported to be associated with mortality and oxygen use in patients with CS. Males and females respond differently to hypoxia. We designed this cohort study to evaluate the effects of sex on the association between the arterial partial pressure of oxygen (PaO2) and in-hospital mortality. Methods We used the Medical Information Mart for Intensive Care (MIMIC) IV database for this cohort study. The outcome was in-hospital mortality. The relationship between the PaO2 and in-hospital mortality was compared with sex (via an interaction test) using multivariable Cox regression models. Presence of interaction between PaO2 and sex was tested by using inter interaction terms. Results A total of 1,772 patients with CS were enrolled in this study. The association between PaO2 and in-hospital mortality appeared to differ between males and females [hazard ratio (HR): 0.997, 95% confidence interval (CI): 0.995-0.999 vs. HR: 1.002, 95% CI: 0.999-1.003, P for interaction =0.002]. We repeated the analyses, based on different PaO2 category (PaO2 <60 mmHg; PaO2 60-100 mmHg; PaO2 >100 mmHg) and the results remained stable, P for interaction =0.008. Conclusions Sex affects the relationship between PaO2 and in-hospital mortality in CS patients. Our findings may lead to the development of individualized therapies that focus on the use of different target oxygen partial pressures in different sexes to treat patients with CS.
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Affiliation(s)
- Ning Zhao
- Guangzhou Institute of Cardiovascular Disease, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zelin Pan
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qilin Yang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Juanmei Chen
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Dongxue Ruan
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Meiqi Huang
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Peilin Lu
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Xumin Chen
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Xinqiao Huang
- The Second Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Xiaozhen Lin
- Guangzhou Institute of Cardiovascular Disease, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Pei Mo
- Guangzhou Institute of Cardiovascular Disease, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Lim HS. How does protocolization improve outcomes in cardiogenic shock due to end-stage heart failure? Int J Cardiol 2022; 369:33-36. [PMID: 35931208 PMCID: PMC9771587 DOI: 10.1016/j.ijcard.2022.07.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Protocolized team-based care has been shown to improve outcomes in cardiogenic shock (CS) in patients with end-stage heart failure (ESHF). This study tested the hypothesis that protocolized care improves survival by reducing multi-organ dysfunction prior to orthotopic heart transplantation (OHT) or durable left ventricular assist device (LVAD). METHODS We developed a protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF. Six-month survival pre-ROSE (2014-2018) and post-ROSE (2018-2021) were compared. The Sequential Organ Failure Assessment (SOFA) score was calculated as a measure of multi-organ dysfunction pre-MCS and pre-"Exit" therapy (OHT, LVAD or recovery). RESULTS 101 consecutive patients with CS due to ESHF who were deteriorating on inotropes (INTERMACS 1 or 2) were included (63 in Pre-ROSE and 38 in Post-ROSE). The proportions of patients who died on support (26 (41%) vs 11 (29%), p = 0.213) or bridged to "Exit" therapy were comparable between Pre- and Post-ROSE: OHT (28 (44%) vs 21 (55%), p = 0.292); durable LVAD (8 (13%) vs 5 (13%), p = 0.947); or recovery (1 (2%) vs 1 (3%), p = 0.715). SOFA score prior to "Exit" therapy was higher Pre-ROSE compared to Post-ROSE (4 (2-7) vs 2 (1-5), p = 0.012). Six-month survival from initial MCS (71% vs 41%, p = 0.004) and in patients who underwent "Exit" therapy (100% vs 71%, p = 0.001) were higher Post-ROSE vs Pre-ROSE, respectively. Higher pre-"Exit" SOFA score was associated with 6-month survival. None of the patients with Pre-"Exit" SOFA score ≥ 9 survived at 6 months. CONCLUSION Protocolization of CS care in ESHF improved six-month survival by improving multi-organ dysfunction (SOFA score) prior to OHT and LVAD implant.
