A comprehensive view of cardiogenic shock
Cardiovascular specialists to explore the past, present, future and more of cardiogenic shock
Cardiogenic shock, a life-threatening condition in which a person’s heart can’t pump enough blood to meet the needs of the body, is most often caused by serious a heart attack or advanced heart failure. Historically, data related to cardiogenic shock have been limited, inconsistent and challenging to interpret. As a result, varying treatment recommendations exist around best practices.
Sunday morning’s in-depth session, Moving the Needle in Cardiogenic Shock: A Conversation With the Giants — The Intersection of Critical Care, Interventional and Heart Failure Cardiology and Cardiac Surgery, seeks to expand the conversation on the subject.
Prior to the session, cardiac experts and moderators David Morrow, MD, MPH, FAHA, and Susanna Price, MD, PhD, provided valuable analysis on the evolution of this life-threatening condition to Scientific Sessions Daily News.
Dr. Morrow is the director of the Levine Cardiac Intensive Care Unit (CICU) at Brigham and Women’s Hospital in Boston and co-chair of the AHA’s Cardiogenic Shock Registry Steering Committee.
Dr. Price is a consultant cardiologist and intensivist based at Royal Brompton Hospital in London and chair of the National Health Service (NHS) Pan-London Cardiogenic Board.
“We are nowhere near to having cardiogenic shock ‘solved,’” Dr. Morrow said. “If we hope to improve outcomes, it is essential for us to have a better understanding of the landscape of cardiogenic shock care, its varied clinical presentations, applied interventions, processes of care and outcomes.”
Q: In reviewing the past and present of cardiogenic shock, what have been some of the biggest breakthroughs and developments?
Dr. Morrow: It’s sobering that our biggest breakthrough in managing shock was nearly 25 years ago with the demonstration that early revascularization improves survival in patients with cardiogenic shock due to acute myocardial infarction. Now, a quarter decade later, despite multiple shots on goal with new clinical trials, we have not yet found new treatments that have impacted hard outcomes.
However, we have made substantial recent progress in refining our definitions and classification of cardiogenic shock and its complications, giving us a more refined common language that has promise to reduce variability in clinical trials and perhaps overcome some of the pitfalls that arise in studying such a heterogeneous population. Additionally, coordinated multidisciplinary team-based care has emerged as a likely important factor in improving cardiogenic shock care.
Dr. Price: The developments in interventional cardiology have been extraordinary, such that we can now undertake many cardiovascular interventions (including valve implantation, EP interventions and congenital heart disease interventions) using catheter-based techniques. Unfortunately, although there have been developments in acute mechanical circulatory support, the advances have not been so extensive. Nonetheless, these all add up to game-changers within the management of cardiogenic shock.
I would also add that the widespread availability of echocardiography in the ICU has transformed our ability to assess and guide interventions in these most critically ill patients.
Q. What innovations are on the horizon that will continue to advance cardiogenic shock?
Dr. Morrow: I see three major areas for near-term progress:
1. Dedicated shock registries: There are several registries dedicated to cardiogenic shock that are making successful headway in gathering these data with important opportunities for expansion to capture cardiogenic shock more comprehensively in the next few years. For example, the AHA recently launched the Cardiogenic Shock Registry powered by Get With The Guidelines, which underscores its commitment to advancing care of patients with this life-threatening syndrome.
2. Deep phenotyping: A commonly held belief is that more targeted interventions aimed at the driving pathobiology for an individual patient may be more successful. Therefore, comprehensive phenotyping integrating clinical characteristics, invasive hemodynamics, imaging and biomarkers is an area of intense interest in the field, and one in which we are starting to make some headway with much more to come.
3. Pragmatic clinical trials: Implementation of randomized clinical trials in cardiogenic shock is not easy. One of our major shortcomings has been the paucity of rigorously designed, adequately powered clinical trials. Encouragingly, there is a renewed commitment to the initiation and conduct of randomized trials of therapies for cardiogenic shock and an openness to innovative pragmatic trial designs that may enable a next generation of trials in the field.
Dr. Price: I would also add a fourth:
4. Early recognition: Combining deep phenotyping, genomics, proteomics and metabolomics with standard monitoring and leveraging advances in artificial intelligence (AI) will hopefully allow early recognition of the declining patient or high-risk patient in ways we don’t yet recognize.
Q. Why is multidisciplinary collaboration so important in this area?
Dr. Morrow: I often say that shock care is a team-based sport. One of the most important pieces of evidence from the past five years has been the coalescence of data from multiple observational studies showing an association between implementation of shock teams and lower mortality rates in cardiogenic shock. It takes a substantial commitment of time and resources to make shock teams work 24/7 x 365.
We still need to tease out the critical elements and processes that constitute an effective shock team framework and potentially drive the association with more favorable outcomes.
Dr. Price: I agree. Additionally, training the next generation and transferring knowledge and skills is going to be vital. Communication was facilitated during the pandemic, allowing rapid convening of remote multidisciplinary teams and bringing expertise to the bedside no matter where the patient finds himself or herself. This was a game-changer.
Q. Why should members attend this session, and what do you want them to take away from it?
Dr. Morrow: Cardiogenic shock is a profoundly morbid culmination or complication of so many cardiovascular disorders. Because of that, we anticipate that this forward-looking session will be of broad interest to specialists, clinicians and researchers committed to advancing care of this challenging syndrome.
Dr. Price: Cardiogenic shock, which represents one of the most extreme manifestations of acute cardiovascular disease, is at the cutting edge of the interface between cardiology, critical care and extracorporeal support. The potential to change outcomes in these critically ill patients is extraordinary, knowledge is expanding rapidly and this session represents the opportunity to hear some of the very best outlining and debating of the latest advances in the field.
The extensive session includes a panel of specialists who will join Drs. Morrow and Price to address a breadth of interests on cardiogenic shock, from registries and clinical trials to pathophysiology and equity. They are:
- Judith S. Hochman, MD, MA, FAHA
- JoAnn Lindenfeld, MD
- Venu Menon, MD, FAHA
- Robert Roswell, MD
- Holger Thiele, MD