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Fu D, Stawiarski K, Núñez Gil IJ, Ramakrishna H. Cardiogenic Shock Update: New Trials, Evolving Management Paradigms, and Artificial Intelligence. J Cardiothorac Vasc Anesth 2024; 38:2100-2104. [PMID: 38981771 DOI: 10.1053/j.jvca.2024.06.008] [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: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Danni Fu
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | - Kristin Stawiarski
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | - Iván J Núñez Gil
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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2
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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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Koester M, Dangl M, Albosta M, Grant J, Maning J, Colombo R. US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:44-51. [PMID: 38378376 DOI: 10.1016/j.carrev.2024.02.007] [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] [Received: 11/22/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear. METHODS The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period. RESULTS The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372). CONCLUSIONS From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.
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Affiliation(s)
| | - Michael Dangl
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Michael Albosta
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Jelani Grant
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jennifer Maning
- Cardiovascular Division, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rosario Colombo
- Cardiovascular Division, Department of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
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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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Alviar CL, Hall S, Mebazaa A. Outcomes of Patients With Cardiogenic Shock in Hub and Spoke Centers: The importance of Protocol Standardization at a Network Level. J Card Fail 2024; 30:576-579. [PMID: 38367907 DOI: 10.1016/j.cardfail.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/19/2024]
Affiliation(s)
- Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medical Center and NYU Grossman School of Medicine, New York, NY; Cardiac Intensive Care Unit and Pharmacy Department, Bellevue Hospital Center, New York, NY, Health and Hospital Corporation, New York, NY
| | - Sylvie Hall
- Cardiac Intensive Care Unit and Pharmacy Department, Bellevue Hospital Center, New York, NY, Health and Hospital Corporation, New York, NY
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6
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Rheaume MJ, Um KJ, Amin F, Belley-Côté EP. Pulmonary Artery Catheters: Old Dog With New Tricks? Can J Cardiol 2024; 40:674-676. [PMID: 38141811 DOI: 10.1016/j.cjca.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/25/2023] Open
Affiliation(s)
- Michael J Rheaume
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kevin J Um
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Faizan Amin
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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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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9
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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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Aboal J, Pascual J, Loma-Osorio P, Nuñez M, Badosa E, Martín C, Ferrero M, Moral S, Ballesteros E, Pedraza J, Tapia S, Brugada R. Impact of a Cardiogenic Shock Program on Mortality in a Non-Transplant Hospital. Heart Lung Circ 2024; 33:38-45. [PMID: 38151398 DOI: 10.1016/j.hlc.2023.11.010] [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: 01/27/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Cardiogenic shock is associated with high in-hospital morbidity and mortality. Improvements in this care process could lead to better outcomes. METHODS This retrospective study of patients with cardiogenic shock compared two periods: no specific program to address cardiogenic shock and implementation of a cardiogenic shock program. This program included the establishment of a multidisciplinary team (shock team), early alert to the transplant hospital, initiation of a ventricular assist extracorporeal membrane oxygenation (ECMO) program, and extension of continuous care by acute cardiovascular care specialists. The primary objective was to analyse whether there were differences between in-hospital mortality and mortality during follow-up. Predictors of in-hospital mortality were examined as a secondary objective. RESULTS A total of 139 patients were enrolled: 69 of them in the previous period and 70 in the cardiogenic shock program period. There was a significant reduction in in-hospital mortality (55.1% vs 37.1%; p=0.03) and mortality during follow-up (62.7% vs 44.6%; p=0.03) in the second period. Diabetes mellitus, ejection fraction, out-of-hospital cardiac arrest, and implementation of the cardiogenic shock program were independent predictors of in-hospital mortality. CONCLUSIONS The implementation of a comprehensive cardiogenic shock program in a non-transplanting hospital improved in-hospital and follow-up mortality of patients in cardiogenic shock.
