Patients with cardiogenic shock need defined pathways of escalation and care to improve survival.
Cardiogenic shock (CS) occurs when a cardiac disorder means it can no longer supply adequate blood and oxygen to vital organs. This causes a life-threatening state known as hypoperfusion that can rapidly lead to multi-organ failure and death.
Nearly 1 in 10 patients suffering from a heart attack will develop cardiogenic shock, and upto half of patients will not survive to hospital discharge.
These high death rates are partly attributable to delays in recognition of CS and subsequent timely access to the evidence-based interventions and expertise required for optimal patient management.
Early identification of CS, rapid intervention to reverse the underlying cause, and immediate haemodynamic stabilisation with or without the use of mechanical circulatory support (MCS) technologies are vital to improve survival. Observational data suggest that input and support from specialist multidisciplinary CS teams (CS-MDT) at an early stage in the patient pathway impacts survival. The CS-MDT provides 24/7 case-based discussion and treatment recommendations up to and including transfer to the CS Centre where indicated. Similarly, and in parallel with other acute illnesses such as stroke and myocardial infarction, cohorting of patients in regional, specialist CS Centres, is likely to improve patient outcomes. CS Centres acting as the hub of a regional network would provide the entire spectrum of cardiac diagnostics and therapeutics and access to invasive haemodynamic monitoring and MCS technologies required to manage this complex and dynamic condition. CS Centres also work closely with supra-regional Advanced Heart Failure Centres (AHFCs), where not colocated, to ensure all patients with CS who might benefit from advanced heart failure therapies including heart transplant are discussed.
The cardiology Getting it Right First Time (GIRFT) report emphasises the importance of networked models of care. Robust process, efficient pathways and effective training and education across networks are likely to be the first step towards improving clinical outcomes in CS.
In this document, we outline several recommendations as part of a systems approach to improving patient survival and experience. These include but are not limited to:
- Increase awareness among healthcare staff that any deteriorating patient with an elevated NEWS-2 score and evidence of hypoperfusion should prompt consideration of CS as a potential cause. Echocardiography (or focused cardiac ultrasound [FoCUS]) and electrocardiogram should follow urgently
- Improve access to echocardiography out-of-hours (including FoCUS with expert review), to support/exclude the diagnosis of CS or other cardiac pathologies
- Adopt SCAI staging as the standardised descriptor of CS to facilitate triage, communication and expediency of discussion with a CS Centre
- Establish CS Centres as part of regional CS networks to bring together the most critically ill patients with the right clinical expertise
- Ensure equity of access to CS expertise and care, including shorttern MCS, through the design of CS networks and distribution of CS Centres
- Develop clear pathways of care and protocols for CS care within networks to complement existing acute cardiac care pathways, including 24/7 access to CS-MDTs and transfer to CS Centres • Develop network protocols for patient selection for short-term MCS
- Define a minimum CS dataset, and collect this data, including through existing national audits, encompassing the entire patient pathway
- Prioritise high-quality research in CS to address important areas of uncertainty, including patient selection for short-term MCS and cost-effectiveness of improved care pathways
The national Cardiac Pathway Improvement Programme (CPIP) represents an opportunity to embed many of these recommendations, to potentially transform outcomes in these patients, and CPIP leaders nationally and regionally should work with stakeholders and CS experts to implement them.
