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Cardiogenic shock protocol improves survival
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LAS VEGAS — A protocol developed by the National Cardiogenic Shock Initiative improved outcomes for patients with acute MI and cardiogenic shock, according to findings presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
The data came from 35 sites that agreed to treat patients with acute MI and cardiogenic shock with a best practice algorithm, Mir B. Basir, DO, interventional cardiologist at Henry Ford Heart and Vascular Institute, said during a press conference.
“Overall mortality in cardiogenic shock is high, around 50%, and there has not been that much change since the advent of the SHOCK trial, which cemented early revascularization as the gold standard therapy in these patients,” Basir told Cardiology Today’s Intervention. “We put together best practices with mechanical circulatory support and created an algorithm to treat patients with cardiogenic shock. When we looked at the outcomes in five health care systems in the Detroit area, we showed we had an improved survival rate of around 75%. We then expanded the pilot study from Detroit to 68 hospitals across the country.”
Inclusion and exclusion criteria were the same as in the SHOCK trial, with the additional exclusion of intra-aortic balloon pump counterpulsation before mechanical circulatory support, he said. The findings were simultaneously published in Catheterization and Cardiovascular Interventions.
All 171 patients (mean age, 63 years; 77% men; 68% with confirmed acute MI and cardiogenic shock) received mechanical circulatory support with an Impella device (Abiomed), with 92% receiving the Impella CP, according to the researchers.
“The algorithm comes down to five major things,” Basir said in an interview. “One is to initiate hemodynamic support before escalating doses of inotropes. The second is to use right heart catheterization to enable better decisions; blood pressure alone cannot tell you how the right side and left side of the heart are doing and how much reserve the patient has in terms of cardiac output. The third is to implant the hemodynamic support device before PCI so patients don’t deteriorate as you’re doing the procedure. The fourth is to improve the processes of care so these patients are treated within 90 minutes, not just in terms of door-to-balloon time but also in door-to-support time. That is where the shock team comes in; it is important to get our ED colleagues involved and to have a cath lab available 24 hours per day. The fifth thing is to mitigate any device-related complications.”
Among the cohort, 83% of patients were on inotropes or vasopressors, 20% had a witnessed out-of-hospital cardiac arrest, 29% had in-hospital cardiac arrest and 10% were receiving active CPR at time of mechanical circulatory support implantation.
In accordance with the protocol, 74% of patients had their Impella device implanted before PCI. The researchers performed right heart catheterization in 92% of patients.
Basir said 78% of patients presented with STEMI, and among that group, the mean door-to-support time was 85 minutes and the mean door-to-balloon time was 87 minutes.
Seventy-two percent of patients survived to discharge. Basir and colleagues identified the following predictors of mortality: Creatinine of at least 2 mg/dL, lactate 4 mg/dL or more, cardiac power output less than 0.6 W and age at least 70 years.
Predictors of mortality after the mechanical circulatory support procedure were lactate more than 4 mg/dL (44% sensitivity, 89% specificity) and cardiac power output less than 0.6 W at 12 to 24 hours (38% sensitivity, 88% specificity). Patients with lactate < 4 mg/dL and cardiac power output of 0.6 W or more at 12 to 24 hours were more likely to survive than those who did not have both (95% vs. 50%; P < .01).
At 24 hours, compared with those who died, those who survived had higher cardiac output (P = .02), higher cardiac index (P = .04), higher hemoglobin (P = .01), higher systolic BP (P = .01), lower heart rate (P = .03) and lower hepatic enzymes (P < .01).
Twelve patients had major bleeding, one of whom had fatal access-site bleeding, and two patients had device-related thrombus, according to the researchers.
“We have been contacted by a lot of people who want to improve the processes of care for these patients,” Basir said in an interview. “These practices don’t go against any standard practices of care that we already use. We have had good results so far, and I think there will be a lot more adoption of the algorithm we have been using for the last 3 years.” – by Erik Swain
References:
Basir MB, et al. Featured Clinical Research I. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 19-22, 2019; Las Vegas.
Basir MB, et al. Catheter Cardiovasc Interv. 2019;doi:10.1002/ccd.28307.
Disclosure: The study was funded in part by Abiomed and Chiesi. Basir reports he consults for Abbott, Cardiovascular Systems Inc., Chiesi and Zoll.