Management of Cardiogenic Shock: AHA Scientific Statement
- van Diepen S, Katz JN, Albert NM, et al., on behalf of the American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline.
- Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017;Sep 18:[Epub ahead of print].
The following are summary points from the American Heart Association Scientific Statement on Contemporary Management of Cardiogenic Shock (CS):
- Before the routine use of early revascularization, myocardial infarction (MI)-associated CS had an in-hospital mortality exceeding 80%, but after the advent of revascularization, the mortality is 27-51% (mortality remains high).
- The common physiological characteristic among all phenotypes is a low cardiac index (CI), but ventricular preload—pulmonary capillary wedge pressure (PCWP) or central venous pressure, volume, and systemic vascular resistance—may vary. The classic “cold and wet” profile (a low CI, an elevated systemic vascular resistance, and a high PCWP) is the most frequent CS phenotype, accounting for nearly two thirds of patients with MI-associated CS. In addition to the classic types of CS, there are two uncommon but hemodynamically distinct entities of normotensive CS (systolic blood pressure >90 mm Hg) and right ventricular (RV) CS. The study authors suggest that all patients with CS be evaluated with an electrocardiogram, chest x-ray, and comprehensive echocardiogram with the specific purpose of understanding the dominant mechanism responsible for acute hemodynamic instability.
- There is a direct relationship between adjusted in-hospital mortality and hospital volume. According to a study from the Nationwide Inpatient Sample, mortality was 37%, 39.3%, 40.7%, and 42% in hospitals that treated ≥107, 59-106, 28-58, and <27 cases per year (p < 0.05). Therefore, the authors suggest that establishing systems of care with high-volume hospitals used as hubs integrated with emergency medical systems and spoke centers with clearly defined protocols for early recognition, management, and transfer has the potential to improve patient outcomes.
- The authors recommend an early revascularization strategy (either percutaneous coronary intervention or coronary artery bypass grafting) for all suitable patients with suspected acute coronary syndrome–associated CS, including patients with uncertain neurological status or those who have received prior fibrinolysis, regardless of the time delay from MI onset. When an early invasive approach cannot be completed in a timely fashion, fibrinolysis can be considered in CS associated with ST-segment elevation MI.
- Pulmonary artery catheterization (PAC) remains a potentially important diagnostic and management tool for CS. Hemodynamic data provided by a PAC can confirm the presence and severity of CS; involvement of the RV, pulmonary artery pressures, and transpulmonary gradient; and vascular resistance of the pulmonary and systemic arterial beds.
- Norepinephrine is associated with fewer arrhythmias and may be the vasopressor of choice in many CS patients.
- Temporary over durable mechanical circulatory support (MCS) as a first-line device should be considered when immediate stabilization is needed to enable recovery of the heart and other organ systems. Intra-aortic balloon pump can be considered in patients with CS with acute mitral regurgitation or a ventricular septal defect, and it can be considered in select patients with profound CS when other MCS devices are not available. Veno-arterial extracorporeal membrane oxygenation (ECMO) may be the preferred temporary MCS option when there is poor oxygenation that is not expected to rapidly improve with an alternative temporary MCS device or during cardiopulmonary resuscitation.
- Long-term durable MCS devices can be considered primary devices in patients with CS who are not likely to recover without long-term MCS support, have the capacity for meaningful recovery, and do not have irreversible end-organ dysfunction, systemic infections, or relative contraindications to durable MCS implantation.
- All patients being evaluated for MCS implantation should concurrently be assessed for transplantation.
- The benefits and limitations of palliative care in patients with CS should be discussed.
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