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Cardiogenic Shock

Timing is everything

It can happen anywhere[1]

Cardiogenic Shock - Where does it happen

Cardiogenic shock patients represent a wide spectrum of disease that requires tailored therapy to improve hemodynamic derangements[2]

Develop a treatment plan

Identify

Any attempt to improve outcomes in CS should begin with its early identification. Models of care including a multi-disciplinary CS team, hold potential for the early identification and individualized treatment of CS.[3]

Initiate

Experts suggest use of advanced hemodynamic monitoring to diagnose and/or manage patients with CS.[4] To avoid the negative impact of inotropes, consideration should be given to early initiation of intra-aortic balloon pumping.[5],[6]

Evaluate

Quick feedback loops incorporating patient status and hemodynamics are required to assess the need for response to initial therapies.[2]

Escalate

When patients do not respond to treatments initiated, consider the next level of support and transfer to experienced shock centers if required.[4]

Identification is critical

Stages of Cardiogenic Shock[4]

At Risk: A patient with risk factors for cardiogenic shock who is not currently experiencing signs or symptoms. For example, large acute myocardial infarction, prior infarction, acute and/ or acute on chronic heart failure.

Beginning: A patient who has clinical evidence of relative hypotension or tachycardia without hypoperfusion.

Classic: A patient presenting with hypoperfusion requiring intervention beyond volume resuscitation(inotrope, pressor, or mechanical support). These patients typically present with relative hypotension.

Deteriorating: A patient who fails to respond to initial interventions. Similar to Stage C and getting worse.

Extremis: A patient being supported by multiple interventions who may be experiencing cardiac arrest with ongoing CPR.

Hear Dr Baran speak on the SCAI classification

Any attempt to improve outcomes in cardiogenic shock should being with early identification.
Models of care including a multi-disciplinary CS team hold potential for early identification and individualized treatment.[3]

Initiate early

Retrospective analysis indicates early use of mechanical circulatory support (MCS) is an important therapeutic intervention. Early use of intra-aortic balloon counterpulsation is associated with survival benefits, regardless of the etiology.[5]

Learn more about the use of IABP

30-day survival was 76% when IABP was placed within < 1 hour of onset of cardiogenic shock.[5]

Early initiation of IABP may provide hemodynamic benefit as primary treatment for advanced decompensated heart failure.[6]

Primary circulatory support with the Sensation Plus 50 cc IABP showed a significant increase in improved organ perfusion assessed by SVO2.[6]

Starting support immediately reduces stroke work, possibly decreasing myocardial oxygen consumption. IABP counterpulsation decreases LV afterload, preload and intraventricular dyssynchrony.[6]

To avoid the negative impact of vasoactive drugs, consideration should be given to early initiation of IABP therapy.[5],[6]

Evaluate effectiveness

Tailor the care to the patient and escalate as needed. Evaluating the response to therapy is critical in making adjustments to the plan of care.[2]

IABP response chart

Identification of predictors of response to IABP support would allow us to tailor therapy and reserve use of more powerful MCS devices for patients that have more advanced stages of CS.[5]

Listen to Dr. Nathan discuss evaluation and the heart team approach

IABP: the safe first-line MCS option

Article Number of patients Mortality Bleeding Stroke Vascular complications AKI
Dhruva 2019[8] 1680
Matched pairs
from NCDR*
Favors IAB
Absolute
difference 10.9%
Favors IAB
Absolute
difference 15.4%
NA NA NA
Amin 20199[9] 48,306
Premier database*
Favors IAB
p < 0.0001
Favors IAB
p = 0.045
Favors IAB
p < 0.0001
NA Favors IAB
p = 0.052
Wernly 2019[10] 588
Meta-analysis
from 4 RCT**
No difference
p = 0.38
Favors IAB
p = 0.002
No difference
p = 1.00
Favors IAB
p = 0.01
NA
Schrage 20191[11] 237
Matched pairs
from IABP-Shock II**
No difference
p = 0.64
Favors IAB
p < 0.01
NA Favors IAB
p = 0.01
NA