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Affiliation(s)
- Jaime Aboal
- University Hospital Dr. Josep Trueta, Girona, Spain.
| | | | | | - Maria Nuñez
- University Hospital Dr. Josep Trueta, Girona, Spain
| | | | | | | | - Sergio Moral
- University Hospital Dr. Josep Trueta, Girona, Spain
| | - Esther Ballesteros
- Territorial Management of Radiology and Nuclear Medicine of Girona, Girona, Spain; Biomedical Research Institute, Girona (IdIBGi), Girona, Spain
| | | | - Simón Tapia
- University Hospital Dr. Josep Trueta, Girona, Spain
| | - Ramon Brugada
- University Hospital Dr. Josep Trueta, Girona, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain; Biomedical Research Institute, Girona (IdIBGi), Girona, Spain
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11
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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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12
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Nakata J, Yamamoto T, Saku K, Ikeda Y, Unoki T, Asai K. Mechanical circulatory support in cardiogenic shock. J Intensive Care 2023; 11:64. [PMID: 38115065 PMCID: PMC10731894 DOI: 10.1186/s40560-023-00710-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
Cardiogenic shock is a complex and diverse pathological condition characterized by reduced myocardial contractility. The goal of treatment of cardiogenic shock is to improve abnormal hemodynamics and maintain adequate tissue perfusion in organs. If hypotension and insufficient tissue perfusion persist despite initial therapy, temporary mechanical circulatory support (t-MCS) should be initiated. This decade sees the beginning of a new era of cardiogenic shock management using t-MCS through the accumulated experience with use of intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), as well as new revolutionary devices or systems such as transvalvular axial flow pump (Impella) and a combination of VA-ECMO and Impella (ECPELLA) based on the knowledge of circulatory physiology. In this transitional period, we outline the approach to the management of cardiogenic shock by t-MCS. The management strategy involves carefully selecting one or a combination of the t-MCS devices, taking into account the characteristics of each device and the specific pathological condition. This selection is guided by monitoring of hemodynamics, classification of shock stage, risk stratification, and coordinated management by the multidisciplinary shock team.
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Affiliation(s)
- Jun Nakata
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research, Suita, Osaka, Japan
| | - Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kuniya Asai
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Carter AJ, Raffoul J, Lane L, LeSage L, Langenhorst S, Smolin M, Dempsey M, Hughes D, Gleason M, Weiss S, Anderson WD. Facility-based approach for the management of acute ST segment elevation myocardial infarction with cardiogenic shock in a rural medical centre: the Durango model. Open Heart 2023; 10:e002299. [PMID: 38065583 PMCID: PMC10711864 DOI: 10.1136/openhrt-2023-002299] [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: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Cardiogenic shock (CS) complicates 5%-15% of cases of acute myocardial infarction (AMI) with inpatient mortality greater than 40%. The implementation of standardised protocols may improve clinical outcomes in patients with AMI-CS. METHODS AND ANALYSIS The Durango model is a prospective single-centre registry designed to enable early identification of patients with STEMI-CS to facilitate primary reperfusion therapy with a shock team management algorithm in a rural level II heart attack centre. This prospective registry includes all patients >18 years of age presenting with STEMI with or without CS beginning on 1 February 2023. The primary outcome measures are adherence to model-based documentation of SCAI shock Classification prehospital and in the ED with appropriate STEMI shock alert for AMI and stages C, D, E shock; use of mechanical circulatory support Pre-PCI and door to support time <90 min. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board with a waiver of informed consent. The findings will be submitted for publication in a peer-review open access journal on completion of the study. CONCLUSIONS The Durango model will demonstrate that the implementation of a STEMI shock team can be feasible in a rural medical centre through comprehensive education of a diverse group providers with different levels of experience, continuous model/device proficiency training and performance feedback.
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Affiliation(s)
| | - Jad Raffoul
- Cardiology, Mercy Regional Medical Center, Durango, Colorado, USA
| | - Linden Lane
- Cardiology, Mercy Regional Medical Center, Durango, Colorado, USA
| | - Leah LeSage
- Cardiology, Mercy Regional Medical Center, Durango, Colorado, USA
| | | | - Matthew Smolin
- Cardiology, Mercy Regional Medical Center, Durango, Colorado, USA
| | - Michael Dempsey
- Critical Care, Mercy Regional Medical Center, Durango, Colorado, USA
| | - David Hughes
- Emergency Department, Mercy Regional Medical Center, Durango, Colorado, USA
| | - Michael Gleason
- Emergency Department, Mercy Regional Medical Center, Durango, Colorado, USA
| | - Steven Weiss
- Critical Care, Mercy Regional Medical Center, Durango, Colorado, USA
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14
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Stevenson MJ, Kenigsberg BB, Singam NSV, Papolos AI. Shock Teams: A Contemporary Review. Curr Cardiol Rep 2023; 25:1657-1663. [PMID: 37861851 DOI: 10.1007/s11886-023-01983-7] [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] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams. RECENT FINDINGS To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limited available data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.
