Team-based Cardiogenic Shock Care Improves Outcomes: Study

Team-based cardiogenic shock care may be associated with improved outcomes, new study results suggest.

Researchers working out of the INOVA Heart and Vascular Institute in Falls Church, Va., and publishing in the Journal of the American College of Cardiology, sought to determine whether standardized team-based approaches to care for cardiogenic shock improve outcomes, and also whether a risk score is able to guide clinical decision making.

“Despite the growing body of evidence supporting timely recognition of cardiogenic shock, hemodynamic monitoring, tailored escalation to mechanical circulatory support, and centralized care, variations in practice patterns in cardiogenic shock management endure and may contribute to persistently high mortality rates,” they wrote in their paper. “We hypothesized that the deployment of a multidisciplinary “shock team” providing timely diagnosis and utilizing standardized protocols would reduce practice variations and improve clinical outcomes.”

The observational study included 204 consecutive patients with cardiogenic shock, from whom etiology, demographic characteristics, right heart catheterization, mechanical circulatory support use, and survival data were extracted. The researchers then determined 24-hour thresholds for arterial pulsatility index (PAPi; >1.0), lactate (<3.0 mg/dL), and cardiac power output (>0.6 W). They also measured cardiac power output and PAPi at baseline and at 24 hours after diagnosis with cardiogenic shock. Logistic regression analysis was used to develop validated risk stratification score.

Team-based Care Works

According to the study results, 30-day survival improved from 47% in 2016 to 57.9% in 2017 and 76.6% in 2018 (P<0.01 for both comparisons). Age over 71 years, diabetes mellitus, dialysis, vasopressor use at time of diagnosis for cardiogenic shock, lactate levels ≥3.0 mg/dL, CPO <0.6 W, and PAPi <1.0 at 24 hours after diagnosis and implementation of therapies were all identified as independent predictors of 30-day mortality. The researchers used the data to develop a 3-category risk score consisting of 1 to 2 points assigned to each variable: 0 to 1 (low), 2 to 4 (moderate), and more then 5 (high).

“Our observational study suggests that the implementation of a shock team predicated on a multidisciplinary standardized team-based approach emphasizing timely diagnosis, mandatory invasive hemodynamics, and appropriate use of mechanical circulatory support is not only feasible but may result in improved survival in all-comer patients with cardiogenic shock. In addition, a validated score that uses demographic, laboratory, and hemodynamic markers can help to stratify risk and guide clinical decision-making in patients with all phenotypes of cardiogenic shock.”

The Future

The researchers emphasized the potential impact of the analysis results on the design of future studies.

“We believe that concerted efforts to apply standardized multidisciplinary care in a coordinated regional approach may not only reduce practice variation and improve patient outcomes, but may also facilitate pragmatic trial designs evaluating current and future novel therapies for a clinical syndrome that for too long has been marked by excessive morbidity and mortality.”

Standardized Team-Based Care for Cardiogenic Shock | JACC: Journal of the American College of Cardiology: A new paradigm for cardiogenic shock care https://t.co/XDvcn4EXld

— Christopher O'Connor (@coconnormd) April 2, 2019

Need to be banding together multicenter studies as we all roll out our #waronshock teams. @ShashankSinhaMD @JHMontfort10 @IAmDrIbrahim @SunitChaudhryMD @stephenpanmd @yehyamin @Abraham_Jacob https://t.co/aY6j5jN3CF

— Andrew J Sauer MD (@AndrewJSauer) April 2, 2019

Excellent outlined approach with outcomes. Another example of the need for HD to guide therapy with pac, use of CPO and PAPi and markers of perfusion using lactate. Becoming standard of care… https://t.co/VsC0jvy4f9

— Gregory Macaluso (@gmac78) April 2, 2019