Cardiogenic Shock: Reducing Mortality Through Prevention and Rapid Treatment

[00:00:00] I’m Yvonne Commodore-Mensah, Board President for PCNA. I’d like to welcome you to this episode of Heart to Heart Nurses. PCNA supports your professional journey with accessible continuing education, practical patient resources and a vibrant community that understands the unique challenges and rewards of cardiovascular nursing. Together, we’re advancing the knowledge that defines excellence in cardiac care while celebrating the difference you make every day.

Geralyn Warfield (host):

I’d like to welcome our audience today to our conversation with Amy Sheppard. Amy, could you introduce yourself to us?

Amy Sheppard (guest):

Sure. My name is Amy Sheppard. I’m the STEMI and Cardiogenic Shock Program Manager at the University of Wisconsin Hospital and Clinics.

Geralyn Warfield (host): (00:20)

Well, why don’t we go ahead and start right off talking about the signs and symptoms of cardiogenic shock.

Amy Sheppard (guest): (00:25)

Yeah, I’ll just start off by saying cardiogenic shock is, the mortality for this—it’s a very highly lethal, or the level of mortality for these patients is about 50%.

And the needle in outcomes for these patients has not really been moved in the last 20, 30 [years]—or ever, really. So, we’re really trying to make advances to move the needle.

And so, recognition is one of those things that can be very tricky with these patients because there’s various levels of cardiogenic shock. And so, when we look at the Society of Cardiovascular Angiography and Intervention (SCAI), and we use this SCAI shock pyramid, which goes level A, B, C, D, and E.

A: being at risk

B: being beginning

C: being classic shock

D: deterioration

E: extremis

So, A being the least of that. And so, we look at the patients for the at-risk level. At-risk being like a patient, maybe had a heart attack, they have heart failure. We know these patients are at risk, but they’re not really exhibiting symptoms at that time. But we need to keep in the back of our head that cardiogenic shock could be a possibility with this patient.

B is where that patient starts to exhibit symptoms, maybe hypotension, maybe not hypotension, but hypoperfusion. And the patient could go quickly into classic shock, D or E. It is not a linear progression, either, so they could go from B to D to E. So, we call B as ‘bad.’ So, catching those patients before they get to C, D, or E.

And we know that patients in B in the first 24 hours have the ability to decompensate quicker than any of the other levels of shock.

So then with C, the classic shock, we’re looking at patients who may be on an inotrope, or have an assist device put in.

D is where that patient is really deteriorating. Hemodynamics are not doing well, we have them on multiple pressers, mechanical circulatory to support.

And then E, extremis, where that patient is circulatory collapse. So very, very sick.

So, when we look at the signs and symptoms of cardiac shock, typically we see patients who are low blood pressure—but not always. And it really kind of depends, too, because we can have patients who are…there’s different types. We have different phenotypes.

So, we now don’t look at cardiogenic shock as just cardiogenic shock as a whole.

There’s cardiogenic shock for AMI patients.

Then we have cardiogenic shock for heart failure patients. And we even kind of break that heart failure patient population down to de novo, meaning new onset heart failure, or acute-on-chronic. And how we treat those patients may be different, if it’s acute MI versus heart failure.

So, we know that patients with heart failure are decompensating over time. They may be walking around with a very low cardiac output, and out in the community and living their life.

So, if I were in cardiogenic shock as with an AMI versus the heart failure patient, we’re going to feel that more profoundly, because it’s such an immediate insult versus compensating over a period of time for heart failure patients, if that makes sense.

Geralyn Warfield (host): (04:08)

So, what exactly does this cardiogenic shock, what does that entail for the heart? Is it affecting the muscle, the electrical system, for people that aren’t as familiar with it?

Amy Sheppard (guest): (04:17)

It basically affects the muscle, right? But then along with that, we can get patients who maybe are having electrical issues such as a VT, ventricular tachycardia storm, it’s called. So, they’re going in and out of VT because their heart’s so sick. And they’re just not able to perfuse in that VT.

So that’s also another form of cardiogenic shock related to, perhaps, some other injury to the heart. It could be a previous MI with scarring. It could be heart failure.

But the typical things we see are usually from acute MI or heart failure, and typically muscle cardiomyopathies.

Geralyn Warfield (host): (04:57)

So, it sounds like from the description of symptoms that you have listed for us that we would see this, typically, in older individuals, or for those that you’ve just described might be having an acute MI at any point in their life. Is that an accurate assessment or maybe not?

Amy Sheppard (guest): (05:12)

No, and that’s a very good point to bring up. This can happen in people who may get myocarditis, so they might get an infection.

Maybe they were sick with some other virus and that virus attacked the heart. We do see young patients getting cardiogenic shock because of that. Really, that doesn’t have anything to do with their lifestyle, per se, in terms of preventative cardiology. It’s just that they get a virus that attacks the heart.

