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Tips to Build a Cardiogenic Shock Team
Cardiogenic shock mortality has not declined in 30 years, but progress is being made with a shock-team approach.
In the United States in 2018, we are blessed to have a massive, well-organized infrastructure to allow rapid, safe access to PCI therapy for STEMI. More than 1,000 acute care facilities offer emergency reperfusion therapy. The U.S. overall mortality for patients with STEMI not in cardiogenic shock has dropped from 12% to 14% to 2% to 3% with this therapy. Thus, more than 20,000 U.S. patients with STEMI have their lives saved each year.
All health care providers providing STEMI care must be proud of this accomplishment, but we must be sobered by the lack of progress in dropping mortality in patients with acute MI with cardiogenic shock (AMICS). Pioneering work done in Aachen, Germany, and Ann Arbor, Michigan, in the mid-1980s demonstrated that balloon angioplasty could drop cardiogenic shock mortality from 90% to 50%. Unfortunately, there has been no progress in improving outcomes for AMICS since then.
In the past year, a large German AMICS trial showed 40% to 50% mortality in these patients. Karl Heinrich Scholz, MD, head of the department of cardiology at St. Bernward Hospital in Hildesheim, Germany, and colleagues reported an extraordinary time dependency for survival in the FITT-STEMI trial. This was a prospective registry of 48 German hospitals with 24/7 STEMI care who treated 699 patients with AMICS from 2006 to 2015. Although in-hospital mortality was 3.7% for the 10,776 patients not in shock, it was 39% for the patients with AMICS. Importantly, mortality was highly dependent on time to therapy. For patients in shock who were treated within 1 hour, mortality was 20%, whereas it was 80% for patients treated at 6 hours for onset of shock. The FITT-STEMI experience demonstrates that rapid identification and treatment of AMICS is essential to improve survival (See Figure).
Importance of the Shock Team
Although it sounds simplistic, to treat cardiogenic shock, you have to treat shock. The longer the shock state exists, the worse end-organ hypoperfusion, ischemia and acidosis become. Frequently, the myocardium can be salvaged with reperfusion only to have the patient succumb to renal failure, liver failure and bowel or brain ischemia. The FITT-STEMI data demonstrate that, like traumatic or hemorrhagic shock, a “golden hour” for care exists for AMICS. This is why having a shock team in place is so important.
In April 2016, the FDA approved a percutaneously delivered microaxial, transvalvular mechanical circulatory support device (Impella 2.5, Impella CP, Impella 5.0 and Impella LD; Abiomed) for use in AMICS. This device has enormous promise to revolutionize the care of AMICS, just like PCI for STEMI has done. Our team has reported a 76% survival-to-discharge rate in the Detroit Cardiogenic Shock Initiative. This prospective, multicenter registry was organized around the concept of inviting highly experienced users of mechanical circulatory support to rapidly identify patients presenting in AMICS. These patients are taken immediately to the cath lab, supported with mechanical circulatory support, had PCI of culprit vessel(s) and placement of a Swan-Ganz pulmonary artery catheter to determine the ability to wean or escalate support. These data were used to manage the level of support and, ultimately, timing of device removal.
Based on the impressive results in Detroit, a National Cardiogenic Shock Initiative has been launched. Currently, 45 U.S. centers will be prospectively enrolling all patients with AMICS treated with mechanical circulatory support in the form of the Impella devices.
Essential Characteristics
Based on our 2-year experience with the Detroit and national shock initiatives, we have identified a series of characteristics that are likely to be associated with high rates of survival. We will describe the elements we are looking for in AMICS centers of excellence. In essence, these elements can be used as a blueprint for developing a center of excellence and an AMICS team (see Table).
Elizabeth H. Bradley, PhD, now president of Vassar College, and colleagues have identified the presence of an institutional champion as the most powerful predictor for a hospital to achieve excellent door-to-balloon times in STEMI care. We believe an institutional champion is even more essential to a shock team to instill the goal of a shortened door-to-support time in patients with cardiogenic shock. This individual may be an emergency medicine physician, a general cardiologist, an invasive cardiologist or a left ventricular assist device and transplant surgeon. All these disciplines at some point need to be involved in the team. But ultimately, one person must spearhead the process, set institutional goals and review outcomes to see where improvement can be made.
Before an institution embarks on developing a shock program, it must have a sufficient volume of AMICS cases. Ideally, centers should treat at least 10 patients with AMICS per year. This allows maintenance of physicians’ implant skills and ICU nursing skills for management of the device.
If insufficient volume exists, protocols for transfer to regional centers should be developed, following a hub-and-spoke model. Henry Ford Health System functions as a hub-and-spoke model with Henry Ford Hospital in Detroit and five regional hospitals across southern Michigan. Similarly, large referral centers should develop hub-and-spoke models to align smaller hospitals with their institution.
