Management of cardiogenic shock

Abstract

Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.

Central illustration

Treatment algorithm highlighting the key considerations in the diagnosis and management of cardiogenic shock. A level I shock centre has cardiac catheterisation and advanced MCS available 24 hrs, 7 days/week with on-site cardiothoracic surgery support, level II has PCI facilities 24/7 but is without on-site MCS. AMI: acute myocardial infarction; CI: cardiac index; CICU: cardiac intensive care unit; CPO: cardiac power output; ECG: electrocardiogram; Hb: haemoglobin; LVAD: left ventricular assist device; MCS: mechanical circulatory support; SCAI: Society for Cardiovascular Angiography and Interventions

Figure 1

Current evidence from randomised clinical trials in cardiogenic shock in the PCI era. The relative risk and 95% confidence intervals (CI) are depicted for the various randomised interventions. The SOAP II trial was neutral with respect to mortality for the overall trial, thus the predefined cardiogenic shock - including various causes of cardiogenic shock - subgroup results need to be interpreted with caution. CABG: coronary artery bypass grafting; CS: cardiogenic shock; IABP: intra-aortic balloon pump; IABP-SHOCK: Intraaortic Balloon Pump in Cardiogenic Shock; SHOCK: SHould we emergently revascularise Occluded Coronaries for cardiogenic shocK; SMASH: Swiss Multicenter trial of Angioplasty for SHock; SOAP II: Sepsis Occurrence in Acutely Ill Patients II; TRIUMPH: Tilarginine Acetate Injection in a Randomized International Study in Unstable MI Patients With Cardiogenic Shock; PCI: percutaneous coronary intervention

Figure 2

Schematic drawings of current percutaneous mechanical support devices for cardiogenic shock with technical features. On the left side are devices for right ventricular support and on the right side those for left ventricular support. a) Impella RP. b) TandemHeart RA-PA (right atrium – pulmonary artery). c) VA extracorporeal membrane oxygenation (ECMO). d) Intra-aortic balloon pump. e) Microaxial devices: including new development of Impella ECP and Thoratec PHP. f) TandemHeart.

Figure 3

Enrolment data for major randomised cardiogenic shock trials. A) Number of patients included in major randomised cardiogenic shock trials including the primary endpoint (EP). Blue bars indicate finalised trials. In parentheses is the clinicaltrials.gov number if available. Data last accessed (on clinicaltrials.gov) 22 October 2020. B) Number of patients included in major randomised cardiogenic shock trials. Red bars indicate ongoing or planned randomised trials. In parentheses is the clinicaltrials.gov number if available. Data last accessed (on clinicaltrials.gov) 22 October 2020. Acronyms and tested strategy of ongoing or planned randomised trials: ACCOST-HH: Adrecizumab vs placebo in cardiogenic shock. Altshock-2: IABP within six hours of onset of cardiogenic shock versus standard of care (no device) in cardiogenic shock. ANCHOR: VA-ECMO under echo guidance via the femoral route, with IABP in the contralateral femoral artery versus standard management of cardiogenic shock (i.e., no devices) complicating myocardial infarction. COCCA: low dose corticosteroid therapy (hydrocortisone and fludrocortisone) versus placebo in cardiogenic shock. DanGer: Impella CP versus control in cardiogenic shock complicating myocardial infarction. DAPT-SHOCK-AMI: Multicentre randomised double-blind trial comparing intravenous cangrelor and oral ticagrelor in patients with acute myocardial infarction complicated by initial cardiogenic shock and treated with primary angioplasty. ECLS-SHOCK: VA-ECMO versus control in severe cardiogenic shock complicating myocardial infarction. ECLS-SHOCK: Extracorporeal life support and revascularisation versus revascularisation alone in patients with severe infarct related cardiogenic shock. ECMO-CS: VA-ECMO versus control in cardiogenic shock complicating myocardial infarction. ECMO-RRT: VA-ECMO plus routine renal replacement therapy versus VA-ECMO and standard of care in cardiogenic shock. EURO-SHOCK: VA-ECMO versus control in cardiogenic shock complicating myocardial infarction. HEMO-ECMO: Simultaneous haemoperfusion with ECMO versus ECMO alone for cardiogenic shock. HYPO-ECMO: VA-ECMO with moderate hypothermia versus VA-ECMO with normothermia in cardiogenic shock. IABP pre Revasc: IABP pre revascularisation versus control in cardiogenic shock complicating acute myocardial infarction. LevoHeartShock: Levosimendan in addition to conventional strategy versus placebo in addition to conventional strategy in cardiogenic shock. PRAGUE OHCA: VA-ECMO versus control in refractory out-of-hospital cardiac arrest. REVERSE: VA-ECMO with Impella CP versus VA-ECMO alone in cardiogenic shock. Ivabradine in CS: Ivabradine vs placebo initiated 3 hrs after dobutamine in patients with cardiogenic shock/stage D heart failure who require dobutamine and whose HR is >100. Note that ACS patients are excluded from this study. EVOLVE-ECMO: In patients with CS on ECMO, initiation of percutaneous LA venting via septal puncture when B-lines detected on lung ultrasound, versus when refractory pulmonary oedema is detected on chest radiograph and/or inadequate LV opening detected on echocardiography. LVVI adjusted dobutamine: initiate dobutamine at 5 mcg/kg/min and adjust according to the ejection volume index versus initiate dobutamine at 5 mcg/kg/min and adjust according to the attending physician in patients with an EF documented at <40% and cardiogenic shock. Note that ACS patients are excluded from this study. TS-CS-OOHCA: Anti-inflammatory effect of therapeutic hypothermia in out of hospital cardiac arrest patients with cardiogenic shock. CPC: cerebral performance category; EP: endpoint; Heart replacement therapy: heart transplant or left ventricular assist device implantation; MACE: major adverse cardiac events; RRT: renal replacement therapy

Figure 4

Left: considerations on potential surgical or percutaneous approaches to unload the left ventricle in the setting of venoarterial extracorporeal membrane oxygenation. Right: venoarterial extracorporeal membrane oxygenation and upgrades in cardiogenic shock and lung failure. A) Conventional set-up of venoarterial extracorporeal membrane oxygenation circuit consisting of venous and arterial femoral cannula with distal perfusion catheter. B) ECMELLA (venoarterial extracorporeal membrane oxygenation and Impella). C) Venoarteriovenous extracorporeal membrane oxygenation configuration with a second cannula originating as Y-configuration from the arterial extracorporeal membrane oxygenation system to jugular vein. D) Simplified venoarteriovenous-extracorporeal membrane oxygenation configuration with a bypass from distal perfusion catheter to both lumens of jugular Shaldon catheter. E) Venoarterial-pulmonary arterial extracorporeal membrane oxygenation with an additional cannula positioned in the pulmonary artery. F) Venoarteriovenous-extracorporeal membrane oxygenation configuration in combination with Impella. Adapted from Lüsebrink et al , with permission from Oxford University Press.