So, those are very sad cases. And it’s really important to get those patients to that quaternary center where we can treat them with those assistive devices, and have that level of expertise to get them the support they need to turn that around before it goes on too long and the damage is beyond repair.

Geralyn Warfield (host): (06:01)

So, outside of these acute incidents, you listed some symptomology that we might be looking for, or at least some underlying disease states or related disease states like hypertension and other things. How would I as a clinician first start to think about cardiogenic shock? I mean, obviously it can happen at any time to anyone, any place. So, in some ways it needs to be part of my thinking all the time. When might I start to maybe suspect even if there’s no symptomology?

Amy Sheppard (guest): (06:30)

So, definitely if you have a patient who maybe they had a STEMI, and a late-presentation STEMI. So we think about those patients who sat at home for more than 12 hours a couple days. And they come in and they have an LAD lesion and we fix it, and we stent it.

But we know they’re at very high risk for mechanical complications. So, ventricular septal defects, papillary muscle rupture, those things are very strong predictors for cariogenic shock. So, keeping that in the back of your head that ‘this patient is at very high risk.’

And then if you start to see those symptoms of hypotension, if you start to notice you’re drawing labs and their lab values for their end organ perfusion such as their liver function, kidney function, we look at lactate levels if there’s death of tissue, right? And we’re looking at that consistently.

But those are things that maybe those incidental findings, not incidental, but you’re looking at the labs, and you see that maybe they don’t have the actual symptoms yet. Typically, they will, though. And that will be the hypotension, the tachycardia, sometimes respiratory distress, they start to get very sick. Decreased urine output, hypoxia, as I mentioned.

So, those are some of the key things that you’re going to see when patients truly are starting to go down that spiral. And we talk about the cardiogenic shock spiral because once you get into that, it’s a cascade effect. Your diastolic filling pressures goes up. Your cardiac output goes down.

With cardiac output going down, you’re getting decreased coronary perfusion. Decreased coronary perfusion leads to ischemia. So, it’s a big cascade.

And then you get those compensatory mechanisms of your blood. So, you start to get vasoconstriction, which is not good for these patients. It’s really we have to get this stopped at the beginning of the spiral, because once you get down into that spiral, the writing’s on the wall.

Geralyn Warfield (host): (08:28)

Right. So, if we are able to catch it at the top of that spiral, I believe you started to talk about some treatment options. Could you talk about those a little bit more?

Amy Sheppard (guest): (08:50)

So, when we see patients in cardiogenic shock, the first thing we’re going to do, generally speaking, because it’s right there, we’re going to put them on a vasoactive drip. A lot of times it’s going to be norepinephrine.

We may put them on an inotrope. And so, we might go with dobutamine because it’s got some of the heart and the beta and alpha properties to help with that support.

And then we’re going to kind of make sure to check their labs and see how they’re doing. Right away we’ll see how that goes. We want to make sure that we’re looking at invasive hemodynamic measures. So, a lot of times we recommend putting the Swan-Ganz catheter in, getting right heart cath, getting numbers, getting them decongested wherever that may be to make sure that we can get them, whether that be a diuretic that we get them, to get that congestion out of the heart.

And then we’ll see how they do.

And if we don’t see them turning around on those measures, we don’t want them sitting on inotropes for an extended period of time. That is shown to not lead to good outcomes for these patients.

So, we want to start looking at, what do we have going on here? What do we have for mechanical circulatory support devices? And that’s kind of where we talk about the cath lab, and treatments for that.

We can take them to the cath lab; we have the whole array of percutaneous left ventricular circulatory support devices that we can use. Typically, we don’t use the balloon pump a whole lot anymore, because the output doesn’t give a whole lot of support, and studies have shown it’s not as beneficial as we once thought it was.

So, we have been going with the Impella® device, which is the Impella® CP, typically. And that’s the lower one, there’s different levels of Impella®. So, we put the patient on the Impella® CP, kind of see how things are going. Doing those serial assessments, making sure we’re looking at the patient’s lactate and organ hypoperfusion. And if those things are turning around, then we’ll sit on that and see how they do.

If we see that patient’s not turning around, we’ve got to pivot. We don’t have time to sit there for days if they’re not turning around. So, we’re really trying to reinforce we need to have good communication, good collaboration, a multidisciplinary team approach, which we do have. So, we have huddles to discuss these things.

So, we may decide to go with the CP, but hey, if we don’t see that CP is working within X amount of hours, let’s either take them to the OR for the Impella 55® which is an OR procedure which is pretty amazing. They go in the axillary artery, and the patient is actually able to sit up and walk around, providing they’re well enough to do. But that’s a really good device for patients that are bridging to transplant or LVAD.

But we do have plans for escalation.