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Affiliation(s)
- Margaret J Stevenson
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA.
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15
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Lee C, Tully A, Fang JC, Sugeng L, Elmariah S, Grubb KJ, Young MN. Building and Optimizing the Interdisciplinary Heart Team. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101067. [PMID: 39129880 PMCID: PMC11308725 DOI: 10.1016/j.jscai.2023.101067] [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: 02/06/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 08/13/2024]
Abstract
A multidisciplinary care team model, or Heart Team approach, has become a central tenet of cardiovascular care. Though initially applied to the management of heart transplantation and subsequently complex coronary artery disease, the Heart Team is now utilized broadly across cardiovascular medicine, including in the treatment of valvular disease, pulmonary embolism, cardiogenic shock, high-risk pregnancies in patients with pre-existing cardiovascular disease, and adult congenital heart disease. The Heart Team model improves interdisciplinary collaboration among specialties, adherence to societal guidelines, and shared decision-making with patients and families. In this review, we highlight the development and rationale supporting the Heart Team model, address the challenges of implementing a multidisciplinary care team, and discuss the optimal methods to continue to build, optimize, and implement this approach.
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Affiliation(s)
- Christopher Lee
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew Tully
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - James C. Fang
- Division of Cardiology, University of Utah Health, Salt Lake City, Utah
| | - Lissa Sugeng
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Sammy Elmariah
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Kendra J. Grubb
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Michael N. Young
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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16
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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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17
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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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18
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Martin-Villen L, Martínez-Sellés M, Diaz-Fernandez JF, Zapata-Fenor L. Cardiogenic shock code 2023, towards a quality multidisciplinary organization. Med Intensiva 2023:S2173-5727(23)00046-2. [PMID: 37173216 DOI: 10.1016/j.medine.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Luis Martin-Villen
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañon, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | - Lluis Zapata-Fenor
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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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: 0] [Impact Index Per Article: 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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20
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Polyzogopoulou E, Bezati S, Karamasis G, Boultadakis A, Parissis J. Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done. J Clin Med 2023; 12:2643. [PMID: 37048727 PMCID: PMC10095596 DOI: 10.3390/jcm12072643] [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: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sofia Bezati
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Grigoris Karamasis
- Second Department of Cardiology, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
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21
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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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22
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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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23
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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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24
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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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25
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Bloom JE, Andrew E, Nehme Z, Beale A, Dawson LP, Shi WY, Vriesendorp PA, Fernando H, Noaman S, Cox S, Stephenson M, Anderson D, Chan W, Kaye DM, Smith K, Stub D. Gender Disparities in Cardiogenic Shock Treatment and Outcomes. Am J Cardiol 2022; 177:14-21. [PMID: 35773044 DOI: 10.1016/j.amjcard.2022.04.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/25/2022]
Abstract
Cardiogenic shock is associated with a high risk for morbidity and mortality. The impact of gender on treatment and outcomes is poorly defined. This study aimed to evaluate whether gender influences the clinical management and outcomes of patients with prehospital cardiogenic shock. Consecutive adult patients with cardiogenic shock who were transferred to hospital by emergency medical services (EMS) between January 1, 2015 and June 30, 2019 in Victoria, Australia were included. Data were obtained from individually linked ambulance, hospital, and state death index datasets. The primary outcome assessed was 30-day mortality, stratified by patient gender. Propensity score matching was performed for risk adjustment. Over the study period a total of 3,465 patients were identified and 1,389 patients (40.1%) were women. Propensity score matching yielded 1,330 matched pairs with no differences observed in baseline characteristics, including age, initial vital signs, pre-existing co-morbidities, etiology of shock, and prehospital interventions. In the matched cohort, women had higher rates of 30-day mortality (44.7% vs 39.2%, p = 0.009), underwent less coronary angiography (18.3% vs 27.2%, p <0.001), and revascularization with percutaneous coronary intervention (8.9% vs 14.2%, p <0.001), compared with men. In conclusion, in this large population-based study, women with cardiogenic shock who were transferred by EMS to hospital had significantly worse survival outcomes and reduced rates of invasive cardiac interventions compared to men. These data underscore the urgent need for targeted public health measures to redress gender differences in outcomes and variation with clinical care for patients with cardiogenic shock.
