Cardiogenic shock: Current status and future directions

Srihari Naidu
Srihari S. Naidu

The patient presenting with acute MI and cardiogenic shock has long presented a challenge for physicians. While advances in therapy, including reperfusion and mechanical support, have been associated with improvements in survival, mortality remains high and there is broad variation in cardiogenic shock outcomes. The complex and urgent nature of shock — coupled with treatment, research and clinical knowledge gaps — creates a need for increased awareness and optimal solutions to care for patients with cardiogenic shock.

The Society for Cardiovascular Angiography and Interventions has organized a new course to provide a comprehensive review of the diagnosis and management of cardiogenic shock, with dedicated presentations on algorithms for shock teams and shock care; devices, drugs and data; contemporary assessment and more.

SCAI SHOCK: A Team-Based Course on Cardiogenic Shock will take place on Oct. 12 and 13 in Boston. Attendees of the meeting can expect case-based presentations, incorporation of novel algorithms, growing basic and clinical science, simulations and more.

Management of shock is a rapidly evolving area of high interest to interventional cardiologists, not only for the associated high mortality and relationship to STEMI, but also for the novel technologies, public reporting and physician scorecard aspects, according to SCAI.

Emmanouil S. Brilakis
Emmanouil S. Brilakis

Cardiology Today’s Intervention spoke with Srihari S. Naidu, MD, FSCAI, director of the Hypertrophic Cardiomyopathy Center and Cardiac Catheterization Laboratories at Westchester Medical Center in New York and associate professor of medicine at New York Medical College, and Cardiology Today’s Intervention Editorial Board Member Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Advanced Coronary Interventions at Minneapolis Heart Institute and adjunct professor of medicine at University of Texas Southwestern Medical School, about the SCAI SHOCK Course. For more information, including the agenda and registration, visit the meeting website.

Cardiology Today’s Intervention: What was the impetus behind the SCAI SHOCK course?

Dr. Naidu: For a while, cardiogenic shock has been the ‘one last frontier’ where we haven’t really budged in terms of mortality. Together with that, there has been a flourishing of new devices in this area and creation of team approaches. A variety of documents have also been issued on the management of cardiogenic shock, including some studies that promote one or differing protocols, but there is a clear lack of consensus. The idea for the SCAI SHOCK course was to tackle some of these issues in a practical manner. Attendees could then go back to their hospitals after the SCAI SHOCK course and put together what they think is a good team approach and a good protocol for cardiogenic shock that works for their institution and, hopefully, over time change the mortality associated with cardiogenic shock.

Dr. Brilakis: The aim was to provide a comprehensive agenda that focuses on the whole spectrum of cardiogenic shock. Oftentimes, the discussion around cardiogenic shock focuses only on devices, but management of cardiogenic shock goes beyond that. Importantly, the course is also open to the entire care team — from interventionalists to techs to nurses. We are bringing in the whole team that takes care of the patient presenting with cardiogenic shock. The agenda emphasizes the collaborative focus by bringing in experts in heart failure, surgeons and other disciplines.

CTI: Why does cardiogenic shock require a multidisciplinary effort?

Dr. Naidu: Many people are involved in the care of cardiogenic shock — interventional cardiologists, HF specialists, critical care physicians, surgeons, techs, nurses and so on. We encourage our colleagues to tackle cardiogenic shock as a team. To get the best outcomes with shock, you can’t have one person on the team who wants to do very aggressive things and one person who wants to do very conservative things. The solution is likely somewhere in the middle for each individual patient and a team approach allows the best possible scenario to come to the forefront.

CTI: What are some of the current controversies surrounding cardiogenic shock?

Dr. Brilakis: In 2018, the confusion surrounding cardiogenic shock is monumental. There is a lack of consensus surrounding management of cardiogenic shock. Our goal is to provide participants with practical and up-to-date information applicable to day-to-day practice.

Another challenge is how often the average interventionalist sees a patient with cardiogenic shock. Some might see one or two cases per month, while others might see one or two cases per year. Unfortunately, some interventionalists don’t understand what shock is and how it is treated. All of this makes it difficult to get your skills up to speed for shock. We need more education overall because shock is not just an everyday occurrence. In addition to providing updates, SCAI SHOCK will also take attendees who don’t deal with shock frequently back to the basics, with information on pharmacology, drips, how to use a Swan-Ganz catheter and how to follow-up or transfer the patients.