The other thing I wanted to mention about that too, is, when we’re making decisions to put these devices in, we really look at the patient and their situation and we call it the ‘exit strategy’ for these patients. Because if we know this patient likely isn’t going to have recovery of their native heart, if they’re not a candidate for LVAD, not a candidate for transplant, and we put them on these devices, what’s the exit strategy here?

Because we aren’t going to put them on the device for them to die on the device. So then, we start going down the pathway of palliative care discussions and that sort of thing. But we do those Impella® LVADs in the cath lab. And we actually put patient on ECMO in the cath lab, too.

Geralyn Warfield (host): (12:07)

Great. Well, we are going to take a quick break and we will be right back.

Geralyn Warfield (host): (12:26)

We’re back and we’re going to be continuing our conversation about cardiogenic shock. And one of the things that came to mind as you were describing this process, this spiral, this trajectory that patients might be on is that it’s not them by themselves. Obviously, they’ve got their care team, but they also have the individuals in their life, their family, their caregivers. And how do you at your facility or in your organization engage those individuals and help them as well?

Amy Sheppard (guest): (12:50)

That’s a great question. And a very important question.

We do have care coordinators and then we have the clinical team who will do care conferences with the patient. And really kind of lay out, in frank conversations with them, of course in the gentlest way possible, what the prognosis is for their family member. And the different, various strategies that we could take for this patient.

And then, sometimes, we just have to say you know flat out that really there’s not much more that we can do.

So, we do have care conferences with the patients, we have care coordinators. And if the patient is not able to chime in on their own care because they are unconscious, then we do have the family. And we talk about what loved one would want. And sometimes, they’re like, “My loved one would not want all this. We don’t want to pursue, they may be candidates for LVAD, transplant, but they would not want that. That’s not what they want.” If they don’t think their loved one would have the meaningful life that they know…maybe they’ve expressed that wish to them, then sometimes we just, we’ll go the palliative route.

And then there’s other times where they want everything done. If we are able to do that, we will.

And then there’s times we have to be like, “Your loved one is not a candidate for that, so we’re sorry that’s not going to be an option for you.” Those are very hard conversations to have.

And these patients are so sick. So the family, a lot of times these things just happen out of the blue. Yesterday they were fine. They had a massive MI. Now we’re dealing with these kind of conversations.

Geralyn Warfield (host): (14:29)

So, as we’re thinking about ourselves and our families and making our wishes known to our loved ones, and I know that is a super difficult conversation, especially when you’re healthy and you don’t want to think about maybe something happening, do you find that some family members, some individuals, even if this is an unexpected event that happens, that they are prepared based on conversations that they’ve already had on their wishes?

I know that that is accurate, that some families are better at talking about these things than others, but I think my question is really about, do you ever see specificity about things like LVADs and all those kinds of things, or do you mostly see general kinds of wishes that people have already thought about in advance?

Amy Sheppard (guest): (14:58)

Yeah, I think, especially with that heart failure population, they actually have, a lot of times they know their trajectory or where it’s going, where it could go, right? Those kind of patients are more in tune with the options down the road and may or may not want to go that route. So those patients, I think, that subset, they may have more insight into that, have expressed that.

Whereas, I think when you’re looking at the young, 55-year-old man who has a STEMI and now is in cardiogenic shock, they may not even know those things are an option. And so those are conversations that usually, typically don’t happen [in advance].

Geralyn Warfield (host): (15:44)

Is there one key takeaway that you would like to leave with our audience about our conversation today?

Amy Sheppard (guest): (15:49)

I think related to the PCNA, just educating patients on prevention and detection of cardiac disease and, really, it’s a lifestyle. Because we do not want to get to the point of STEMI, cardiogenic shock.

Albeit, like I said, there are some lead to cardiogenic shock that are not related to preventative cardiology, but I think that’s such a key piece—really educating our patients and also getting out into the community and community awareness. If you’re having chest pain, don’t wait for days. Call 911. Heart failure: signs and symptoms, what leads to heart failure. Really getting on the front of it.

But if we are in the point where we’re STEMI, timely reperfusion, getting them to the cath lab.

And then with cardiogenic shock, keeping your eyes open. Being aware, and early escalation. The referrings cannot call the receiving center for shock too soon. We want to know about these patients. Maybe they’re not quite ready to come to us, but we can help guide you and we will take your patients when they need us and we don’t want to wait too long. We want to get to them so we can get them the treatment they need sooner than later because that’s what’s going to give them the best outcome.

Geralyn Warfield (host): (17:12)

We are so grateful to you for your time, for educating our audience about cardiogenic shock and the need for us to have conversations with our families and loved ones about what our needs and wants are as we move forward. Thank you so very much for being here.

This is your host, Geralyn Warfield, and we will see you next time.

Thank you for joining us for this episode of Heart to Heart Nurses. We invite you to visit pcna.net for education and resources that will empower you to provide preventive cardiovascular care with confidence and expertise.