Algorithms, Clinical Research & Data, AMI Cardiogenic Shock
NCSI to RECOVER IV
Babar Basir, DO, FACC, FSCAI, discusses the reproducible and consistent results seen with use of the National Cardiogenic Shock Initiative (NCSI) protocol and looks ahead to proving these concepts to the rest of the medical community in the RECOVER IV trial. He gave this presentation at the 2022 SCAI Scientific Sessions.
NCSI is the largest prospective North American study of acute myocardial infarction (AMI) cardiogenic shock in the past 2 decades, recruiting the sickest cohort of patients, including 25% who were in SCAI Stage E shock. Key aspects of the protocol include using hemodynamic support early, minimizing use of vasopressors and inotropes, and routinely using right heart catheterization (RHC).
“When you diagnose and think of cardiogenic shock, you should be thinking about hemodynamic support, because these patients are actively having end-organ dysfunction, and so the idea of moving and treating these patients early is of critical importance,” Dr. Basir explains. “We know from multiple studies now that intra-aortic balloon pump is ineffective in AMI cardiogenic shock.” Basir explains not only does IABP fail to provide enough support in cardiogenic shock, but the use of IABP delays more effective treatment and patients therefore tend to be sicker by the time support is escalated.
Dr. Basir provides a brief overview of what following the NCSI protocol looks like. “What we do is we take these patients directly to the [cath] lab, confirm the diagnosis, put in hemodynamic support device, revascularize them, and then do a right heart catheterization to really understand where they are hemodynamically.” He explains that they can then assess patient needs and ask key questions such as: Is an Impella CP® enough? Do we need right-sided support? Do we need escalation of support? What’s our vasopressor and inotrope dosing?
“We have to realize that the support device is the actual treatment,” Basir emphasizes. “You’re not delaying care for these patients. You’re actually treating them.” He explains that a support device is a strategy for treating large AMIs, multivessel coronary artery disease, patients with underlying cardiomyopathies, and prolonged cardiac arrest. “All of them benefit from advanced hemodynamic support devices.” In addition, he emphasizes, “When you actually think of the support device as the treatment, I think it’s easier to overcome the challenges and discussions about door-to-balloon times with your colleagues.”
Looking ahead, Dr. Basir explains that right-sided failure is still undertreated. “Some of us are OK putting in an Impella CP, and really reluctant to put in a large-bore venous access support device. And I think that really has to change. 40% of AMI cardiogenic shock patients have concomitant right ventricular dysfunction. In NCSI, that was associated with an absolute worse mortality of about 14%. That’s a lot of lives that we can save.”
Dr. Basir looks ahead to the CERAMICS and RECOVER IV trials. CERAMICS (Can Escalation Reduce AMI Mortality in Cardiogenic Shock) is an extension of NCSI looking at escalation when patients don’t meet certain hemodynamic parameters. RECOVER IV is an upcoming trial for which the protocol is still in development.