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Augustin KJ, Wieruszewski PM, McLean L, Leiendecker E, Ramakrishna H. Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit. J Cardiothorac Vasc Anesth 2024; 38:1786-1801. [PMID: 38862282 DOI: 10.1053/j.jvca.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Katrina Joy Augustin
- Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Lewis McLean
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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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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Dennis M, Burrell A, Lal S, Ferguson C, French J, Bowcock E, Kruit N, Burns B, Jain P. Cardiogenic Shock Challenges and Priorities: A Clinician Survey. Heart Lung Circ 2024; 33:1227-1231. [PMID: 38744603 DOI: 10.1016/j.hlc.2024.04.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia's geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described. METHOD We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities. RESULTS There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required. CONCLUSIONS Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value.
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Affiliation(s)
- Mark Dennis
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Aidan Burrell
- Australia and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Intensive Care, Alfred Health, Melbourne, Vic, Australia
| | - Sean Lal
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Caleb Ferguson
- Centre for Chronic & Complex Care Research, Blacktown Hospital, Blacktown, Sydney, and Western Sydney Local Health, Sydney, NSW, Australia; School of Nursing, University of Wollongong, NSW, Australia
| | - John French
- University of New South Wales, Sydney, NSW, Australia; Department of Cardiology, Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Emma Bowcock
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Intensive Care Medicine, Nepean Hospital, Nepean, Sydney, NSW, Australia
| | - Natalie Kruit
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Aeromedical Operations, New South Wales Ambulance, Sydney, NSW, Australia; Department of Anaesthesia, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - Brian Burns
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthesia, Westmead Hospital, Westmead, Sydney, NSW, Australia; Department of Emergency Medicine, Northern Beaches Hospital, Sydney, NSW, Australia
| | - Pankaj Jain
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Carnicelli AP, Dodson K, Bull L, Hajj J, McMurray JD, Tedford RJ, Witer LJ, Yourshaw J, Kilic A, Houston BA. Temporary Mechanical Circulatory Support Coordinator: Conception and Implementation of a Novel Role. Circ Heart Fail 2024; 17:e011603. [PMID: 38853774 DOI: 10.1161/circheartfailure.124.011603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Kaylen Dodson
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Lindsey Bull
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Jennifer Hajj
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Jeffrey D McMurray
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Lucas J Witer
- Division of Cardiothoracic Surgery, Department of Surgery (L.P.W., A.K.), Medical University of South Carolina, Charleston
| | - Jeffrey Yourshaw
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery (L.P.W., A.K.), Medical University of South Carolina, Charleston
| | - Brian A Houston
- Division of Cardiology, Department of Medicine (A.P.C., K.D., L.B., H.J., J.D.M., R.J.T., J.Y., B.A.H.), Medical University of South Carolina, Charleston
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5
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Colombo CN, Tavazzi G, Zanetti M, Dore F, Finazzi S. Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey. Minerva Anestesiol 2024; 90:530-538. [PMID: 38551614 DOI: 10.23736/s0375-9393.24.17908-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units. METHODS A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1st-2nd versus 3rd). RESULTS Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. Among the ICUs, 94.2% routinely use a cardiac output monitoring device (pulmonary artery catheter more frequently in 3rd level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%). CONCLUSIONS According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.
