Algorithms, Case Review, Patient Management, AMI Cardiogenic Shock
AMI Cardiogenic Shock Management with NCSI Study Algorithm
Inder Singh, MD, MS, presents a case study of a patient with AMI cardiogenic shock who was successfully treated following the National Cardiogenic Shock Initiative (NCSI) Study algorithm. Dr. Singh is an interventional cardiologist at Dignity Heart & Vascular Institute in Sacramento, California.
Dr. Singh describes a 75-year-old male presenting with anterolateral STEMI who was treated with thrombolytics prior to transfer to cath lab. The patient experienced VF arrest upon arrival in the cath lab. He was resuscitated and intubated, but clearly in shock.
Dr. Singh evaluated the patient with respect to a cardigonic shock algorithm and the patient met the inclusion criteria with EKG evidence of AMI (STEMI), hypotension (BP 80/41 mmHg) on Levophed™ and NEO-SYNEPRHINE upon arrival to cath lab, and evidence of end organ hypoperfusion (elevated lactate of 8 mmol/L).
Dr. Singh evaluated femoral access for placement of Impella pre-PCI using ultrasound guidance and micropuncture for access. Left ventriculogram revealed clear evidence of massive anterolateral STEMI with significantly compromised LV function (LVEF ~20%, LVEDP very high at 28 mmHg). Placing a PA catheter to better understand patient hemodynamics, Dr. Singh saw no evidence of right-side dysfunction. CPO was 0.5 watts. PAPi of 1.75 confirmed that the right side was doing OK.
Following the NCSI Study protocol, Dr. Singh placed the Impella CP® heart pump pre-PCI, affording him the stability and time to comprehensively treat the patient with laser atherectomy and true bifurcation PCI. Following the procedure, he used the Impella CP with SmartAssist™ to trend CPO and he monitored serial lactates, a very useful parameter in cardiogenic shock.
Continued PA cath, serial lactate, and CPO monitoring allowed objective evaluation and management, helping Dr. Singh wean the patient off pressors and Impella support. At about Day 2, Dr. Singh ordered an echo with Impella support at P-2, which showed LVEF had improved from 20% to 30%. Within a few hours the patient was weaned off Impella. Baseline CPO of 0.5 watts had improved to 1.04 watts at explant. Lactate (baseline 8 mmol/L) had normalized to 0.8 mmol/L at explant. The patient was expeditiously discharged on Day 4 with excellent heart recovery and normal LVEF (60%) at 6 weeks.
With regard to use of the NCSI Study algorithm to expedite patient management at his community hospital, Dr. Singh explains that after a year of using the algorithm, they have found it to be simple and objective. They appreciate that it has been validated across multiple centers. Most notably, he explains, it really improves outcomes. Outcomes at his hospital have improved into the 80% survival range since adopting the protocol, a notable improvement over the 50% or higher mortality seen nationwide for patients with cardiogenic shock. “We owed it to our patients to adopt a robust algorithm,” Dr. Singh explains, noting that it has been a “very fruitful journey with this protocol for us.”