*Impella vs. IABP

**Impella vs. control (IABP and/or medical treatment)

Complications matter

 
No increased bleeding with IABP
Trial IABP No IABP
P value
CRISP AMI: major bleeding[12] 3.1% 1.7% 0.49
CRISP AMI: major vascular[12] 4.3% 1.1% 0.09
SHOCK II: moderate bleeding[13] 17.3% 16..4% 0.77
SHOCK II: major bleeding[13] 3.3% 4.4% 0.51
SHOCK II: major vascular[13] 4.3% 3.4% 0.53

Trial enrollment: CRISP AMI, n = 337; SHOCK II, n = 600

IABP therapy remains the predominant MCS device, a trusted, valuable first-line option[8], [9], [14]

References

  1. 1. L Khalid and S.H. Dhakam A Review of Cardiogenic Shock in Acute Myocardial Infarction. Curr Cardiol Rev. 2008 Feb; 4(1): 34–40.doi: 10.2174/157340308783565456

  2. 2. Atkinson TM, Ohman EM, O'Neill WW, Rab T, Cigarroa JE; Interventional Scientific Council of the American College of Cardiology. A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention: An Interventional Perspective. JACC Cardiovasc Interv. 2016 May 9;9(9):871-83. doi: 10.1016/j.jcin.2016.02.046.

  3. 3. Jones TL, Nakamura K, McCabe JM Cardiogenic shock: evolving definitions and future directions in management. Open Heart 2019;6:e000960. doi: 10.1136/openhrt-2018-000960

  4. 4. Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Cathe¬ter Cardiovasc Interv. 2019;94:29-37 DOI: 10.1002/ccd.28329

  5. 5. Gul et al. Usefulness of Intra=aortic Balloon Pump in Patients with Cardiogenic Shock, Am J Cardiol. 2019 Mar 1;123(5):750-756. doi: 10.1016/j.amjcard.2018.11.041.

  6. 6. Doll et al. A team-based approach to patients in cardiogenic shock. Catheter Cardiovasc Interv. 2016 Sep;88(3):424-33. doi: 10.1002/ccd.26297.

  7. 7. den Uil et al. Primary Intra-aortic Balloon Support versus Inotropes for Decompensated Heart Failure and Low Output: A Randomized Trial EuroIntervention 2019;15:586-593. DOI: 10.4244/EIJ-D-19-00254

  8. 8. Dhruva SS. Utilization and outcomes of Impella vs IABP among patients with AMI complicated by cardiogenic shock undergoing PCI. Published online ahead of print, 2020 Feb 10]. JAMA. 2020;10.1001/jama.2020.0254. doi:10.1001/jama.2020.0254

  9. 9. Amin AP, Spertus JA, Curtis JP, et al. The evolving landscape of Impella use in the United States among patients undergoing percutaneous coronary intervention with mechanical circulatory support. Circulation. 2020;141:273–284 doi.org/10.1161/CIRCULATIONAHA.119.044007

  10. 10. Wernly et al. Mechanical circulatory support with Impella versus intra-aortic balloon pump or medical treatment in cardiogenic shock-a critical appraisal of current data. Clin Res Cardiol. 2019 Nov;108(11):1249-1257. doi: 10.1007/s00392-019-01458-2.

  11. 11. Schrage et al. Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock Circulation. 2019 Mar 5;139(10):1249-1258. doi: 10.1161/CIRCULATIONAHA.118.036614.

  12. 12. Patel et al. Intra-aortic balloon counterpulsation and infarct size in patients with acute anterior myocardial infarction without shock: the CRISP AMI randomized trial JAMA. 2011 Sep 28;306(12):1329-37. doi: 10.1001/jama.2011.1280.

  13. 13. Thiele et al. Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med. 2012; 367:1287-1296 DOI: 10.1056/NEJMoa1208410.

  14. 14. Vallabhajosyula et al. Mechanical Circulatory Support-Assisted Early Percutaneous Coronary Intervention in Acute Myocardial Infarction with Cardiogenic Shock: 10-Year National Temporal Trends, Predictors and Outcomes EuroIntervention. 2019 Nov 19. pii: EIJ-D-19-00226. doi: 10.4244/EIJ-D-19-00226.