Systems of Care in Cardiogenic Shock

Abstract

Outcomes for cardiogenic shock (CS) patients remain relatively poor despite significant advancements in primary percutaneous coronary interventions (PCI) and temporary circulatory support (TCS) technologies. Mortality from CS shows great disparities that seem to reflect large variations in access to care and physician practice patterns. Recent reports of different models to standardize care in CS have shown considerable potential at improving outcomes. The creation of regional, integrated, 3-tiered systems, would facilitate standardized interventions and equitable access to care. Multidisciplinary CS teams at Level I centers would direct care in a hub-and-spoke model through jointly developed protocols and real-time shared decision making. Levels II and III centers would provide early access to life-saving therapies and safe transfer to designated hub centers. In regions with large geographical distances, the implementation of telemedicine-cardiac intensive care unit (CICU) care can be an important resource for the creation of effective systems of care.

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Acute MI-Cardiogenic Shock and Endorsed by the Asian Pacific Society of Interventional Cardiology

“…8,9,36,[48][49][50] Shock protocols enabled early identification of the appropriate plan of action and also improved quality measures, such as time to MCS without significantly delaying revascularisation. 36,51…”

Timing and treatment strategies according to SCAI classification in cardiogenic shock

“…This is especially true for those who live in suburban or rural areas and aim to centralize expertise and technology, reduce healthcare cost, and improve outcomes. 34 The multidisciplinary team is composed of intensive care cardiologists, interventional cardiologists, cardiac surgeons, cardio-anesthesiologists, dedicated nurses, and a perfusionist to properly treat patients admitted for CS. Observational data suggest that the presence of a dedicated multidisciplinary shock team has a beneficial impact on in-hospital- and 1-month mortality in patients admitted for CS.…”

The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock

“…Given the time-sensitive nature of CS care and associated intensive resource utilization, shock teams have been developed to efficiently implement care for appropriate populations [6,7,8 ▪▪ ]. In addition to shepherding local resources, shock teams serve as quarterback for hub and spoke models developed to facilitate early transfer of CS patients from community hospitals to tertiary care centers with expertise in CS management [7,19]. Herein, we outline the composition of the modern shock team, specific clinical roles of a shock team, and the growing clinical data supporting the association of shock teams with improved patient outcomes…”

“…Despite this early success, and substantial enthusiasm amongst acute cardiovascular care providers, subsequent randomized controlled trials have failed to show added benefit from additional interventions, such as intra-aortic balloon pump (IABP) and percutaneous ventricular assist devices (pVAD) [2–4]. Persistently high patient morbidity and mortality have prompted considerable efforts to better phenotype CS, identify phenotype-specific treatments, and develop teams dedicated to the early treatment of CS [5–7,8 ▪▪ ].…”