Escalation Therapy, Hemodynamics, Patient Management, AMI Cardiogenic Shock
Best Practices for Identifying and Managing AMI Cardiogenic Shock
This video reviews cardiogenic shock guidelines and best practices for identifying, stabilizing, revascularizing, and reassessing high-risk cardiogenic shock patients. Cathy Axberg, an advanced Impella® trainer with Abiomed, presents these guidelines as part of an ongoing educational effort to help hospitals, physicians, and clinical staff provide individualized patient care and improve outcomes.
The first page of the guidelines summarizes key best practices:
Identify patients with suspected cardiogenic shock and activate the cath lab
Stabilize early with Impella® heart pump support prior to PCI and minimize use of inotropes and pressors
Revascularize, per guidelines
Assess for myocardial recovery and wean, escalate care, or initiate transfer to another facility
Identification. Evaluate the criteria for shock, including: systolic blood pressure (SBP) <90 mmHg for more than 30 minutes; inotrope/vasopressor support and/or IABP to maintain SBP >90 mmHg; and end-organ hypoperfusion markers, such as decreased urine output and serum lactate >2 mmol. Best practices for confirming the diagnosis of cardiogenic shock include STEMI/non-STEMI, ECG ST-segment abnormalities, troponin levels, echocardiography to assess cardiac function, and PA catheter data, if available to determine if cardiac index (CI) is less than 2.2 L/min/m2 and pulmonary capillary wedge pressure (PCWP) is greater than 15 mmHg.
Stabilization and Revascularization. Obtain and evaluate peripheral vascular access for consideration of mechanical circulatory support (MCS). Other best practices for the interventional team in the cath lab include assessing hemodynamics, placing Impella if appropriate, and weaning catecholamines once the patient is on Impella support. If the patient is having an acute MI, proceed with coronary angiography and PCI. If not done already, place a PA catheter for comprehensive reassessment of hemodynamics.
Recovery Assessment. Prior to discharge from the cath lab, reassess hemodynamics via PA catheter. Best practices include measuring cardiac power output (CPO) and pulmonary artery pulsatility index (PAPI) to evaluate the adequacy of left-sided Impella support and right heart function. If, for example, CPO is <0.6 despite left-sided Impella, and PAPI <1, consider right-sided support with the Impella RP® heart pump and, if there is persistent hypoxia, consider V-A ECMO or V-V ECMO with Impella LV support at low speed to unload the left ventricle. If CPO is >0.6 and the RV is preserved, admit the patient to the ICU to maximize supportive care and actively assess for myocardial recovery.
The AMI cardiogenic shock guidelines also present criteria for ongoing patient assessment for myocardial recovery and weaning. If patients meet the criteria for myocardial recovery, wean and explant Impella after a minimum of 48 hours. If recovery is inadequate or there are no signs of recovery in the first 48 to 72 hours, consider escalation of care or transfer.