Cardiogenic Shock: Are We Finally Moving the Needle?

For the past 20 years, mortality for cardiogenic shock has been high (at around 50%) and without improvement. However, with new developments, there is hope that outcomes could improve for patients with cardiogenic shock.

The SCAI 2022 Scientific Sessions featured several exciting presentations dedicated to cardiogenic shock and focused on two promising aspects of shock care: the first on the dedicated shock teams and protocols, and the second on upcoming clinical trials.

Cardiogenic shock teams are multidisciplinary teams activated to guide the care of patients with refractory shock. Multiple single center and national studies have demonstrated survival benefit from implementation of such shock teams operating within formalized protocols. Shock teams are thought to improve care through more timely and appropriate use of mechanical circulatory support. Importantly, shock remains a highly complex clinical syndrome and care necessitates individualized care pathways. The goal of standardized protocols is not to limit care to an algorithm, but to ensure effective use of the available tools appropriate for the specific clinical picture.

An upcoming wave of clinical trials, many of which are still enrolling, will hopefully lead to improvements in shock care. Several were discussed at the SCAI scientific sessions. First, the door to unload (DTU-STEMI) trial is studying the impact of LV unloading with Impella in the care of patients with ST segment elevation myocardial infarction. Second, the ISO-Shock trial is studying the impact of super saturated oxygen in the treatment of patients with acute myocardial infarction and cardiogenic shock. And finally, CERAMICS is a trial formally studying the impact of protocols in cardiogenic shock.

In addition, there are also many other upcoming randomized controlled trials on the use of mechanical circulatory support (MCS) in cardiogenic shock: ECLS Shock and Euro Shock (VA-ECMO in acute myocardial infarction [AMI] with cardiogenic shock), ALTSHOCK-2 (intra-aortic balloon pump in heart failure with cardiogenic shock), and RECOVER IV (Impella in AMI with cardiogenic shock). The results from these trials will help guide decision making on how to use MCS in cardiogenic shock.

There is hope that we are now improving outcomes in cardiogenic shock. Shock teams and protocols are associated with improved survival, and a wave of new clinical trials will hopefully provide insight on how to improve the care of patients with cardiogenic shock.

1/2 #SCAI2022: “How to Integrate SCAI Stages into Cardiogenic Shock Management”⚡️💥… #TeamOfTeams @scai pic.twitter.com/RwfTkXPcS0

— Alex Truesdell (@agtruesdell) May 20, 2022

Final Analysis of the #NCSI presented today as @SCAI 25% Stage E shock. Reproducible across 80 US centers. #MCS #PAC #ShockProtocol #ShockTeam pic.twitter.com/7rQvnUqwI7

— Babar Basir (@Babar_Basir) April 28, 2021

References:

Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, Rosner C, Raja A, Barnett SD, Saulino P, deFilippi CR, Gurbel PA, Murphy CE, O’Connor CM. Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol. 2019 Apr 9;73(13):1659-1669. doi: 10.1016/j.jacc.2018.12.084. Erratum in: J Am Coll Cardiol. 2019 Jul 23;74(3):481. PMID: 30947919.

Papolos AI, Kenigsberg BB, Berg DD, Alviar CL, Bohula E, Burke JA, Carnicelli AP, Chaudhry SP, Drakos S, Gerber DA, Guo J, Horowitz JM, Katz JN, Keeley EC, Metkus TS, Nativi-Nicolau J, Snell JR, Sinha SS, Tymchak WJ, Van Diepen S, Morrow DA, Barnett CF; Critical Care Cardiology Trials Network Investigators. Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams. J Am Coll Cardiol. 2021 Sep 28;78(13):1309-1317. doi: 10.1016/j.jacc.2021.07.044. PMID: 34556316.

Basir MB, Kapur NK, Patel K, Salam MA, Schreiber T, Kaki A, Hanson I, Almany S, Timmis S, Dixon S, Kolski B, Todd J, Senter S, Marso S, Lasorda D, Wilkins C, Lalonde T, Attallah A, Larkin T, Dupont A, Marshall J, Patel N, Overly T, Green M, Tehrani B, Truesdell AG, Sharma R, Akhtar Y, McRae T 3rd, O’Neill B, Finley J, Rahman A, Foster M, Askari R, Goldsweig A, Martin S, Bharadwaj A, Khuddus M, Caputo C, Korpas D, Cawich I, McAllister D, Blank N, Alraies MC, Fisher R, Khandelwal A, Alaswad K, Lemor A, Johnson T, Hacala M, O’Neill WW; National Cardiogenic Shock Initiative Investigators. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019 Jun 1;93(7):1173-1183. doi: 10.1002/ccd.28307. Epub 2019 Apr 25. PMID: 31025538.