Top Things to Know: Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management
Published: February 26, 2024
Prepared by Mark N. Belkin, MD, FACC, FHFSA, Assistant Professor of Medicine; Advanced Heart Failure, Cardiac Transplantation, & Mechanical Circulatory Support; The University of Chicago Medicine
- Older adults are increasingly presenting with cardiogenic shock (CS), including more frequent use of temporary mechanical circulatory support (tMCS), however there are limited data to guide the care of this high-risk population, and available guidance has an over-reliance on chronological age without accounting for geriatric co-morbidities.
- In addition to age, comprehensive risk assessment of older patients performed by an interdisciplinary team includes patient baseline characteristics, clinical trajectory, anticipated quality-of-life outcomes, and healthcare center capabilities.
- Shared decision-making and advanced care planning are integral to aligning treatment choices with patient values and preferences, while following the ethical principles of beneficence and non-maleficence.
- A high index of suspicion for CS in older adult patients facilitates timely recognition and optimal management. In addition to known best-practices in management of CS, the use of vasoactive agents requires close monitoring of concomitant renal and hepatic dysfunction, which is often prevalent in older adult populations.
- Mechanical ventilation and renal replacement therapy are often utilized in CS management, but they are both associated with increased mortality in older patients. When possible, advanced care planning regarding use, and duration, of these therapies with older patients prior to initiation is helpful.
- Mostly due to underlying risk factors, older patients are at an increased risk for complications related to percutaneous coronary intervention (PCI), surgical revascularization, and percutaneous or valvular interventions thus patient-centered treatment options accounting for age-associated impairments are important to discuss with an inter-disciplinary team, including a geriatric specialist.
- The initiation of tMCS in older patients may be appropriate following a heart team discussion accounting for known contraindications to advanced therapies, patient values regarding aggressive care, and likelihood of an exit strategy from the therapy.
- Durable left ventricular assist device (LVAD) technology has progressed significantly, with two-, and five-, year survival rivaling that of heart transplantation (HT). For older patients, assessment of frailty, end-organ dysfunction, malnutrition, and caregiver support are important during the decision-making process.
- Candidacy for HT in older patients requiring intensive care unit management is challenging and controversial, and consideration of HT in patients ≥ 70 years-old requires a careful assessment of potential risks and benefits. Further data are needed on HT incidence and outcomes in this older population.
- Consultation with a palliative care team early in the treatment course for older adults with CS can aid in decision-making regarding advanced therapies, provide clinical support in the event of adverse outcomes, and optimize quality of life when facing critical illness or end-of-life situations.
- Further research is needed to identify older patients that may benefit from more aggressive treatment of CS. These include increasing their representation in CS clinical trials and incorporating meaningful endpoints specific to this population.
Citation
Blumer V, Kanwar MK, Barnett CF, Cowger JA, Damluji AA, Farr M, Goodlin SJ, Katz JN, McIlvennan CK, Sinha SS, Wang TY; 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: ascientific statement from the American Heart Association. Circulation. Published online February 26, 2024. doi: 10.1161/CIR.0000000000001214