Strategies for Indentification, Action
Members of our shock team have been meeting with interventional cardiologists and their teams at the regional hospitals, sharing our data and protocol and asking them to voluntarily use it. Our physician outreach coordinator also helps coordinate meetings with referring physicians. The main goal of all this outreach is education about how to handle a patient in shock. One main question is when to send a shock patient to a larger institution and when to treat a shock patient locally. The economics of AMICS care with Impella provides a positive margin for both receiving and transferring institutions, so that should not influence the decision-making process. But much goes into the medical decisions once shock is identified.
Emergency medical services (EMS) must be part of the equation, too. Members of our shock team have met with regional EMS providers to educate on the characteristics of shock and ensuing treatment. We’ve educated on the transfer of patients from a spoke hospital to a hub hospital that have mechanical circulatory support devices with large-bore access, including the use of a leg immobilizer. We’ve found that members of the EMS community have been willing partners.
To optimize shock outcomes at the treating facilities, the AMICS team must be activated in a sequential, organized manner. Some may want to enlist the help of the Admission Transfer Management Office to establish an approach. First, ED physicians must rapidly identify potential patients with AMICS, or verify if EMS has provided early identification. Noncardiac cases of shock must be rapidly excluded. Aortic dissection, cardiac tamponade, tension pneumothorax, hemorrhagic and septic shock need to be considered. The ED staff should have rapid, early consultation with the invasive cardiologist so that a triage plan can be outlined. Most importantly, an institutional goal for door-to-support time should be less than 90 minutes to provide early resuscitative care.
Strong Internal Team
Building an internal shock team is personalized to each hospital, looking at who is willing and able to support the initiative. The right experience for the treating team is imperative. The invasive cardiologists must have familiarity with large-bore femoral access and closure. They must have skills with ultrasound- or fluoroscopy-guided puncture of the femoral artery, gaining experience by using the device in elective cases. Of equal importance, an understanding of hemodynamics with focus on cardiac power output and right heart function (pulmonary artery pulsatility index or central venous pressure/pulmonary capillary wedge pressure ratios) is essential for postoperative management. Plus, the shock-team champion should reach out to the cath lab staff to ensure they understand and can support the protocol of treatment.
Those managing the patient in ICU or cardiac care unit also become an integral part of the shock team. Physicians and nurses who provide care in the intensive care setting must be familiar with the equipment and devices used. The device may wander — often it gets pulled into the left ventricle — and it may need to be repositioned. In addition, close attention needs to be paid to the perfusion of the instrumented leg. Limb ischemia can be life-threatening.
Early on in our team building at Henry Ford Hospital, we involved one of the lead techs in the cath lab. He was involved in all cardiogenic shock cases that came in the door. As a result, he became an early adopter of best practices with our patients with cardiogenic shock. As the initiative expanded, we tapped his expertise to educate other techs, nurses and staff in the cath lab and the cardiac care unit, visiting different shifts to discuss things like how to move patients with mechanical circulatory support and best practices on postprocedure management of the mechanical circulatory support in the unit. He became a source of great support for ongoing care of patients with AMICS and mechanical circulatory support.
Actions in the ICU
Once the patient reaches the ICU, consultation with HF teams and VAD surgeons must occur. If the patient is doing well, timing of device explant and further follow-up care can begin to be organized. More importantly, if the patient is not doing well, discussions need to occur about level of aggressiveness. This must take into account patient and family wishes. If an aggressive approach is chosen, the team must figure out why the patient is not improving. Right HF may require right ventricular support devices. The mechanical circulatory support may not be providing adequate power, and escalation to Impella 5.0 or a combination of Impella and extracorporeal membrane oxygenation (ECPELLA) may be required. In younger patients, surgical VAD may be considered.
A new era has evolved in the management of AMICS. An organized approach with multiple individuals from various disciplines are required. Our team is honored to help support the lifesaving efforts to additional hospitals by providing a protocol and data that show positive outcomes when building a strong shock team. When performance metrics are achieved (see Table), we believe an institutional survival rate of 80% is achievable.
- References:
- Basir MB, et al. Catheter Cardiovasc Interv. 2018;doi:10.1002/ccd.27427.
- Bradley EH, et al. Circulation. 2006;doi:10.1161/CIRCULATIONAHA.105.590133.
- Lee L, et al. Circulation. 1988;doi:10.1161/01.CIR.78.6.1345.
- Scholz KH, et al. Eur Heart J. 2018;doi:10.1093/eurheartj/ehy004.
- For more information:
- William W. O’Neill, MD, FACC, MSCAI, is medical director of the Center for Structural Heart Disease at Henry Ford Hospital, Henry Ford Health System, and a member of the Cardiology Today’s Intervention Editorial Board.
- Mir Basir, DO, is an interventional cardiologist at Henry Ford Hospital, Henry Ford Health System.
- Ruth Fisher, MBA, CMPE, is vice president of heart and vascular services at Henry Ford Health System. The authors can be reached at woneill1@hfhs.org.
- Centers interested in participating in the National Cardiogenic Shock Initiative can contact the authors at www.henryford.com/cardiogenicshock.
Disclosures: O’Neill reports he is a consultant for Edwards Lifesciences and Medtronic. Basir and Fisher report no relevant financial disclosures.