Cardiogenic shock centres for optimal care coordination and improving outcomes in cardiogenic shock

Abstract

This article refers to 'Impact of hospital transfer to hubs on outcomes of cardiogenic shock in the real world' by D.Y. Lu et al., published in this issue on pages 1927-1937.Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult to the subsequent occurrence of organ failure and death. 1 Despite advanced management, including aetiological treatment and mechanical circulatory support (MCS), CS represents the most severe manifestation of acute heart failure 2 with in-hospital mortality varying between 30-50%, depending on the underlying aetiology. 1,3-5 CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested. Evidence from randomized trials is limited, mostly because small numbers of patients are recruited, with only approximately 2000 patients being randomized in CS trials. 4 In addition, blinding is often not possible, and the primary endpoints often differ among the studies. Furthermore, designing new outcome trials in CS remains particularly challenging in this critical and very costly scenario in cardiology. In these conditions, gaps in evidence are extensive in terms of disposition decisions, use of haemodynamic monitoring, and timely deployment of interventions. 1,[3][4][5] As a result of limited evidence base and inequal distribution of facilities there is a wide heterogeneity of patterns of care between the hospitals treating CS, which may delay timely deployment of appropriate resources or may delay the patient transfer to an experienced centre for haemodynamic support or definitive intervention. Recently, new approaches to care of CS patients have focused on mechanisms beyond medical therapies per se, implying that CS management should consider appropriate organization of the health care services in order to facilitate optimal care coordination and to minimize time delay. 6 There is growing interest for developing CS centres and CS teamsThe opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.

Risk stratification in cardiogenic shock: from clinical utility to improving outcomes

“…In terms of clinical utility for clinical practice, a risk score model would ideally inform clinical decision‐making ( Figure ). The risk score should help to efficiently triage ‘selected patients’ to an appropriate care location, from ‘spoke’ to ‘hub’ hospitals, in order to facilitate specific interventions tailored to the aetiology and severity of CS 18,19 . Transferring patients who are too sick or out of the window of benefit may be futile, 4,18 while careful selection for transfer of targeted patients who may be potentially candidates for advanced therapies, may contribute to better outcomes.…”

“…The risk score should help to efficiently triage ‘selected patients’ to an appropriate care location, from ‘spoke’ to ‘hub’ hospitals, in order to facilitate specific interventions tailored to the aetiology and severity of CS 18,19 . Transferring patients who are too sick or out of the window of benefit may be futile, 4,18 while careful selection for transfer of targeted patients who may be potentially candidates for advanced therapies, may contribute to better outcomes. If positive results in the ongoing randomized controlled trials will confirm the clinical efficacy of MCS, a well calibrated risk score, complementary to SCAI CS classification, may assist clinical decision‐making and may serve to select CS patients who derive clinical benefit from early implant of MCS.…”

Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors

“…[19][20][21][22][23][24] It is therefore recommended that they are administered at the lowest possible dose and the shortest possible duration. 1 Although transfer to specialized tertiary care centres and escalation to mechanical circulatory support (MCS) is advocated in case of CS refractory to medical treatment 1,25 , the use of inotropes and/or vasopressors remains mandatory for the initial stabilization of the patient. 2 Therefore, we aimed to review current evidence and approaches on medical therapy in CS, mainly focusing on the use of inotropic and vasopressor agents.…”