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Canadian Journal of Cardiology

Mechanical Circulatory Support in Cardiogenic Shock: Shock Team or Bust?

  • Daniel H. Kim
    Correspondence
    Corresponding author: Dr Daniel H. Kim, Interventional, Advanced Heart Failure, Transplant/MCS Program, University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta TG6 2B7, Canada.
    Affiliations
    Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Published:November 08, 2019DOI:https://doi.org/10.1016/j.cjca.2019.11.001

      Abstract

      Cardiogenic shock (CS) accounts for 15% of all admissions to cardiac intensive care units, with acute myocardial infarction cardiogenic shock (AMICS) accounting for 30% of these. In contrast to other areas in cardiac care in which survival has continued to improve over the last two decades, CS still carries a mortality of around 40%. Temporary mechanical circulatory support (tMCS) therapies have shown inconsistent results in improving outcomes in CS, with the overall evidence not supporting its use, at least in unselected patients. Some of the main stumbling blocks leading to disappointing results of tMCS in CS are challenging patient identification and selection; delayed timing; lack of a systematic approach; inappropriate use of adjunct therapies and tools; lack of escalation/de-escalation and long-term planning; and disparities in regional/centre access to MCS. Among the most promising solutions to this challenge is the cardiogenic shock team (CST), which takes a standardized multidisciplinary approach to the acute management of CS. This paradigm brings expertise from advanced heart failure, interventional cardiology, cardiac surgery, cardiac intensive care, nursing, and others to address all of the aforementioned issues effectively. Unsurprisingly, hurdles to implementation exist, such as establishing effective team dynamics, maintenance of competence, and securing and maintaining adequate resources. However, although the shock-team approach is still in the early stages of clinical evolution, preliminary studies have been encouraging and suggest the value of broader application and evaluation.

      Résumé

      Les cas de choc cardiogénique représentent 15 % de toutes les admissions aux unités de soins intensifs de cardiologie, les cas de choc cardiogénique dû à un infarctus du myocarde aigu comptant pour 30 % de ces admissions. Contrairement à ce que l'on observe dans d’autres domaines des soins en cardiologie, où la survie ne cesse de s’améliorer depuis 20 ans, le choc cardiogénique est toujours associé à un taux de mortalité d’environ 40 %. Le traitement par assistance circulatoire mécanique temporaire (ACMt) donne des résultats inégaux quant à l’amélioration de l’issue du choc cardiogénique, et les données probantes montrent qu’il n’est généralement pas recommandé, du moins pas dans tous les cas. Parmi les pierres d’achoppement qui ont mené aux résultats décevants de l’ACMt pour le traitement du choc cardiogénique, citons la difficulté de reconnaître et de sélectionner les bons candidats; les délais de mise en œuvre; l’absence d’une approche systématique; l’utilisation inappropriée des traitements d’appoint et des autres outils; les lacunes en matière de protocoles d’escalade et de désescalade thérapeutiques et de planification à long terme; et les disparités dans l’accès à l’ACMt entre les régions et les grands centres. La mise sur pied d’une équipe d’intervention en cas de choc cardiogénique, qui permet l’adoption d’une approche multidisciplinaire uniformisée, constitue l’une des solutions les plus prometteuses à ce problème. Ce modèle permet de rassembler des experts de différents domaines : insuffisance cardiaque avancée, cardiologie interventionnelle, chirurgie cardiaque, soins intensifs en cardiologie, soins infirmiers et autres, afin de résoudre efficacement tous les problèmes susmentionnés. Comme on pouvait s’y attendre, des obstacles entravent la mise en œuvre d’un tel modèle, notamment l’instauration d’une dynamique d’équipe efficace, le maintien des compétences et l’obtention et le maintien de ressources adéquates. Même si l’approche consistant à mettre en place une telle « équipe de choc » en est encore aux premières étapes de son évolution clinique, les études préliminaires sont encourageantes et donnent à penser qu’une application et une évaluation élargies ne sont pas dénuées de valeur.
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