Managing Cardiogenic Shock: A Case-Based Approach

Alex Truesdell, MD, and Michele Voeltz, MD, co-host this case-based discussion of cardiogenic shock management sponsored by the Society for Cardiovascular Angiography & Interventions (SCAI). “This is not your mother and father’s cath lab or ICU anymore,” Dr. Truesdell emphasizes, explaining that it is incumbent upon clinicians to increase their training on cardiogenic shock to meet the needs of this patient population.

Katherine Kunkel, MD, presents a complex case to frame this discussion. The patient presents with STEMI and his condition worsens requiring urgent intubation, insertion of Impella CP® heart pump, and VA ECMO. “This is the guy that doesn’t walk out of the hospital,” she explains. “This is the guy that if he goes to Hospital A, maybe he does OK, but if he goes to Hospital B, maybe he doesn’t. And that’s really one of the gaps that we need to seek to bridge so that we’re all on the same page.”

Benham Tehrani, MD, FSCAI, acknowledges the clinical gaps in knowledge for managing cardiogenic shock in his discussion of shock protocols, shock teams, shock centers, and shock networks. He highlights the ongoing efforts to standardize cardiogenic shock care through implementation of dedicated shock teams with protocols that are easy to understand, easy to follow, and easy to implement and reproduce. He expresses hope that studies currently underway, such as the DanGer Shock trial and RECOVER IV, will soon provide data to inform clinical practice as well as guidelines.

Reshad Garan, MD, discusses patient trajectories, including right ventricular failure, escalation, and futility. He emphasizes the importance of using PA catheters for early recognition of RV failure and explains that RV function typically recovers well when supported early. He discusses the importance of early escalation in patients with biventricular failure. Dr. Garan also addresses the ability to recognize and avoid the “bridge to nowhere,” when no durable destination exists for patients and mechanical circulatory support (MCS) is more likely to prolong the dying process than provide a chance of survival. 

Timothy D. Smith, MD, FACC, FSCAI, discusses the importance of quality of care and best practices for managing shock in the cardiovascular ICU. He also points out that early recognition is key to survival in cardiogenic shock, emphasizing that if you don’t have the resources to care for shock patients, it is important to recognize it, stabilize the patient, and transfer the patient to a Level 1 or quaternary center. He describes the shock team at his institution and emphasizes “hemodynamics are absolutely dynamic and must be trended” when caring for shock patients.