New AHA Scientific Statement on Cardiogenic Shock

Megan Brooks

October 26, 2017

DALLAS, TX — The contemporary management of cardiogenic shock is the focus of a scientific statement from the American Heart Association (AHA)[1].

Cardiogenic shock is a life-threatening, multifactorial, and hemodynamically diverse high-acuity illness that is frequently associated with multisystem organ failure, the writing committee notes.

Despite improving survival for patients with cardiogenic shock, morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes, they point out.

The scientific statement on cardiogenic shock summarizes contemporary understanding of the epidemiology, pathophysiology, and in-hospital best care practices in a single clinical resource document. It was published October 17, 2017 in Circulation.  

The statement offers a stepwise management algorithm that integrates medical, surgical, and mechanical circulatory support (MCS) therapies, calls for the development of regionalized systems of care, and outlines future research priorities.

"Cardiogenic shock management recommendations were previously distributed between a number of disease-specific guidelines. We felt there was the need to develop a single comprehensive reference document that highlighted the contemporary best practices in carcinogenic shock from resuscitation through to recovery, destination therapy, or palliation," committee chair Dr Sean van Diepen (University of Alberta, Edmonton) told | Medscape Cardiology.

"In addition, some regions have implemented cardiogenic shock systems of care with mobile shock teams. The AHA and Mission Lifeline wanted to provide professional society guidance on cardiogenic shock care systems and teams with the goal of potentially harmonizing and implementing best practices," said van Diepen.

The 51-page statement includes eight tables focusing on the following topics:

  • Pragmatic and clinical trial definitions of cardiogenic shock.

  • Cardiogenic shock center characteristics.

  • Considerations for initial critical care monitoring in patients with cardiogenic shock.

  • Mechanism of action and hemodynamic effects of common vasoactive medications in cardiogenic shock.

  • Initial vasoactive management considerations in types of cardiogenic shock.

  • Critical care complication prevention bundles in patients with cardiogenic shock.

  • Suggestions for global palliative care management in cardiogenic shock.

  • Potential priorities for future cardiogenic shock research.

"We have several take-home messages," van Diepen told | Medscape Cardiology.

First, cardiogenic shock has several hemodynamic phenotypes, and it is not only a "cold-and-wet" presentation. "We advocate tailoring vasoactive support to the hemodynamic presentation and to the underlying etiology," he said.

Second, hospital volume is associated with improved survival in patients with cardiogenic shock, and the committee suggests that "all care regions develop cardiogenic-shock care systems with central 'hub' hospitals that have the onsite resources and therapeutic technologies to comprehensively centralize the care of this patient population," van Diepen said.

Third, ACS is the most frequent cause of cardiogenic shock, "and we advocate for early angiography and revascularization in this population," he said.

Fourth, "a collaborative team approach (including interventionalists, surgeons, heart-failure/transplant, cardiac-intensivists, and palliative-care physicians) is required to care for this acute population. Mechanical circulatory support decisions should be made by a multidisciplinary team, and we suggest that temporary support devices are most appropriate as the initial form of support for most patients," van Diepen noted.

Finally, he said the amount of evidence to guide clinical-practice decisions in this population is "sparse, and more research in the cardiogenic shock population is needed."

van Diepen has no relevant financial disclosures. Disclosures for the writing committee are listed in the paper.

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