Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Abstract

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities. Cardiogenic shock (CS) is a low-cardiac-output state resulting in life-threatening end-organ hypoperfusion and hypoxia.1,2 Acute myocardial infarction (MI) with left ventricular (LV) dysfunction remains the most frequent cause of CS. 1,3 Advances in reperfusion therapy have been associated with improvements in survival, but significant regional disparities in evidence-based care have been reported, and in-hospital mortality remains high (27%-51%).1,4-9 Management recommendations are distributed between disease-specific statements and guidelines, and a dedicated and comprehensive clinical resource in this area is lacking. Thus, consolidating the evidence to define contemporary best medical and surgical CS practices for both MI-associated CS and other types of CS may be an important step in knowledge translation to help attenuate disparities in evidence-based care.Regional systems of care coupled with treatment algorithms have improved survival in high-acuity time-sensitive conditions such as MI, out-of-hospital cardiac arrest (OHCA), and trauma.10-12 Applying a similar framework to CS management may lead to similar improvements in survival, and CS systems of care are emerging within existing regional cardiovascular emergency care networks; however, guidance from a national expert group on structure and systems of care has not been available. 13,14 Accordingly, the purposes of this American Heart Association (AHA) scientific statement on CS are to summarize our contemporary understanding of the epidemiology, pathophysiology, and in-hospital best care practices into a single clinical resource document; to suggest a stepwise management algorithm that integrates medical, surgical, and mechanical circulatory support (MCS) therapies; and to propose a Mission: Lifelinesupported pathway for the development of integrated regionalized CS systems of care. DEFINITION OF CSAcute cardiac hemodynamic instability may result from disorders that impair function of the myocardium, valves, conduction system, or pericardium, either in isolation HISTORICAL PERSPECTIVESBefore the routine use of early revascularization, MIassociated CS had an in-hospital mortality exceeding 80%. A registry trial of 250 patients with acute MI described the association between bedside physical examination (Killip classification) for the as...

Circulating levels of microRNA 423‐5p are associated with 90 day mortality in cardiogenic shock

“…Invasive haemodynamic monitoring is not routinely advocated, 1 and we believe that our cohort reflects current clinical practice. The observation that miR-423-5p level above median was associated with a lower cardiac index is limited by the small proportion of patients (21%) with pulmonary artery catheters.…”

“…1 In-hospital mortality is close to 40% even with current treatment. 1 In-hospital mortality is close to 40% even with current treatment.…”

The future of cardiac transplantation

“…Future studies will help parse out specific patient-device-timing combinations to optimize outcomes. There has been a recent scientific statement on cardiogenic shock from the American Heart Association reviewing contemporary medical, surgical, mechanical circulatory support treatment approaches, and future research initiatives (38).…”

Medications in Cardiogenic Shock

“…Gene therapy is another area and further results of these new approaches are awaited [10]. Medications and their characteristics prescribed in CS patients are listed in Table 18.1 [11]. Initial vasoactive management strategies in different types of CS are presented in Table 18.2.…”