Dr. Naidu: With a systematic approach in place, we could potentially change the poor mortality rate associated with shock. Improving recognition of cardiogenic shock is also key; however, physicians currently lack a strong definition of cardiogenic shock, which can hinder their ability to identify when a patient has entered a shock state. There are different types of shock. In full-blown shock, they have systemic inflammation and likely already end-organ failure. It is key to understand where in the spectrum of cardiogenic shock a patient is.

Dr. Brilakis: Another issue with shock is use of right heart catheterization. In the ESCAPE trial, we saw right heart catheterization didn’t help with management of chronic HF. But, many took that as saying that right heart catheterization doesn’t help any HF, including shock. This course will have sessions featuring tips and tricks for right heart catheterization, as well as drips, Swan-Ganz catheterization, and options for hemodynamic support, including intra-aortic balloon pumps, TandemHeart percutaneous ventricular assist devices (TandemLife), Impella heart pumps (Abiomed) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Dr. Naidu: Many more patients currently receive support than right heart cath. This isn’t to say that one is better than the other. We aim to provide expert opinion on the various approaches. We want to look at the whole picture and come up with multiple ways of caring for the patient with shock.

CTI: What do you hope attendees take away from SCAI SHOCK?

Dr. Naidu: It would be great if attendees leave SCAI SHOCK feeling like they are in better shape to tackle cardiogenic shock. When patients come in and are in shock, we hope attendees will have a systematic approach to follow patients meticulously during their stay, including earlier recognition of the degree of shock, and a clear strategy with a collaborative team. Shock is something we’re all in together.

Dr. Brilakis: In 2018, if you’re going to be a state-of-the-art interventionalist, you have to understand and apply the basic concepts and devices for treating cardiogenic shock. – by Katie Kalvaitis

Disclosures: Brilakis and Naidu are co-chairs of SCAI SHOCK 2018.

Srihari Naidu
Srihari S. Naidu

The patient presenting with acute MI and cardiogenic shock has long presented a challenge for physicians. While advances in therapy, including reperfusion and mechanical support, have been associated with improvements in survival, mortality remains high and there is broad variation in cardiogenic shock outcomes. The complex and urgent nature of shock — coupled with treatment, research and clinical knowledge gaps — creates a need for increased awareness and optimal solutions to care for patients with cardiogenic shock.

The Society for Cardiovascular Angiography and Interventions has organized a new course to provide a comprehensive review of the diagnosis and management of cardiogenic shock, with dedicated presentations on algorithms for shock teams and shock care; devices, drugs and data; contemporary assessment and more.

SCAI SHOCK: A Team-Based Course on Cardiogenic Shock will take place on Oct. 12 and 13 in Boston. Attendees of the meeting can expect case-based presentations, incorporation of novel algorithms, growing basic and clinical science, simulations and more.

Management of shock is a rapidly evolving area of high interest to interventional cardiologists, not only for the associated high mortality and relationship to STEMI, but also for the novel technologies, public reporting and physician scorecard aspects, according to SCAI.

Emmanouil S. Brilakis
Emmanouil S. Brilakis

Cardiology Today’s Intervention spoke with Srihari S. Naidu, MD, FSCAI, director of the Hypertrophic Cardiomyopathy Center and Cardiac Catheterization Laboratories at Westchester Medical Center in New York and associate professor of medicine at New York Medical College, and Cardiology Today’s Intervention Editorial Board Member Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Advanced Coronary Interventions at Minneapolis Heart Institute and adjunct professor of medicine at University of Texas Southwestern Medical School, about the SCAI SHOCK Course. For more information, including the agenda and registration, visit the meeting website.

Cardiology Today’s Intervention: What was the impetus behind the SCAI SHOCK course?

