Advanced Cardiogenic Shock Programs a Good Match for Sickest Patients, Study Finds

There was a survival advantage to having hospitals with mechanical circulatory support (MCS) escalation capabilities treat people with acute myocardial infarction with cardiogenic shock (AMICS), according to registry data.

In these very sick individuals treated at so-called “CERAMICS” centers with such an ability to upgrade MCS devices — going from left-side support with the Impella 5.5, say, to right ventricular (RV) MCS, then all the way to extracorporeal membrane oxygenation (ECMO) — 71% survived to hospital discharge.

In particular, survival reached 67.7% for people in the most severe stage E shock at these CERAMICS-eligible hub hospitals, which was an improvement over the 50% rate of survival to discharge (P=0.05) observed in the larger landscape of hospitals with cardiogenic shock programs meeting criteria from the National Cardiogenic Shock Initiative (NCSI).

“Stage E patients enrolled in CERAMICS had improved survival compared to those in NCSI, suggesting such patients may benefit from the care of hospitals capable of MCS escalation,” reported Mir Babar Basir, DO, of Henry Ford Health in Detroit, at the Society for Cardiovascular Angiography & Interventions (SCAI) annual meeting held in Montreal.

Meanwhile, for patients in stage C/D shock, survival was 75.7% at these CERAMICS-participating hospitals, about the same as the 79.4% with NCSI centers, suggesting that these patients should present to the closest MCS-capable hospital.

“Early recognition and protocol-driven care are central to improving survival in patients with shock,” said Basir in a statement. “Most stage C and D shock patients can be successfully treated at local PCI [percutaneous coronary intervention]-capable hospitals, ensuring patients get care quickly, close to home. However, the sickest patients benefit from timely transfer to centers with advanced MCS capabilities. After decades of limited progress, it’s encouraging to see this shock-care approach delivering real improvements for patients.”

There were 20 U.S. CERAMICS hospitals in the study deemed capable of MCS escalation. Eighteen of these sites had already adopted the NCSI treatment algorithm, an initial program for team-based protocolized care in AMICS that emphasizes rapid placement of Impella MCS, PCI, and invasive monitoring of hemodynamics.

Basir and colleagues took the NCSI shock protocol a step further with their CERAMICS MCS escalation strategy.

The premise is that approximately 30-40% of patients with AMICS have concomitant RV failure, which is associated with worse morality and may therefore benefit from consideration of early RV MCS. “There were concerns with the [original] cardiogenic shock initiative in the sense that it included study or sites that had limited ICU [intensive care unit] capabilities and limited capabilities of MCS escalation,” Basir noted during a press conference at SCAI.

“The data suggest that patients do just as well being treated in their local communities first and then needing escalation or utilizing escalation strategies as needed,” he concluded.

Basir said the next phase of research is to expand a similar shock protocol to international sites.

For the present retrospective study, the authors screened 325 AMICS patients from 2022 to 2025 and identified 124 for their analysis. Patients were most commonly excluded for having an intra-aortic balloon pump for their primary MCS (n=64), CPR lasting over 30 minutes (n=59), and unwitnessed arrest (n=32).

In the 124 CERAMICS patients included study cohort, shock was present on admission in 83.1% of cases, with stage C/D shock observed in 61.3%. Nearly 90% had a ST-segment elevation MI (STEMI), and 18.5% had received support prior to the hospital transfer. In a comparator group of 406 patients enrolled in NCSI hospitals, shock was present in 66.7% of cases, stage C/D shock in 70.4%, a little over 80% had STEMI, and 16.5% had received support prior to hospital transfer.

Compared with NCSI, patients in CERAMICS centers were older and more likely to present in stage E shock (38.7% vs 29.6%).

On average, CERAMICS patients received MCS within about 76 minutes of arriving at the hospital and had door-to-balloon times within 72 minutes.

The number of AMICS patients meeting hemodynamic criteria for MCS escalation — having RV dysfunction, need for more than two vasoactive agents, or a cardiac power output reading under 0.6 W — came out similar between NCSI centers and CERAMICS centers. This was about 50% post-PCI and at 12 hours and about 35% at 24 hours, study authors reported.

Escalation of MCS was approximately doubled in CERAMICS centers (22% vs 10%, P=0.05); this was evident when it came to upgrades to ECMO, for example (15.3% vs 7.6%).