Cardiogenic Shock per the American Heart Association (AHA)

This an open access from the AHA regarding management of Cardiogenic Shock. This is good stuff. There’s nothing brand new (to me at least) but it’s always good have the (mostly) updated data in one place. Of course, I’m solely going to touch on the topics of Medical Management because I can’t perform PCI nor introduce Impellas (yet).
Here are a couple of key points that I like:
  • Although the CICU environment may be best suited to centralize cardiac care of patients with CS, attending cardiologists and teams may not have the dedicated training to address the ancillary multi-system organ failure often associated with CS.” There are little smiling emojis with the hearts for eyes all over this point. I don’t want to incite a specialty war here, but I prefer to be involved in the care of these patients. That’s my specialty-induced bias. 
  • They don’t recommend a set MAP target. This makes a lot of sense to me since everyone is different and BP does not equal a good cardiac output. Lots of training in the CVICU world proved this to me (thanks fellowship!). What they recommend is to look at the patient, check lactates, mixed venous blood gases, UOP, LFTs, renal function, temperature, and, of course, look at your patient! I purposefully repeated the last part to emphasize it.
  • This next point is a mixed bag. First of all, they call out dopamine for what it is; “Dopamine was associated with a higher rate of arrhythmias in the CS and overall populations and was associated with higher risk of mortality in the CS subgroup”. But then they go ahead and list it as first line using either it or Norepinephrine in table 5 for initial vasoactive management considerations (which is a great table, by the way). They also show a dose-related receptor binding model which I could’ve sworn was disproven. I need to find that data now for you all. 
  • Thank you for not touching on the mode of mechanical ventilation in these patients. Also, good job in addressing the “potential deleterious effect of hyperoxia in patients with ACS, HF, and OHCA and in general ICU patients”. That’s something we see too often that we need to improve upon. 
  • Did I already mention that I liked table 5? Well, I like table 5. 
A couple points I don’t like:
  • They recommend checking CVPs. Ugh. I guess if you trend the number instead of of just taking the textbook numbers as being normal then you may be okay. Ultimately, I recommend that you become comfortable with bedside echo, the intensivists new best friend. At the time of this writing, the ever elusive method to volume status continues to be ever elusive.
  • They don’t really dig in to the argument of using CRRT/ultrafiltration to offload the heart which I believe is reasonable. I’m not going to go into the studies of early vs. late dialysis nor the studies of using ultrafiltration to offload the heart. That’s a topic for another day. I guess the AHA felt the same way regarding cardiogenic shock.
  • The whole dopamine thing I ranted about above. Yeah, I don’t like that.
At the end of it all, just read the article for yourself. It’s worth your time instead of scrolling through Instagram a few times. Thanks to the authors. These things must be a beast to put together. Click here for my blog post on mechanical circulatory support.

van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association (AHA). Circulation. 2017 Oct 17;136(16):e232-e268. doi: 10.1161/CIR.0000000000000525. Epub 2017 Sep 18. PMID: 28923988.
Link to Article


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