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Affiliation(s)
- Costanza N Colombo
- University of Pavia, Pavia, Italy -
- Department of Anesthesia and Intensive Care, IRCCS Foundation Policlinico San Matteo, Pavia, Italy -
| | - Guido Tavazzi
- Department of Anesthesia and Intensive Care, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
- Department of Surgical, Pediatric, and Diagnostic Sciences, University of Pavia, Pavia, Italy
| | - Michele Zanetti
- Unit of Computer Science for Clinical Knowledge Sharing, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Francesca Dore
- Laboratory of Clinical Data Science, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Stefano Finazzi
- Laboratory of Clinical Data Science, Department of Medical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
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Garan AR, Kataria R, Li B, Sinha S, Kanwar MK, Hernandez-Montfort J, Li S, Ton VANK, Blumer V, Grandin EW, Harwani N, Zazzali P, Walec KD, Hickey G, Abraham J, Mahr C, Nathan S, Vorovich E, Guglin M, Hall S, Khalife W, Sangal P, Zhang Y, Kim JH, Schwartzman A, Vishnevsky A, Burkhoff D, Kapur NK. Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis. J Card Fail 2024; 30:564-575. [PMID: 37820897 DOI: 10.1016/j.cardfail.2023.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of "spoke" centers to tertiary/"hub" centers with higher capabilities. However, outcomes associated with such transfers are largely unknown beyond those reported in individual health networks. OBJECTIVES To analyze a contemporary, multicenter CS cohort with the aim of comparing characteristics and outcomes of patients between transfer (between spoke and hub centers) and nontransfer cohorts (those primarily admitted to a hub center) for both acute myocardial infarction (AMI-CS) and heart failure-related HF-CS. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality. METHODS The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high-volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020. RESULTS Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these patients, 528 (58.1%) had heart failure-related CS (HF-CS), and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stages C and D, when compared to nontransfer patients. Transfer patients had higher mortality rates (37% vs 29%, < 0.001) than nontransfer patients; the differences were driven primarily by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer or within 24 hours of arrival was associated with decreased mortality rates. Among transfer AMI-CS patients, BMI > 28 kg/m2, worsening renal failure, lactate > 3 mg/dL, and increasing numbers of vasoactive drugs were associated with increased mortality rates. CONCLUSION More than half of patients with CS managed at high-volume CS centers were transferred from another hospital. Although transfer patients had higher mortality rates than those who were admitted primarily to hub centers, the outcomes and their predictors varied significantly when classified by HF-CS vs AMI-CS.
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Affiliation(s)
| | - Rachna Kataria
- Brown University, Lifespan Cardiovascular Center, Providence, RI
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Shashank Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | | | - Song Li
- University of Washington Medical Center, Seattle, WA
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Neil Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Karol D Walec
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | | | | | - Maya Guglin
- Indiana University Health Advanced Heart and Lung Care, Indianapolis, IN
| | - Shelley Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, TX
| | | | - Paavni Sangal
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | | | | | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA.
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7
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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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8
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Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
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Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
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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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10
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Hanson ID, Rusia A, Palomo A, Tawney A, Pow T, Dixon SR, Meraj P, Sievers E, Johnson M, Wohns D, Ali O, Kapur NK, Grines C, Burkhoff D, Anderson M, Lansky A, Naidu SS, Basir MB, O'Neill W. Treatment of Acute Myocardial Infarction and Cardiogenic Shock: Outcomes of the RECOVER III Postapproval Study by Society of Cardiovascular Angiography and Interventions Shock Stage. J Am Heart Assoc 2024; 13:e031803. [PMID: 38293995 PMCID: PMC11056148 DOI: 10.1161/jaha.123.031803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND The Society for Cardiovascular Angiography and Interventions proposed a staging system (A-E) to predict prognosis in cardiogenic shock. Herein, we report clinical outcomes of the RECOVER III study for the first time, according to Society for Cardiovascular Angiography and Interventions shock classification. METHODS AND RESULTS The RECOVER III study is an observational, prospective, multicenter, single-arm, postapproval study of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support. Patients enrolled in the RECOVER III study were assigned a baseline Society for Cardiovascular Angiography and Interventions shock stage. Staging was then repeated within 24 hours after initiation of Impella. Kaplan-Meier survival curve analyses were conducted to assess survival across Society for Cardiovascular Angiography and Interventions shock stages at both time points. At baseline assessment, 16.5%, 11.4%, and 72.2% were classified as stage C, D, and E, respectively. At ≤24-hour assessment, 26.4%, 33.2%, and 40.0% were classified as stage C, D, and E, respectively. Thirty-day survival among patients with stage C, D, and E shock at baseline was 59.7%, 56.5%, and 42.9%, respectively (P=0.003). Survival among patients with stage C, D, and E shock at ≤24 hours was 65.7%, 52.1%, and 29.5%, respectively (P<0.001). After multivariable analysis of impact of shock stage classifications at baseline and ≤24 hours, only stage E classification at ≤24 hours was a significant predictor of mortality (odds ratio, 4.8; P<0.001). CONCLUSIONS In a real-world cohort of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support, only stage E classification at ≤24 hours was significantly predictive of mortality, suggesting that response to therapy may be more important than clinical severity of shock at presentation.
