Pub Date: Thursday, Mar 04, 2021
Author: Emmanouil S. Brilakis, MD, PhD
Affiliation: Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
Cardiogenic shock (CS) remains the leading mechanism of death in acute myocardial infarction (AMI) patients. Approximately 30% of all CS patients have AMICS1 and despite modest earlier improvements in outcomes, mortality remains high2 with significant variations between hospitals,3 highlighting the need for standardizing and optimizing the care of these high-risk patients. Building on the 2017 American Heart Association statement on the “Contemporary management of cardiogenic shock”,4 Henry et al provide a state-of-the-art update on the invasive management of AMICS, summarizing recent developments in the field, as well as future challenges and opportunities.5
There are 5 key "ingredients" for the managements of AMICS [(a) early diagnosis and triage; (b) initial stabilization and diagnostic evaluation including hemodynamic assessment; (c) culprit-only coronary revascularization; (d) judicious use of mechanic circulatory support; (e) expert in-hospital treatment]6,7 which are discussed in detail in the Henry et al document:
First, early diagnosis and treatment of AMICS is key for improving outcomes and disrupting the downward spiral of CS. Cardiogenic shock is characterized by inadequate end organ perfusion due to cardiac dysfunction. Although the operational definition of CS varies between studies and clinical settings, a Society for Cardiovascular Angiography and Intervention (SCAI) clinical expert consensus statement on the classification of CS recently proposed 5 stages based on clinical findings, biomarkers and hemodynamics: stage A is “at risk” for CS, stage B is “beginning” shock, stage C is “classic” CS, stage D is “deteriorating”, and E is “extremis”8. The difference between stages B and C is the presence of hypoperfusion which is present in stages C and higher. Initial retrospective validation studies have demonstrated good correlation of the SCAI shock stages with mortality,9 but additional prospective studies are needed. The SCAI shock stages can help determine further treatment; stages A and B proceed with coronary angiography and revascularization, whereas stages C, D, and E first require stabilization.
Second, initial stabilization involves vasopressors (norepinephrine is preferred) at the lowest possible doses to maintain mean arterial pressure >65 mmHg and often intubation and mechanical ventilation. Physical examination can help determine the presence and severity of shock. Emergency echocardiography can help clarify the cause of shock including the occurrence of mechanical AMI complications that in most cases require urgent surgery. Coronary angiography can help define the culprit lesion(s) and plan revascularization. Right heart catheterization can help determine the severity of left and right ventricular dysfunction and guide further treatment potentially improving outcomes,10 but may need to be delayed in AMICS until after coronary revascularization has been achieved.
Third, the role of mechanical circulatory support (MCS) remains controversial in AMICS patients, given lack of randomized-controlled trial data showing benefit. Henry et al provide a balanced discussion of the potential benefits of MCS (improve systemic and myocardial perfusion, reduce myocardial workload, and reduce the need for vasopressors) and associated risks (bleeding, vascular access complications, delayed coronary reperfusion, and hemolysis). While awaiting the results of multiple ongoing trials of MCS in AMICS (including 4 trials on veno-arterial extracorporeal membrane oxygenators [VA-ECMO]) Henry et al recommend that “early MCS placement prior to PCI may be considered for patients with AMICS who exhibit refractory hemodynamic instability despite aggressive medical therapy”.
Fourth, early revascularization of the infarct-related artery remains the only treatment modality proven in randomized-controlled trials to improve the outcomes of AMICS.11 Given potential time delays and the patients’ often critical condition, percutaneous coronary intervention (PCI) is performed in most cases, with coronary artery bypass graft surgery usually reserved for patients with mechanical AMI complications or after failure of PCI. In AMICS patients with multivessel coronary artery disease, PCI should only be performed in the culprit lesion in the acute setting, given higher mortality observed in the multivessel PCI arm of Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial.12 Whether the benefits of more aggressive antiplatelet treatments (reduce stent thrombosis and other thromboembolic complications) exceed the associated risks (bleeding) remains controversial and requires individualized clinical decision making.
