Patient Management, AMI Cardiogenic Shock
A Contemporary Survey of Cardiogenic Shock Management Practices
Emmanouil Brilakis, MD, PhD, FACC, discusses results from a survey of contemporary cardiogenic shock management practices. Dr. Brilakis is the director at the Center for Complex and Coronary Interventions at the Minneapolis Heart Institute.
As senior author of “Cardiogenic Shock Management: International Survey of Contemporary Practices” recently published in Journal of Invasive Cardiology, Dr. Brilakis explains that the purpose of the survey was to look for opportunities for practitioners to standardize cardiogenic shock care to get the best outcomes for patients.
The survey was sent to a diverse group of physicians and 64% of the 211 respondents were interventional cardiologists. “Almost half of the respondents actually do not have advanced heart failure or other major resources,” Dr. Brilakis explains, “so the reality is that many of those shock patients get treated by centers who are not necessarily fully equipped to handle the full breadth and complexity of some of those patients.”
One of the results that surprised Dr. Brilakis was that only about half (55%) of the respondents had an established cardiogenic shock algorithm or protocol—"a protocol, which we now know more and more,” he emphasizes, “is critical to get the best outcome for those patients.”
Dr. Brilakis was also surprised to find that only 25% of respondents routinely used pulmonary artery catheters. “So this is another area that I think there is room for improvement,” he notes. “Use of more invasive hemodynamics to manage those patients can be useful.”
A third surprising finding was that only 21% of respondents stated that they had completely stopped using IABP for cardiogenic shock and moved to Impella®, a finding that Dr. Brilakis attributes to the availability of the devices and experience with the devices at the respondents’ institutions.
Regarding use of mechanical circulatory support (MCS), the survey found that 45% of respondents consider MCS when response is not optimal with 2 vasopressors and 43% consider MCS based on PAC measurements of cardiac output or cardiac power. Impella was the preferred device in 48% of respondents, IABP in 44%, and veno-arterial (V-A) ECMO in 8%. MCS was initiated before PCI in 44% and its initiation was dependent on hemodynamics. In addition, when revascularization was needed, 72% performed culprit-lesion only revascularization and in patients presenting with STEMI and CS, 66% initiated MCS with Impella, ECMO, or IABP prior to performing revascularizations.
“For me, the number one thing right now is education,” Dr. Brilakis states, emphasizing the needs for understanding how essential it is to use a Swan-Ganz in every patient with cardiogenic shock and the importance of early intervention with hemodynamic support.
Dr. Brilakis concludes by mentioning the need for additional formal randomized trials in the areas of advanced hemodynamic support devices in the setting of cardiogenic shock, routine LV unloading in patients on V-A ECMO, and more standardized approaches to diagnosing and treating cardiogenic shock patients as well as which devices to use in which patients to get the best possible outcomes.