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Affiliation(s)
- Ivan D. Hanson
- Department of Cardiovascular MedicineWilliam Beaumont University HospitalRoyal OakMI
| | - Akash Rusia
- Department of Advanced Heart Failure, Baylor Scott & White Health–The Heart HospitalPlanoTX
| | - Andres Palomo
- Department of Cardiovascular MedicineWilliam Beaumont University HospitalRoyal OakMI
| | - Adam Tawney
- Department of Cardiovascular MedicineWilliam Beaumont University HospitalRoyal OakMI
| | - Timothy Pow
- Department of Cardiovascular MedicineWilliam Beaumont University HospitalRoyal OakMI
| | - Simon R. Dixon
- Department of Cardiovascular MedicineWilliam Beaumont University HospitalRoyal OakMI
| | | | - Eric Sievers
- Department of Cardiovascular SurgeryJackson‐Madison County HospitalJacksonTN
| | | | - David Wohns
- Division of CardiologySpectrum HealthGrand RapidsMI
| | - Omar Ali
- Department of CardiologyDetroit Medical CenterDetroitMI
| | - Navin K. Kapur
- Department of CardiologyTufts University School of MedicineBostonMA
| | - Cindy Grines
- Northside Hospital Cardiovascular InstituteAtlantaGA
| | | | - Mark Anderson
- Department of Cardiac SurgeryHackensack University Medical CenterHackensackNJ
| | | | - Srihari S. Naidu
- Department of CardiologyWestchester Medical Center and New York Medical CollegeValhallaNY
| | - Mir B. Basir
- Division of CardiologyHenry Ford HospitalDetroitMI
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11
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Sarma D, Jentzer JC. Cardiogenic Shock: Pathogenesis, Classification, and Management. Crit Care Clin 2024; 40:37-56. [PMID: 37973356 DOI: 10.1016/j.ccc.2023.05.001] [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: 11/19/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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12
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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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13
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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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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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Alvarez Villela M, Fu D, Roslin K, Smoller R, Asemota D, Miklin DJ, Kodra A, Vullaganti S, Roswell RO, Rangasamy S, Saikus CE, Kon ZN, Pierce MJ, Husk G, Stevens GR, Maybaum S. Defining levels of care in cardiogenic shock. Front Cardiovasc Med 2023; 10:1206570. [PMID: 38028504 PMCID: PMC10644172 DOI: 10.3389/fcvm.2023.1206570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Background Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Methods Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Results Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. Conclusion This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.
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Affiliation(s)
- Miguel Alvarez Villela
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Danni Fu
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Kylie Roslin
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Rebecca Smoller
- Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Daniel Asemota
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Daniel J. Miklin
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Arber Kodra
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Sirish Vullaganti
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Robert O. Roswell
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Sabarivinoth Rangasamy
- Department of Cardiology, Northern Westchester Hospital, Northwell Health, Mount Kisco, NY, United States
| | - Christina E. Saikus
- Department of Cardiothoracic Surgery, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Zachary N. Kon
- Department of Cardiothoracic Surgery, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Matthew J. Pierce
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Gregg Husk
- Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, NY, United States
| | - Gerin R. Stevens
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, United States
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Simon Maybaum
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY, United States
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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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