Fellows Course: Contemporary Insights into Cardiogenic Shock and STEMI

 

Navin Kapur, MD, FAHA, FACC, FSCAI, shares contemporary insights into cardiogenic shock and STEMI management, highlighting classification systems and algorithms, as well as clinical data and best practices for managing cardiogenic shock. Dr. Kapur is an interventional cardiologist and advanced heart failure specialist as well as the executive director of the Cardiovascular Center for Research & Innovation at Tufts Medical Center in Boston. This discussion was part of Abiomed’s MCS & Complex Coronary Intervention virtual fellows course held on September 26, 2020.

Dr. Kapur highlights the following key messages throughout the video:

  • RV dysfunction is more common than we think in the setting of cardiogenic shock
  • Importance of monitoring metabolic parameters, notably lactate, as well as hemodynamic parameters such as cardiac power output (CPO)
  • Futility of escalating inotropes/vasopressors
  • Need for more mechanistic insight into the hemodynamic effects of ECMO combined with Impella® heart pump
  • Importance of hemodynamically driven algorithms for improved survival in MI cardiogenic shock
  • Critical importance of selective and appropriate use of PA catheters to improve survival in cardiogenic shock

Dr. Kapur discusses the importance of hemodynamic variables, such as cardiac index (CI) and pulmonary capillary wedge pressure (PCWP), for identifying patients at high risk of mortality from cardiogenic shock. He presents the SCAI staging system for cardiogenic shock and discusses data validating the SCAI stages as well as the need for specific and uniform definitions for each SCAI stage for myocardial infarction cardiogenic shock and heart failure associated cardiogenic shock.

“What we’re learning in our critical care pathways,” Dr. Kapur explains, “is that the sooner we can start removing volume from these patients with hemodynamic support on board, then the more likely we’re able to stabilize and recover these patients.” 

Dr. Kapur describes the upcoming RECOVER IV randomized controlled trial, which will implement best practices for managing cardiogenic shock. “And that means providing early support, pre-PCI support, hemodynamic guidance, having a strategy for escalation, and then also making sure we have vascular safety strategies as well, to mitigate any of those complications related to MCS use.” He also discusses the STEMI door-to-unloading (DTU) pilot and pivotal studies, noting, “it’s very important to understand that LV unloading and delayed reperfusion reduces ischemia the moment you start to unload the heart and starts to attenuate that likelihood for reperfusion injury.” 

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