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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 Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - Emily Andrew
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Anna Beale
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Y Shi
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pieter A Vriesendorp
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - Shelley Cox
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Michael Stephenson
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, 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
| | - Karen Smith
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.
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26
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
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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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29
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Sinha SS, Rosner CM, Tehrani BN, Maini A, Truesdell AG, Lee SB, Bagchi P, Cameron J, Damluji AA, Desai M, Desai SS, Epps KC, deFilippi C, Flanagan MC, Genovese L, Moukhachen H, Park JJ, Psotka MA, Raja A, Shah P, Sherwood MW, Singh R, Tang D, Young KD, Welch T, O'Connor CM, Batchelor WB. Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes. Circ Heart Fail 2022; 15:e009279. [PMID: 35510546 DOI: 10.1161/circheartfailure.121.009279] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about clinical characteristics, hospital course, and longitudinal outcomes of patients with cardiogenic shock (CS) related to heart failure (HF-CS) compared to acute myocardial infarction (AMI; CS related to AMI [AMI-CS]). METHODS We examined in-hospital and 1-year outcomes of 520 (219 AMI-CS, 301 HF-CS) consecutive patients with CS (January 3, 2017-December 31, 2019) in a single-center registry. RESULTS Mean age was 61.5±13.5 years, 71% were male, 22% were Black patients, and 63% had chronic kidney disease. The HF-CS cohort was younger (58.5 versus 65.6 years, P<0.001), had fewer cardiac arrests (15.9% versus 35.2%, P<0.001), less vasopressor utilization (61.8% versus 82.2%, P<0.001), higher pulmonary artery pulsatility index (2.14 versus 1.51, P<0.01), lower cardiac power output (0.64 versus 0.77 W, P<0.01) and higher pulmonary capillary wedge pressure (25.4 versus 22.2 mm Hg, P<0.001) than patients with AMI-CS. Patients with HF-CS received less temporary mechanical circulatory support (34.9% versus 76.3% P<0.001) and experienced lower rates of major bleeding (17.3% versus 26.0%, P=0.02) and in-hospital mortality (23.9% versus 39.3%, P<0.001). Postdischarge, 133 AMI-CS and 229 patients with HF-CS experienced similar rates of 30-day readmission (19.5% versus 24.5%, P=0.30) and major adverse cardiac and cerebrovascular events (23.3% versus 28.8%, P=0.45). Patients with HF-CS had lower 1-year mortality (n=123, 42.6%) compared to the patients with AMI-CS (n=110, 52.9%, P=0.03). Cumulative 1-year mortality was also lower in patients with HF-CS (log-rank test, P=0.04). CONCLUSIONS Patients with HF-CS were younger, and despite lower cardiac power output and higher pulmonary capillary wedge pressure, less likely to receive vasopressors or temporary mechanical circulatory support. Although patients with HF-CS had lower in-hospital and 1-year mortality, both cohorts experienced similarly high rates of postdischarge major adverse cardiovascular and cerebrovascular events and 30-day readmission, highlighting that both cohorts warrant careful long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03378739.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Carolyn M Rosner
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Behnam N Tehrani
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Aneel Maini
- Georgetown University Medical School' Washington' DC (A.M.)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Seiyon Ben Lee
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Pramita Bagchi
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - James Cameron
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Abdulla A Damluji
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mehul Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Shashank S Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Christopher deFilippi
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - M Casey Flanagan
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Leonard Genovese
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - James J Park
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Anika Raja
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Palak Shah
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Matthew W Sherwood
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Daniel Tang
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Karl D Young
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Timothy Welch
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Wayne B Batchelor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
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30
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 710] [Impact Index Per Article: 355.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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31
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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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32
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 873] [Impact Index Per Article: 436.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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33
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Shah T, Kapadia S, Lansky AJ, Grines CL. ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes. Curr Cardiol Rep 2022; 24:529-540. [PMID: 35286662 DOI: 10.1007/s11886-022-01676-7] [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: 02/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men. RECENT FINDINGS This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.
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Affiliation(s)
- Tayyab Shah
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA.
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34
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Vallabhajosyula S, Katz JN, Menon V. Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock. Circ Heart Fail 2022; 15:e008736. [PMID: 35187948 DOI: 10.1161/circheartfailure.121.008736] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (S.V.)
| | - Jason N Katz
- Division of Cardiovascular Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - Venu Menon
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (V.M.)