Fifth, expert in-hospital treatment is key for patient recovery, as the catheterization laboratory is only the beginning of the patients’ hospitalization. Meticulous transition of care to the intensive care unit using a checklist can minimize the risk of various components of care “being lost in translation”. Management of AMICS patients by a multidisciplinary team that uses protocols to optimize hemodynamics through thoughtful use of MCS/vasopressors and promptly detects and treats any complications that may arise can maximize the likelihood of recovery.13-15
Management of AMICS patients who have had cardiac arrest is even more complicated given the potential for hypoxic-ischemic encephalopathy, requiring careful assessment of the potential for recovery before proceeding with cardiac catheterization, as well as prompt targeted temperature management.
How should clinicians and researchers use the current document? Figure 4 provides a concise and practical step-by-step treatment algorithm for AMICS patients. Following this algorithm can help prevent overlooking critical aspects of the care of AMICS patients while individualizing use of the various treatment modalities. Moreover, the section “Conclusions and future directions” provides an up-to-date summary of key areas where additional research is needed, covering the entire spectrum of AMICS management from diagnosis to initial and subsequent in-hospital treatment.
Currently treatment of AMICS is similar to where PCI of chronic total occlusions was 10 years ago,16-17 with tremendous variability between various physicians and centers and confusion about which treatment strategy to use and when. Standardization and technical innovations have led to remarkable improvements in the outcomes of chronic total occlusion PCI.18 Similarly, the field of AMICS offers tremendous opportunities for both building state-of-the-art clinical practices and for helping advance the basic and clinical science behind those practices. Henry et al should be congratulated for paving the way to better AMICS treatments.
Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Pina IL, Kapur NK, Dangas GD; on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing. Invasive management of acute myocardial infarction complicated by cardiogenic shock: a scientific statement from the American Heart Association [published online ahead of print Thursday, March 4, 2021]. Circulation. 2021;143:e•••–e•••. doi: 10.1161/CIR.0000000000000959
- Berg DD, Bohula EA, van Diepen S, et al. Epidemiology of Shock in Contemporary Cardiac Intensive Care Units. Circ Cardiovasc Qual Outcomes 2019;12:e005618.
- Omer MA, Tyler JM, Henry TD, et al. Clinical Characteristics and Outcomes of STEMI Patients With Cardiogenic Shock and Cardiac Arrest. JACC Cardiovasc Interv 2020;13:1211-9.
- Shaefi S, O'Gara B, Kociol RD, et al. Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock. J Am Heart Assoc 2015;4:e001462.
- van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017;136:e232-e68.
- Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Pina IL, Kapur NK, Dangas GD; on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing. Invasive management of acute myocardial infarction complicated by cardiogenic shock: a scientific statement from the American Heart Association [published online ahead of print Thursday, March 4, 2021]. Circulation. 2021;143:e•••–e•••. doi: 10.1161/CIR.0000000000000959
- Brilakis ES, Eckman P. The five key "ingredients" for improving outcomes in cardiogenic shock complicating acute myocardial infarction. Catheter Cardiovasc Interv 2018;91:462-3.
- Chioncel O, Parissis J, Mebazaa A, et al. Epidemiology, pathophysiology and contemporary management of cardiogenic shock - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020.
- Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv 2019;94:29-37.
- Jentzer JC, Henry TD, Barsness GW, Menon V, Baran DA, Van Diepen S. Influence of cardiac arrest and SCAI shock stage on cardiac intensive care unit mortality. Catheter Cardiovasc Interv 2020.
- O'Neill WW, Grines C, Schreiber T, et al. Analysis of outcomes for 15,259 US patients with acute myocardial infarction cardiogenic shock (AMICS) supported with the Impella device. Am Heart J 2018;202:33-8.
- Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. Jama 2006;295:2511-5.
- Thiele H, Akin I, Sandri M, et al. One-Year Outcomes after PCI Strategies in Cardiogenic Shock. N Engl J Med 2018;379:1699-710.
- Tehrani BN, Truesdell AG, Sherwood MW, et al. Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol 2019;73:1659-69.
- Taleb I, Koliopoulou AG, Tandar A, et al. Shock Team Approach in Refractory Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support. Circulation 2019;140:98-100.
- Basir MB, Kapur NK, Patel K, et al. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv 2019;93:1173-83.
- Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv 2012;5:367-79.
- Patel VG, Brayton KM, Tamayo A, et al. Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies. JACC Cardiovasc Interv 2013;6:128-36.
- Brilakis ES, Mashayekhi K, Tsuchikane E, et al. Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. Circulation 2019;140:420-33.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --