ReviewHeart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations: Review of Heart Failure-Related Cardiogenic Shock
Section snippets
Definitions, Profiles and Staging
Based on studies of patients with AMI, CS is defined by a systolic blood pressure (SBP) <90 mm Hg or the need for pharmacological or mechanical support to maintain SBP > 90 mm Hg in combination with evidence of end-organ hypoperfusion.9,4 Reduced cardiac output (CO) with normal or elevated filling pressures is a requisite hemodynamic condition. Ambulatory patients with HF who have been prescribed neurohormonal antagonists commonly have a SBP < 90 mm Hg, elevated intracardiac filling pressures10,
Pathophysiology
Pressure-volume loop analysis provides a useful conceptual framework for understanding CS pathophysiology (see Supplementary videos). In acute CS such as AMI-CS or fulminant myocarditis, the end-systolic pressure volume relationship shifts downward and rightward, reflecting a sudden reduction in ventricular contractility, with attendant declines in stroke volume, CO and blood pressure and increases in PCWP and central venous pressure (CVP). In the transition from acute to chronic HF,
Initial Evaluation of Cardiogenic Shock
The initial assessment of patients presenting with CS should involve a focused history, physical examination and directed imaging (see Supplementary Tables 1 and 2). The nature and duration of symptoms may identify precipitating factors for decompensation and the rapidity of clinical deterioration. Acute myocarditis with high-risk presentations or fulminant myocarditis is especially important to recognize because endomyocardial biopsy and immunosuppressive treatment may be indicated.29,30
The
Clinical Trajectory and Outcomes
The clinical trajectory of CS follows 3 possible pathways: (1) NHR with sufficiency myocardial stabilization to allow for the weaning of vasoactive and/or tMCS support; (2) stabilization as a bridge to heart replacement therapy (HRT) with HT or VAD; or (3) death. Given the dynamic nature and rapid progression of CS, it is often not feasible to discern which pathway is most likely, so a “bridge-to-decision” strategy is employed. Throughout the clinical trajectory of the patient with CS, it is
CICU Staffing
The care of patients with HF-CS is complex, challenging and resource-intensive. The optimal organizational structure and staffing models remain to be defined, but high-intensity staffing with a dedicated cardiac intensivist37 or comanagement among cardiologists and intensivists may be associated with improved mortality rates.38 Consensus documents from both the ACC/AHA and the European Society of Cardiology suggest that management of CS in the CICU requires 24/7 care in an advanced center
Decongestive Strategies
Signs and symptoms of congestion complicate the overwhelming majority of acute decompensated heart failure (ADHF) hospitalizations and, not surprisingly, congestion is an important therapeutic target in HF-CS.23 Increased SBV, defined as the volume of circulating blood above the amount required to fill a vessel to the point of increasing wall stress and intravascular pressure, is associated with increased rates of in-hospital mortality among patients with HF-CS. 55 Moreover, elevations in
Inotropes, Vasopressors and Vasodilators
Intravenous (IV) inotropes and vasopressors remain important therapies in the initial management of HF-CS and have a Class IC indication.2 Despite being widely used in clinical practice, scant evidence is available to guide their use.62 In particular, the optimal MAP and cardiac output are not known. Rational prescription of these agents is, therefore, based on pharmacologic principles that are tailored to patient physiology and response to treatment (Table 2). An important caveat is that these
Mobility and Nutrition
Because of the presence of monitoring devices, tMCS devices, or hemodynamic or electrical instability, patients with CS are often restricted to bedrest, resulting in limited mobility that can exacerbate underlying deconditioning and may have detrimental effects on various body systems.64 Early mobilization can prevent or reduce these effects and is associated with improved outcomes in patients after critical illness. Early mobilization has recently been studied in a variety of critical
Temporary Mechanical Circulatory Support Devices
Percutaneous tMCS devices are used with increasing frequency to increase MAP and to maintain end-organ perfusion in patients with CS, despite lack of evidence demonstrating improved outcomes over the IABP. Each tMCS device has unique hemodynamic effects, risk profiles and clinical considerations (Table 3) (Supplementary videos).
Device selection should be based on the underlying pathophysiology, urgency, magnitude, and duration of hemodynamic support, device availability and
Intra-aortic Balloon Pump
Based on the concept of counter-pulsation, IABPs are balloon-mounted catheters with a capacity of 40--55 cc placed in the descending aorta. IABPs inflate during diastole, thereby augmenting central aortic root diastolic pressure and coronary perfusion, and they deflate during systole, thereby creating a negative pressure sink that reduces LV afterload. IABPs can decrease LV cardiac work and myocardial oxygen consumption and provide up to 0.5--1 L/min of augmented cardiac output. Randomized
Impella
Use of transvalvular microaxial flow pumps such as the Impella devices (Abiomed, Danvers, MA) for both AMI-CS and HF-CS is growing.89 Impella devices use the principle of an Archimedes screw in which rotational kinetic energy from an impeller is transferred to blood and displaces blood from the LV to the aorta. The net result is a decrease in LV pressure and volume, known as LV unloading, and reduced myocardial oxygen consumption. Increased blood delivery to the aorta increases mean arterial
TandemHeart
The TandemHeart (TH) system (LivaNova, London, United Kingdom) employs trans-septal cannulation of the left atrium to bypass blood to the femoral artery. This configuration significantly decreases LV preload and stroke volume and reduces the LV work load.98,99 A small randomized controlled trial comparing TH and IABP in CS showed hemodynamic superiority of TH yet no difference in 30-day mortality.100 TH is often used if contraindications to transvalvular approaches, such as LV thrombus or
Venoarterial Extracorporeal Membrane Oxygenation
VA-ECMO employs an extracorporeal centrifugal flow pump to displace and oxygenate blood from venous to arterial circulation. VA-ECMO is capable of providing full cardiopulmonary support and can be placed at the bedside, making it especially useful in later stages of shock or CA. VA-ECMO is associated with a higher rate of complications than other tMCS devices.101 VA-ECMO provides retrograde flow into the aorta, thereby increasing LV afterload and LV filling pressures and leading to pulmonary
TandemHeart RVAD and ProtekDuo
The TH RV assist device (TH-RVAD) provides RV support by using an extracorporeal centrifugal flow pump to displace blood from the RA to the PA. Several studies have demonstrated significant hemodynamic efficacy with the TH-RVAD in patients with AMI-CS and HF-CS.105,106 The ProtekDuo is a dual-lumen cannula that can enables single venous access via the right internal jugular vein for use with the TH-RVAD. Similar to the TH-LVAD, an oxygenator can be added to the system in patients with hypoxemia.
Vascular Safety
The limb ischemia and bleeding associated with tMCS use in CS are major determinants of morbidity and mortality.107 Best practices for vascular safety should be used whenever possible, including ultrasound and fluoroscopic guidance, micropuncture needle access, initial and final runoff angiography, use of distal perfusion catheters from ipsilateral or contralateral arteries, preclosure of arteriotomy sites, and dedicated vascular safety bundles to minimize harm from large-bore peripheral access.
Systems of Care
CS is a heterogenous, time-sensitive condition that demands complex decision making and specialized interventions. Early recognition and treatment are needed to avoid CS progression, which confers greater likelihood of mortality and may preclude or compromise outcomes of LVAD or transplant.108 The use of standardized staging definitions facilitates communication and can provide criteria for the transfer of patients to higher levels of care.2 The National Cardiogenic Shock Initiative outlined
Palliative Care
Early involvement of palliative care in the clinical course of the patient with CS is appropriate to clarify the goals and limits of care and to provide patient and caregiver support. Despite the known high mortality rates of CS, palliative care is consistently underused.111 Palliative care consultation has been shown to be associated with lower rates of invasive procedures, readmissions and hospital costs.112 As in other areas of medicine, shared decision making remains pivotal to
Knowledge Gaps and Perspective
Although there have been important advances in contemporary HF-CS management, there is a paucity of data addressing extensive gaps in evidence. Given the difficulty in performing randomized trials in CS, current management recommendations are mostly empirical or extrapolated from AMI-CS trials. In general, there is a poor level of evidence for many of the interventions in AMI-CS, and this is especially true for HF-CS.113
High-priority areas for research include: (1) the role of PAC and invasive
Conclusions
HF-CS is a complex syndrome that is increasingly prevalent in the modern CICU. Because of its distinctive presentation, pathophysiology, trajectory, treatment objectives, and outcomes, care of the critically ill patient with HF-CS requires a comprehensive, multidisciplinary approach and early referral of appropriate patients to advanced HF centers. Research to address major evidence gaps is urgently needed.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
Dr. Jacob Abraham has received speaker/consulting honoraria from Abbott and Abiomed.
Dr. Dan Burkhoff has received an unrestricted institutional educational grant from Abiomed and is a consultant to PVLoops LLC.
Dr. Shashank S. Sinha is a consultant for Abiomed.
Dr. Jaime Hernandez-Montfort is a consultant for Abiomed.
Dr. Navin K. Kapur has received institutional
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