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35
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Shankar A, Gurumurthy G, Sridharan L, Gupta D, Nicholson WJ, Jaber WA, Vallabhajosyula S. A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221075064. [PMID: 35153521 PMCID: PMC8829716 DOI: 10.1177/11795468221075064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.
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Affiliation(s)
- Aditi Shankar
- Department of Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | - Lakshmi Sridharan
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Divya Gupta
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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36
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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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Ponamgi SP, Maqsood MH, Sundaragiri PR, DelCore MG, Kanmanthareddy A, Jaber WA, Nicholson WJ, Vallabhajosyula S. Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock: A review of contemporary literature. World J Cardiol 2021; 13:720-732. [PMID: 35070114 PMCID: PMC8716976 DOI: 10.4330/wjc.v13.i12.720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/24/2021] [Accepted: 12/03/2021] [Indexed: 02/06/2023] Open
Abstract
Acute myocardial infarction (AMI) with left ventricular (LV) dysfunction patients, the most common cause of cardiogenic shock (CS), have acutely deteriorating hemodynamic status. The frequent use of vasopressor and inotropic pharmacologic interventions along with mechanical circulatory support (MCS) in these patients necessitates invasive hemodynamic monitoring. After the pivotal Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial failed to show a significant improvement in clinical outcomes in shock patients managed with a pulmonary artery catheter (PAC), the use of PAC has become less popular in clinical practice. In this review, we summarize currently available literature to summarize the indications, clinical relevance, and recommendations for use of PAC in the setting of AMI-CS.
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Affiliation(s)
- Shiva P Ponamgi
- Division of Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE 68154, United States
| | - Muhammad Haisum Maqsood
- Department of Medicine, Lincoln Medical Center/Cornell University, Bronx, NY 10451, United States
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC 30260, United States
| | - Michael G DelCore
- Division of Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE 68154, United States
| | - Arun Kanmanthareddy
- Division of Cardiovascular Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE 68154, United States
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, High Point, NC 27262, United States
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38
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Proudfoot AG, Kalakoutas A, Meade S, Griffiths MJD, Basir M, Burzotta F, Chih S, Fan E, Haft J, Ibrahim N, Kruit N, Lim HS, Morrow DA, Nakata J, Price S, Rosner C, Roswell R, Samaan MA, Samsky MD, Thiele H, Truesdell AG, van Diepen S, Voeltz MD, Irving PM. Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach. Circ Heart Fail 2021; 14:e008635. [PMID: 34807723 PMCID: PMC8692411 DOI: 10.1161/circheartfailure.121.008635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
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Affiliation(s)
- Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
- Department of Anaesthesiology & Intensive Care, German Heart Centre Berlin, Germany
- Queen Mary University of London, London, UK
- Corresponding author: Alastair Proudfoot, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, Mobile: 07779011194,
| | | | - Susanna Meade
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Mark JD Griffiths
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mir Basir
- Department of Cardiology, Henry Ford Health System, Detroit, MI USA
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine and Division of Respirology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Natalie Kruit
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Hoong Sern Lim
- Department of Cardiology, University of Birmingham NHS Foundation Trust, Birmingham, UK
| | - David A. Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Mark A Samaan
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Marc D. Samsky
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Peter M Irving
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King’s College London, UK
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39
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Warren AF, Rosner C, Gattani R, Truesdell AG, Proudfoot AG. Cardiogenic Shock: Protocols, Teams, Centers, and Networks. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary ‘shock team’ approach to CS management. A volume–outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of ‘shock hubs’ as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke ‘shock network’ approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.