Dr. Naidu: For a while, cardiogenic shock has been the ‘one last frontier’ where we haven’t really budged in terms of mortality. Together with that, there has been a flourishing of new devices in this area and creation of team approaches. A variety of documents have also been issued on the management of cardiogenic shock, including some studies that promote one or differing protocols, but there is a clear lack of consensus. The idea for the SCAI SHOCK course was to tackle some of these issues in a practical manner. Attendees could then go back to their hospitals after the SCAI SHOCK course and put together what they think is a good team approach and a good protocol for cardiogenic shock that works for their institution and, hopefully, over time change the mortality associated with cardiogenic shock.

Dr. Brilakis: The aim was to provide a comprehensive agenda that focuses on the whole spectrum of cardiogenic shock. Oftentimes, the discussion around cardiogenic shock focuses only on devices, but management of cardiogenic shock goes beyond that. Importantly, the course is also open to the entire care team — from interventionalists to techs to nurses. We are bringing in the whole team that takes care of the patient presenting with cardiogenic shock. The agenda emphasizes the collaborative focus by bringing in experts in heart failure, surgeons and other disciplines.

CTI: Why does cardiogenic shock require a multidisciplinary effort?

Dr. Naidu: Many people are involved in the care of cardiogenic shock — interventional cardiologists, HF specialists, critical care physicians, surgeons, techs, nurses and so on. We encourage our colleagues to tackle cardiogenic shock as a team. To get the best outcomes with shock, you can’t have one person on the team who wants to do very aggressive things and one person who wants to do very conservative things. The solution is likely somewhere in the middle for each individual patient and a team approach allows the best possible scenario to come to the forefront.

CTI: What are some of the current controversies surrounding cardiogenic shock?

Dr. Brilakis: In 2018, the confusion surrounding cardiogenic shock is monumental. There is a lack of consensus surrounding management of cardiogenic shock. Our goal is to provide participants with practical and up-to-date information applicable to day-to-day practice.

Another challenge is how often the average interventionalist sees a patient with cardiogenic shock. Some might see one or two cases per month, while others might see one or two cases per year. Unfortunately, some interventionalists don’t understand what shock is and how it is treated. All of this makes it difficult to get your skills up to speed for shock. We need more education overall because shock is not just an everyday occurrence. In addition to providing updates, SCAI SHOCK will also take attendees who don’t deal with shock frequently back to the basics, with information on pharmacology, drips, how to use a Swan-Ganz catheter and how to follow-up or transfer the patients.

Dr. Naidu: With a systematic approach in place, we could potentially change the poor mortality rate associated with shock. Improving recognition of cardiogenic shock is also key; however, physicians currently lack a strong definition of cardiogenic shock, which can hinder their ability to identify when a patient has entered a shock state. There are different types of shock. In full-blown shock, they have systemic inflammation and likely already end-organ failure. It is key to understand where in the spectrum of cardiogenic shock a patient is.

Dr. Brilakis: Another issue with shock is use of right heart catheterization. In the ESCAPE trial, we saw right heart catheterization didn’t help with management of chronic HF. But, many took that as saying that right heart catheterization doesn’t help any HF, including shock. This course will have sessions featuring tips and tricks for right heart catheterization, as well as drips, Swan-Ganz catheterization, and options for hemodynamic support, including intra-aortic balloon pumps, TandemHeart percutaneous ventricular assist devices (TandemLife), Impella heart pumps (Abiomed) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Dr. Naidu: Many more patients currently receive support than right heart cath. This isn’t to say that one is better than the other. We aim to provide expert opinion on the various approaches. We want to look at the whole picture and come up with multiple ways of caring for the patient with shock.

CTI: What do you hope attendees take away from SCAI SHOCK?

Dr. Naidu: It would be great if attendees leave SCAI SHOCK feeling like they are in better shape to tackle cardiogenic shock. When patients come in and are in shock, we hope attendees will have a systematic approach to follow patients meticulously during their stay, including earlier recognition of the degree of shock, and a clear strategy with a collaborative team. Shock is something we’re all in together.

Dr. Brilakis: In 2018, if you’re going to be a state-of-the-art interventionalist, you have to understand and apply the basic concepts and devices for treating cardiogenic shock. – by Katie Kalvaitis

Disclosures: Brilakis and Naidu are co-chairs of SCAI SHOCK 2018.