HFSA 2021: Management Considerations for HFCS

Jaime Hernandez-Montfort, MD, discusses management considerations for heart failure-related cardiogenic shock (HFCS). Dr. Hernandez-Montfort is the executive director of the advanced heart failure and recovery program at Baylor Scott & White Health in central Texas. He gave this presentation at the 2021 Heart Failure Society of America (HFSA) Annual Scientific Meeting.

Dr. Hernandez-Montfort shares a vision for advanced heart failure and recovery programs, which entails system-based protocols and a team-based management approach. He emphasizes the importance of invasive hemodynamic assessment in heart failure, citing data from The Cardiogenic Shock Working Group cohort demonstrating that complete invasive hemodynamic assessment was associated with improved survival across different SCAI stages of cardiogenic shock.

Dr. Hernandez-Montfort also explains that heart failure shock, like acute myocardial infarction (AMI) cardiogenic shock, is associated with increased mortality with escalating doses of inotropes and vasoactive drugs, noting that patients on these drugs require a time-sensitive cardiogenic shock team consultation. He describes standardizing utilization and dosing of inotropes and vasopressors as “a safety net of your program.”

He talks about processes to escalate advanced heart failure evaluations and the importance of the I-NEED-HELP algorithm, which, while obvious to heart failure specialists, is important for frontline intensive care and emergency medicine personnel to understand as it provides clarity on the risks posed by these surrogate markers of severity and assists in decision making for referral to advanced heart failure specialists.

I-NEED-HELP:

I: IV inotropes

N: NYHA IIIB/IV or persistently elevated natriuretic peptides

E: End-organ dysfunction

E: Ejection fraction ≤35%

D: Defibrillator shocks

H: Hospitalizations > 1

E: Edema despite escalating diuretics

L: Low blood pressure, high heart rate

P: Prognostic medication – progressive intolerance or down-titration of GDMT

Dr. Hernandez-Montfort concludes by reemphasizing the need for system-wide protocols and the importance of building bridges in advanced heart failure care. This can set expectations for transitions to native heart survival, heart replacement therapies, or early palliative care consultation.