Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center

Abstract

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Keywords: acute cardiovascular syndrome; acute heart failure; cardiogenic shock; mechanical cardiac support; multidisciplinary team.

Figure 1

Temporal trend mortality reduction from first time quartile to fourth quartile in overall population and in patients > 80 years. (First quartile: 7 March 2012–12 July 2014; Second quartile: 12 July 2014–4 April 2017; Third quartile: 4 April 2017–19 August 2019; Fourth quartile: 19 August 2019–3 July 2021).

Figure 2

Temporal trend in Impella CP and IABP use. (First quartile: 7 March 2012–12 July 2014; Second quartile: 12 July 2014–4 April 2017; Third quartile: 4 April 2017–19 August 2019; Fourth quartile: 19 August 2019–3 July 2021).

Figure 3

Change in management of inotropic drug therapies over time. (First quartile: 7 March 2012–12 July 2014; Second quartile: 12 July 2014–4 April 2017; Third quartile: 4 April 2017–19 August 2019; Foutth quartile: 19 August 2019–3 July 2021).