How Can Management of Cardiogenic Shock Be Improved?

Elevating patients with cardiogenic shock (CS) to mechanical circulatory support (MCS) early on could yield greater reductions in mortality due to CS, as opposed to the strategy of managing patients with medical therapies before escalating to MCS, according to a new review. 

“We haven’t really moved the needle in terms of mortality in the last 30-40 years,” senior author Phyllis Billia, MD, PhD, associate professor of medicine at the University of Toronto, Toronto, Ontario, Canada, and director of the Mechanical Circulatory Support program at the Peter Munk Cardiac Center in Toronto, told Medscape Medical News. “Even though we’ve come up with different ways to treat shock, and we have had clinical trials in shock, the end result is that we’re still having high mortality.”

In their review, the investigators cited multiple sources that have estimated the rates of acute mortality at between 30% to 50%. 

The data were published on January 9 in the Canadian Journal of Cardiology.

Early Recognition

The standard approach to CS management, or what authors described as the “escalate” approach, is a stepwise progression of treatments that first involves administering medications and assessing their impact before considering MCS, explained Billia. The key to the success of the proposed approach is the early identification of CS in presenting patients, she added.

The idea is that identifying patients early can enable the termination of the inflammatory cytokine storm. “If you can identify [patients] early and start MCS early, then you may be able to shorten the treatment time, so that in the long run, intensive care unit stays are shorter. The patients get to their definitive management, whatever that happens to be,” said Billia. 

Early symptoms that suggest CS include low blood pressure, cold and clammy skin, and altered level of consciousness, she added. “There are certain things when you first see the patient that tell you we’re in trouble.” 

The population of patients who present with CS has changed because of the efficacy of medications to treat patients with myocardial infarction (MI), said Billia. Previously, most patients who presented with CS were post-MI patients, but they increasingly tend to be patients with chronic heart failure. 

MCS can be a bridge to recovery, to another technology that provides extended MCS, or to heart transplantation, explained Billia. If the prognosis is poor, then the next step is palliative care.

If the plan is to bridge the patient to transplantation, then the choice of MCS must be robust enough to sustain the possible wait for an organ, added Billia. A clinical trial designed as a registry, case-control study would likely be suitable to demonstrate the viability of the “elevate” management approach to CS, she said. 

Call to Arms

Shelley Hall, MD, chief of transplant cardiology, MCS, and advanced heart failure at Baylor, Scott, and White Health in Dallas and president of the Texas Chapter of the American College of Cardiology, Austin, Texas, said that the paper represents the direction in which CS management is headed.

“It’s a call to arms to our community that we get back to the basics, which is early recognition and then early elevation, which I think we all agree upon,” said Hall. “It is a statement that the community can get around. Do I think this will change behaviors? While I hope so, probably not, due to many hurdles we cannot control.”

A barrier to the implementation of the proposed approach to hasten initiation of MCS is that many hospitals are not sufficiently equipped to initiate MCS, according to Hall. 

“These are high-resource utilization patients,” she said. “It’s easy to say to do this in a tertiary hospital like mine, where we have all the bells and whistles and we can pull out all the stops if we need to. That is not the majority of healthcare out there. Most of healthcare is limited in what devices they have. They are lucky if they have anything above a balloon pump, which we already know is ineffectual for most CS.”

Moreover, many hospitals are overcrowded, and conditions do not favor the early identification of patients with, said Hall. “Patients are in the emergency rooms for hours, and there are delays. They are not usually recognized early, and it is not until they are crashing and need to be moved into the intensive care unit that it is recognized that they have been in or are going into CS.”

The data review was conducted without external funding. Billia and Hall reported having no relevant financial relationships.