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Affiliation(s)
- Alex F Warren
- South-East Scotland School of Anaesthesia, Edinburgh, UK; Anaesthesia, Critical Care and Pain, University of Edinburgh, Edinburgh, UK
| | | | | | - Alex G Truesdell
- Inova Heart and Vascular Institute, Falls Church, VA; Virginia Heart, Falls Church, VA
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK; Clinic for Anaesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin, Germany; Queen Mary University of London, London, UK
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40
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Alvarez Villela M, Clark R, William P, Sims DB, Jorde UP. Systems of Care in Cardiogenic Shock. Front Cardiovasc Med 2021; 8:712594. [PMID: 34616782 PMCID: PMC8489379 DOI: 10.3389/fcvm.2021.712594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
Outcomes for cardiogenic shock (CS) patients remain relatively poor despite significant advancements in primary percutaneous coronary interventions (PCI) and temporary circulatory support (TCS) technologies. Mortality from CS shows great disparities that seem to reflect large variations in access to care and physician practice patterns. Recent reports of different models to standardize care in CS have shown considerable potential at improving outcomes. The creation of regional, integrated, 3-tiered systems, would facilitate standardized interventions and equitable access to care. Multidisciplinary CS teams at Level I centers would direct care in a hub-and-spoke model through jointly developed protocols and real-time shared decision making. Levels II and III centers would provide early access to life-saving therapies and safe transfer to designated hub centers. In regions with large geographical distances, the implementation of telemedicine-cardiac intensive care unit (CICU) care can be an important resource for the creation of effective systems of care.
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Affiliation(s)
- Miguel Alvarez Villela
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States.,Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Rachel Clark
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Preethi William
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States.,Division of Cardiology, Banner University Medical Center, Tucson, University of Arizona, Tucson, AZ, United States
| | - Daniel B Sims
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
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41
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Papolos AI, Kenigsberg BB, Berg DD, Alviar CL, Bohula E, Burke JA, Carnicelli AP, Chaudhry SP, Drakos S, Gerber DA, Guo J, Horowitz JM, Katz JN, Keeley EC, Metkus TS, Nativi-Nicolau J, Snell JR, Sinha SS, Tymchak WJ, Van Diepen S, Morrow DA, Barnett CF. Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams. J Am Coll Cardiol 2021; 78:1309-1317. [PMID: 34556316 DOI: 10.1016/j.jacc.2021.07.044] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Single-center studies suggest that implementation of multidisciplinary cardiogenic shock (CS) teams is associated with improved CS survival. OBJECTIVES The aim was to characterize practice patterns and outcomes in the management of CS across multiple centers with versus without shock teams. METHODS The Critical Care Cardiology Trials Network is a multicenter network of cardiac intensive care units (CICUs) in North America. All consecutive medical admissions to each CICU (n = 24) were captured during annual 2-month collection periods (2017-2019; n = 6,872). Shock management and CICU mortality among centers with versus without shock teams were compared using inverse probability weighting. RESULTS Ten of the 24 centers had shock teams. Among 1,242 CS admissions, 44% were at shock team centers. The groups were well-balanced with respect to demographics, shock etiology, Sequential Organ Failure Assessment score, biochemical markers of end organ dysfunction, and invasive hemodynamics. Centers with shock teams used more pulmonary artery catheters (60% vs 49%; adjusted odds ratio [OR]: 1.86; 95% CI: 1.47-2.35; P < 0.001), less overall mechanical circulatory support (MCS) (35% vs 43%; adjusted OR: 0.74; 95% CI: 0.59-0.95; P = 0.016), and more advanced types of MCS (53% vs 43% of all MCS; adjusted OR: 1.73; 95% CI: 1.19-2.51; P = 0.005) rather than intra-aortic balloon pumps. The presence of a shock team was independently associated with lower CICU mortality (23% vs 29%; adjusted OR: 0.72; 95% CI: 0.55-0.94; P = 0.016). CONCLUSIONS In this multicenter observational study, centers with shock teams were more likely to obtain invasive hemodynamics, use advanced types of MCS, and have lower risk-adjusted mortality. A standardized multidisciplinary shock team approach may improve outcomes in CS.
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Affiliation(s)
- Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Erin Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | | | - Stavros Drakos
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniel A Gerber
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James M Horowitz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Jason N Katz
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Ellen C Keeley
- Department of Medicine University of Florida Gainesville, Gainesville, Florida, USA
| | - Thomas S Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey R Snell
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Wayne J Tymchak
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sean Van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher F Barnett
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
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42
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Damluji AA, van Diepen S, Katz JN, Menon V, Tamis-Holland JE, Bakitas M, Cohen MG, Balsam LB, Chikwe J. Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e16-e35. [PMID: 34126755 DOI: 10.1161/cir.0000000000000985] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.
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43
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Moghaddam N, van Diepen S, So D, Lawler PR, Fordyce CB. Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock. ESC Heart Fail 2021; 8:988-998. [PMID: 33452763 PMCID: PMC8006679 DOI: 10.1002/ehf2.13180] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/16/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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