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Affiliation(s)
- Hoong Sern Lim
- University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
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So DYF, Bagai A, van Diepen S, Fordyce CB, Liu S, Avram R, Russo J, Shah AH, Tanguay JF, Goodman SG, Luk A. A Pan-Canadian Survey of Cardiogenic Shock Management: A Report From the Canadian Cardiovascular Research Collaboratory (C3) Cardiogenic Shock Working Group. Can J Cardiol 2022; 38:1732-1735. [PMID: 35940456 DOI: 10.1016/j.cjca.2022.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Derek Y F So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Akshay Bagai
- Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher B Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shuangbo Liu
- Section of Cardiology, St Boniface Hospital, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Avram
- Montreal Heart Institute, Division of Cardiology, Université de Montreal, Montreal, Quebec, Canada
| | - Juan Russo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ashish H Shah
- Section of Cardiology, St Boniface Hospital, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jean-Francois Tanguay
- Montreal Heart Institute, Division of Cardiology, Université de Montreal, Montreal, Quebec, Canada
| | - Shaun G Goodman
- Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adriana Luk
- Division of Cardiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Martínez-Sellés M, Hernández-Pérez FJ, Uribarri A, Martín Villén L, Zapata L, Alonso JJ, Amat-Santos IJ, Ariza-Solé A, Barrabés JA, Barrio JM, Canteli Á, Alonso-Fernández-Gatta M, Corbí Pascual MJ, Díaz D, Crespo-Leiro MG, de la Torre-Hernández JM, Ferrera C, García González MJ, García-Carreño J, García-Guereta L, García Quintana A, Jorge Pérez P, González-Juanatey JR, López de Sá E, Sánchez PL, Monteagudo M, Palomo López N, Reyes G, Rosell F, Solla Buceta MA, Segovia-Cubero J, Sionis Green A, Stepanenko A, Iglesias Álvarez D, Viana Tejedor A, Voces R, Fuset Cabanes MP, Gimeno Costa JR, Díaz J, Fernández-Avilés F. Código shock cardiogénico 2023. Documento de expertos para una organización multidisciplinaria que permita una atención de calidad. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Tehrani BN, Sherwood MW, Rosner C, Truesdell AG, Ben Lee S, Damluji AA, Desai M, Desai S, Epps KC, Flanagan MC, Howard E, Ibrahim N, Kennedy J, Moukhachen H, Psotka M, Raja A, Saeed I, Shah P, Singh R, Sinha SS, Tang D, Welch T, Young K, deFilippi CR, Speir A, O'Connor CM, Batchelor WB. A Standardized and Regionalized Network of Care for Cardiogenic Shock. JACC. HEART FAILURE 2022; 10:768-781. [PMID: 36175063 PMCID: PMC10404382 DOI: 10.1016/j.jchf.2022.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood. OBJECTIVES The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network. METHODS The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events. RESULTS Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44). CONCLUSIONS Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.
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Affiliation(s)
- Behnam N Tehrani
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | | | | | - Mehul Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Edward Howard
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Nasrien Ibrahim
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ibrahim Saeed
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Timothy Welch
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Karl Young
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Alan Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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Bloom JE, Nehme Z, Andrew E, Dawson LP, Fernando H, Noaman S, Stephenson M, Anderson D, Pellegrino V, Cox S, Lefkovits J, Chan W, Kaye DM, Smith K, Stub D. HOSPITAL CHARACTERISTICS ARE ASSOCIATED WITH CLINICAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK. Shock 2022; 58:204-210. [PMID: 36018300 DOI: 10.1097/shk.0000000000001974] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (<18 cases per year), hospitals in the highest volume quartile (>55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P < 0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vincent Pellegrino
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Blackburn, Victoria, Australia
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Bruno RR, Kelm M, Jung C. [Pharmaceutical therapy of infarct-related cardiogenic shock]. Dtsch Med Wochenschr 2022; 147:1173-1182. [PMID: 36070734 DOI: 10.1055/a-1726-0968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.
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Tehrani BN, Drakos SG, Billia F, Batchelor WB, Luk A, Stelling K, Tonna J, Rosner C, Hanff T, Rao V, Brozzi NA, Baran DA. The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design. Can J Cardiol 2022; 38:1286-1295. [PMID: 35288292 PMCID: PMC10625804 DOI: 10.1016/j.cjca.2022.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients. METHODS The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies. CONCLUSIONS The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.
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Affiliation(s)
| | | | - Filio Billia
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada.
| | | | - Adriana Luk
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kelly Stelling
- Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | | | | | | | - Vivek Rao
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nicolas A Brozzi
- Cleveland Clinic Heart, Vascular, and Thoracic Institute, Weston, Florida, USA
| | - David A Baran
- Cleveland Clinic Heart, Vascular, and Thoracic Institute, Weston, Florida, USA.
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Abstract
PURPOSE OF REVIEW The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models. RECENT FINDINGS In the United States, the majority of CICUs are open as opposed to closed units, yet recent data suggests that transition to a closed staffing model is associated with a decrease in mortality. These reductions in mortality in closed CICUs are most pronounced in the most critically ill populations, such as patients with mechanical circulatory support, cardiac arrest, and respiratory failure. In addition, one study has shown that transition to a cardiac intensivist staffed CICU was associated with a reduction in mortality. Finally, multidisciplinary and protocolized teams imbedded within the CICU, specifically 'shock teams,' have recently been developed and may reduce mortality in this particularly sick patient population. SUMMARY Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.
