A 69-year-old woman with heart failure with reduced ejection fraction caused by left ventricular noncompaction (LVNC) came to the UCSF emergency department with tachycardia, dizziness, shortness of breath and swelling, despite taking all prescribed heart failure medications. Intravenous diuretics were administered to treat hypervolemia. Her shortness of breath suddenly worsened and severe hypoxemia developed, consistent with flash pulmonary edema from acute decompensated heart failure.
The cardiogenic shock team, led by UCSF critical care cardiologist Connor O’Brien, MD, was called to assist with management. The patient was intubated and given nitroglycerine. “Her blood pressure plummeted, and her lactate and creatinine started to climb,” O’Brien said. “Chronic heart failure patients are adapted to low oxygen delivery, so their lactate doesn’t increase until they’re in critical condition. She was in cardiogenic shock.”
The lactate rose from 2.5 to 7 mmol/L and creatinine from 1.1 to 1.8 mg/dL, despite treatment with dobutamine. “Recent data support an approach of early recognition and intervention to support end-organ perfusion and prevent progression to hemometabolic shock, which may be irreversible and lead to death,” O’Brien said. The cardiogenic shock team, which includes specialists from critical care cardiology, cardiac surgery and advanced heart failure, rapidly determined that medications were insufficient and that extracorporeal membrane oxygenation (ECMO) was needed. The patient was then cannulated and an Impella device was placed to vent the left ventricle.
“The lactate cleared quickly, and within two days, kidney and liver function returned to normal,” O’Brien said. Weaning off the ECMO was attempted but not possible, so an emergency heart transplant evaluation was performed by the advanced heart failure team followed by a successful heart transplant procedure by the cardiac surgery team. The patient was able to return home and is doing well. “Evaluation and management of cardiogenic shock patients by a multidisciplinary collaborative team has been shown to improve patient outcomes,” O’Brien continued. “That’s why we utilize this approach to patient management at UCSF.”
An evolving physiology with varying symptoms
Clinical investigations of cardiogenic shock have focused primarily on patients with acute myocardial infarction (AMI). But less than one-third of cardiogenic shock patients have AMI, as the Critical Care Cardiology Trials Network (CCCTN) reported in a 2019 Circulation article co-authored by UCSF critical care cardiologist Christopher Barnett, MD, MPH. UCSF is a member of the CCCTN.
Symptoms vary, and the appropriate treatment is determined by the physiology. “Cardiogenic shock can look different every time, depending on the cardiac lesion,” O’Brien explained. “Patients with chronic heart failure can present with advanced shock despite initially appearing not very sick. They may present with subacute symptoms but can quickly take a nosedive, like this patient.”
Cardiogenic shock teams reduce mortality
In 2020, O’Brien led the creation of a dedicated cardiogenic shock team at UCSF, which includes critical care cardiologists, heart failure specialists, cardiac surgeons, interventional cardiologists and specialized nursing staff.
“We have a multidisciplinary approach to cardiogenic shock and a standard algorithm by which to activate the team and get the correct therapy in place as early as possible,” he said. “There had been a stagnancy in cardiogenic shock outcomes for decades, with mortality rates of 40 to 50%. In our cardiogenic shock team’s first year, mortality was reduced below 30%.
“A growing body of evidence shows that shock teams save patients’ lives,” he added. A 2021 CCCTN paper in the Journal of the American College of Cardiology, with Barnett as senior author, found that cardiogenic shock mortality was 23% in hospitals with shock teams versus 29% in hospitals without shock teams. O’Brien, Barnett and other UCSF cardiac critical care specialists published a 2022 review article that described the potential mechanisms by which multidisciplinary shock teams improve outcomes: facilitating early patient phenotyping, rapidly implementing appropriate interventions, and quickly escalating support to prevent end-organ failure.
“No one person can really deliver optimal care in this scenario,” O’Brien said. “It takes a specialized team and requires a lot of coordination. The outcomes data show the investment is worthwhile.”
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