Effect of Cardiogenic Shock Hospital Volume on Mortality in Patients With Cardiogenic Shock

Shaefi, Shahzad; O’Gara, Brian; Kociol, Robb D.; Joynt, Karen E.; Mueller, Ariel; Nizamuddin, Junaid; Mahmood, Eitezaz; Talmor, Daniel; Shahul, Sajid

doi:10.1161/jaha.114.001462

Cited by 128 publications

(87 citation statements)

References 35 publications

(44 reference statements)

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“…Mortality was 37%, 39.3%, 40.7%, and 42% in hospitals that treated ≥107, 59 to 106, 28 to 58, and <27 cases per year (P<0.05). 122 Of note, large-volume sites were more likely to be academic, located in urban areas, and serve as referral hubs. Reasons underpinning this finding have not been clearly elucidated, although we hypothesize that patients treated at high-volume hospitals may be more likely to receive evidence-based care and prompt revascularization by high-volume operators and that high-volume hospitals may include a multidisciplinary team who more frequently implements MCS and cares for patients with multisystem organ failure.…”

Section: Regionalized Systems Of Care Clinical Volume and Patient Outmentioning

confidence: 99%

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

Diepen¹,

Katz²,

Albert³

et al. 2017

Circulation

1,206

1,165

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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...

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Section: Regionalized Systems Of Care Clinical Volume and Patient Outmentioning

confidence: 99%

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

Diepen¹,

Katz²,

Albert³

et al. 2017

Circulation

1,206

1,165

View full text Add to dashboard Cite

show abstract

“…These possibilities warrant further inquiry, particularly given that recent work has shown that center volume of patients with cardiogenic shock is associated with improved patient outcomes. 29 It is important to consider wider contextual issues regarding clinical practice and policy in understanding the results we have established in this study. The United Kingdom has accommodated current international guidance with national recommendations that discourage low-volume centers with consistently <400 PCI cases per annum and encourage regular practice with a minimum annual operator activity of >75 cases per year.…”

Section: Discussionmentioning

confidence: 98%

Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality

O’Neill

Nicholas

Gale

et al. 2017

Circ: Cardiovascular Quality and Outcomes

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T he relationship between procedural volume and patient outcomes is an important consideration in the provision of percutaneous coronary intervention (PCI). Studies that have suggested the existence of a relationship have informed international guidelines 1-3 on the minimum procedural limits recommended for annual center volume to ensure safe and effective patient care. This is also reflected in recent UK guidance on the provision of PCI. 4 For acute myocardial infarction, the establishment of high-throughput, high-volume heart attack centers within networks of acute cardiac care has been promoted as a factor contributing to the decline in cardiovascular mortality in developed healthcare systems. [5][6][7][8][9] Such centers often also have high volumes of elective PCI and in much of the published literature compare favorably with lower volume centers where higher rates of adverse outcomes, longer lengths of hospital stay, and increased costs have been observed. 10,11 These findings have been reflected in the reconfiguration of UK PCI services over the past decade, specifically the expectation that lower volume units undertake at least 400 procedures per annum. See Editorial by Kumbhani and BittlIt is timely and of international importance to review the evidence for and against a relationship between PCI center volume and clinical outcomes in the UK healthcare system. Such a national review contributes to the assessment of the Background-The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry. Methods and Results-A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers. Conclusions-After adjustment for differences in case mix and clinical presentation, this study supports the conclusion o...

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“…Such hospitals are therefore better served partnering with larger institutions as part of a 'spoke and hub' model. [104][105][106][107][108] After Action Reviews Our cardiogenic shock team conducts novel cross-discipline meetings with clinical and non-clinical staff and leaders with 100 % case review. Data related to each shock patient (i.e.…”

Section: The Inova Pathwaymentioning

confidence: 99%

“…Looking forward, in our region and across the US, new networks of partnered multidisciplinary care ought to emerge on a large scale to establish linked regional systems of community hospitals and large centralised centres of excellence emphasising rapid triage, immediate transport and expedited door-to-support for patients with CS, emulating the highly successful military and civilian trauma systems and the cardiovascular communities historical successes in early revascularisation for acute ST-elevation MI. 1,[104][105][106][107][108] Locally, having focused on our 'hub' medical centre ( Figure 5) in 2017, we are currently expanding our protocol and process to our linked 'spoke' hospitals (both internal and external to our health system) in 2018.…”

Section: Future Perspectivementioning

confidence: 99%

‚Combat‛ Approach to Cardiogenic Shock

Truesdell¹,

Tehrani

Singh

et al. 2018

Interventional Cardiology Review

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The incidence of cardiogenic shock is rising, patient complexity is increasing and patient survival has plateaued. Mirroring organisational innovations of elite military units, our multidisciplinary medical specialists at the INOVA Heart and Vascular Institute aim to combine the adaptability, agility and cohesion of small teams across our large healthcare system. We advocate for widespread adoption of our 'combat' methodology focused on: increased disease awareness, early multidisciplinary shock team activation, group decision-making, rapid initiation of mechanical circulatory support (as appropriate), haemodynamic-guided management, strict protocol adherence, complete data capture and regular after action reviews, with a goal of ending preventable death from cardiogenic shock.

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Effect of Cardiogenic Shock Hospital Volume on Mortality in Patients With Cardiogenic Shock

Cited by 128 publications

References 35 publications

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

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

Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality

‚Combat‛ Approach to Cardiogenic Shock

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