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The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock. Curr Opin Cardiol 2022; 37:241-249. [PMID: 35612936 DOI: 10.1097/hco.0000000000000967] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. RECENT FINDINGS Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. SUMMARY Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.
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Xu L, Li Q, Yin D, Song G, Wu H. The clinical efficacy of integrated care in combination with vasopressin for cardiogenic shock induced by acute myocardial infarction: A randomized controlled study protocol. Medicine (Baltimore) 2022; 101:e28985. [PMID: 35512064 PMCID: PMC9276314 DOI: 10.1097/md.0000000000028985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is the most serious complication of acute myocardial infarction (AMI) with high mortality, and the conventional nursing mode can not meet the clinical needs. Studies have shown that integrated care model has advantages for critical and chronic diseases. However, there is no clinical study to evaluate the clinical efficacy of this nursing model on cardiogenic shock induced by acute myocardial infarction (CS-AMI). METHODS This is a prospective randomized controlled trial to study the clinical efficacy of integrated care combined with vasopressin in the treatment of CS-AMI. Participants will be randomized in a 1:1 ratio to receive integrated care combined with vasopressin in the treatment group and conventional care combined with vasopressin in the control group. The patients will be followed up for 3 months after systematic treatment. Observation indicators include: length of hospital stay, quality of life score, blood pressure level, and nursing satisfaction score. Finally, SPASS 20.0 software will be used for statistical analysis of the data. DISCUSSION This study will evaluate the clinical efficacy of integrated nursing combined with vasopressin in the treatment of CS-AMI. The results of this study will provide a reference for selecting appropriate nursing programs for CS-AMI patients. TRIAL REGISTRATION OSF Registration number: DOI 10.17605/OSF.IO/K8CN4.
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Truesdell AG, Ofosu-Somuah A, Ibrahim NE. In Search of Cardiogenic Shock Equity, Equality, and Justice…. JACC Cardiovasc Interv 2022; 15:653-655. [PMID: 35331457 DOI: 10.1016/j.jcin.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church, Virginia, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
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50
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Scolari FL, Trott G, Schneider D, Goldraich LA, Frederico Tonietto T, Moura LZ, Bertoldi EG, Rover MM, Wolf JM, Souza DD, Clausell N, Polanczyk CA, Rohde LE, Rosa RG, Wainstein RV. Cardiogenic shock treated with temporary mechanical circulatory support in Brazil: The effect of learning curve. Int J Artif Organs 2022; 45:292-300. [PMID: 35075937 DOI: 10.1177/03913988211070841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIMS Treatment with mechanical circulatory support (MCS) has been proposed to mitigate mortality in cardiogenic shock (CS). However, there is a lack of data on MCS programs implementation and the effect of the learning curve on its outcomes in limited resources countries such as Brazil. METHODS Prospective cohort of patients with CS admitted in four tertiary-care centers treated with Impella CP or veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Clinical outcomes were peri-procedural complications, short-term mortality rate, and the centers' learning curve. The cohort was divided into two periods: from April 2017 to July 2018 (n = 24), and from August 2018 to December 2020 (n = 25). RESULTS The study enrolled 49 patients [age 59 (43-63) years; 34 (70%) males]. The most common causes for CS were acute myocardial infarction in 22 (45%) and acute decompensation of chronic heart failure in 10 (20%). VA-ECMO was employed in 35 (71%) and Impella CP in 14 (29%) of patients. Overall complications occurred in 37 (76%) of patients, where major bleeding in 19 (38%) was the most common. The overall mortality rate was 61%, but it was lower in the second period (40%) in comparison to the first period (83%), p = 0.002. The learning curve analysis showed a decrease in the mortality rate after 40 consecutive cases. CONCLUSIONS Implementation of a temporary MCS program for refractory CS in a limited resource country is feasible. The learning curve effect might have played a role on survival rate since high morbimortality has decreased within time reaching optimal results by the end of the study.
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Affiliation(s)
- Fernando Luís Scolari
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Geraldine Trott
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Schneider
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Livia Adams Goldraich
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tulio Frederico Tonietto
- Division of Critical Care Medicine, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Lídia Zytynski Moura
- Transplant Division, Cardiology Department, Irmandade Hospital da Santa Casa de Misericórdia de Curitiba, Curitiba, Parana, Brazil
| | | | - Marciane Maria Rover
- Heart Failure and Transplant Division, Instituto de Cardiologia, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jonas Michel Wolf
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Denise de Souza
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Nadine Clausell
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Carisi Anne Polanczyk
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luis Eduardo Rohde
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Regis Goulart Rosa
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Vugman Wainstein
- Research Projects Office, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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