Cardiogenic Shock in Older Adults: Key Points

Blumer V, Kanwar MK, Barnett CF, et al., on behalf of the American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Council on Cardiovascular Surgery and Anesthesia.
Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association. Circulation 2024;Feb 26:[Epub ahead of print].

The following are key points to remember from an American Heart Association Scientific Statement on cardiogenic shock (CS) in older adults, which focuses on age-associated risks and approach to management:

  1. Age is a risk factor for poor prognosis in CS, though evidence is lacking for best management strategies in the older adult population. It is challenging to define what patients should be considered older adults, as chronological age by itself does not fully reflect a patient’s geriatric conditions.
  2. Comprehensive risk assessment of CS in older adults requires an interdisciplinary approach that factors in individual patient characteristics, overall clinical trajectory, and capabilities of the treating health care center. This informs shared decision making and advance care planning, which is critical for care of older adults.
  3. Older adults with CS have variable presentations and a high index of suspicion is required to provide adequate care. As with the general CS population, early recognition and initial stabilization is key to address abnormal hemodynamics, poor perfusion, and multiorgan dysfunction.
  4. Invasive mechanical ventilation and renal replacement therapy are often needed during CS management, although they are associated with potential risk and complications in the older adult population. Shared decision making and identifying care preferences are important when initiating these therapies and should be periodically re-assessed.
  5. In acute myocardial infarction–CS in the older adult population, percutaneous or surgical revascularization can be considered. Decision making should include consideration of age-associated risks and burden of geriatric syndromes.
  6. For older adults with valvular heart disease (e.g., aortic stenosis, aortic regurgitation, mitral regurgitation) contributing to CS, transcatheter and surgical options can be considered based on patient preferences, patient-specific risk, and procedure-specific risk.
  7. When considering temporary mechanical circulatory support (t-MCS), a discussion among the heart team should consider the contraindications to advanced HF therapies. There should be a clear goal or exit strategy to get off t-MCS and plan to minimize device-related complications.
  8. When considering durable left ventricular assist device therapy in older adults, attention should be paid to comorbidity burden, end-organ dysfunction, frailty, malnutrition, and degree of caregiver support.
  9. The International Society for Heart and Lung Transplantation guidelines recommend considering heart transplantation (HT) in patients ≤70 years of age (Class I). HT can also be considered in carefully selected patients ≥70 years of age (Class IIb). Post-transplant survival may be affected by burden of geriatric syndromes and illness severity/complications associated with CS.
  10. Early palliative care consultation is helpful for older adults with CS regardless of severity of CS.
  11. Future work is needed to better understand what subset of older adults with CS benefit most from aggressive therapy options, enhance representation of older adults in clinical trials, and create meaningful endpoints for clinical studies.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Geriatrics, Shock, Cardiogenic

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