Interventional cardiology

Cardiogenic shock outcomes highlight the importance of rapid treatment

Patients with cardiogenic shock complicating acute coronary syndrome have just as good outcomes if managed at smaller centres as with larger centres, according to data from the Victorian Cardiac Outcomes Registry (VCOR).

Outcome data for 1,179 patients managed at 26 hospitals in Victoria showed no differences for patients treated at cardiac surgical centres compared to those without cardiac surgical backup.

Similarly there were no differences based on the volume of PCI procedures performed at a centre in terms of in-hospital major adverse cardiac and cerebrovascular events (MACCE) and long-term mortality.

The findings, published in the journal JACC: Cardiovascular Interventions could be interpreted as showing the value of the CSANZ’s mandated requirements for standardised care and quality of all PCI-capable hospitals in Victoria, the study authors said.

These requirement also ensure that all PCI-capable hospitals have streamlined STEMI care pathways as well as established referral channels to centres with advanced cardiac support capabilities that can be utilised if needed, they noted.

However an accompanying commentary said the findings might also be seen as showing that outcomes are still uniformly ‘dismal’ for a condition with high mortality rates up to 60% despite timely management and advances in PCI.

“Most prominently, the treatment modalities and approaches used during the study period at study hospitals increasingly do not represent best contemporary practice, especially with respect to the use of mechanical circulatory support,” it noted.

The study showed that 90% of patients had a successful PCI with no differences in door-to-balloon time by cardiac surgery capability or PCI volume.

However, despite successful PCI, 42% of patients died while hospitalised, and 51% died within one year.

Notably, only 12% of patients had placement of an intra-aortic balloon pump, fewer than 4% of patients were supported with extracorporeal membrane oxygenation, and no patients were treated with percutaneous mechanical circulatory support, because these devices were not approved in Australia during the study period.

The study investigators, led by Dr Samer Noaman and Dr William Chan at Western Health, Melbourne, concluded that “the nonavailability of cardiac surgery backup should no longer be considered a reason for precluding the treatment of these high-risk patients.”

“These findings have important clinical and policy-changing implications, supporting the emergent treatment of these gravely ill patients at their presenting PCI-capable hospital,” they wrote.

“Mirroring the streamlined STEMI paradigm of care with rapid assessment and an emphasis on shortening ischaemia times, time-critical revascularisation, and initial care and resuscitation of cardiogenic shock patients in all PCI-capable hospitals should be a priority,” they added.

However they acknowledged there was room for improvement in management of patients with cardiogenic shock complicating ACS with protocol-based approaches and the wider use mechanical circulatory support.

They noted that data from the U.S. National Cardiogenic Shock Initiative registry had shown steady improvements in survival, to around 75%, when patients were systematically treated in the framework of a Shock Team. This included “early institution of LV circulatory support with the Impella device, timely revascularisation, and subsequent transfer to a cardiac surgical or advanced heart failure centre following stabilisation if necessary in a hub-and-spoke model of care,” they said.

“Prospective studies are needed to evaluate potential improvement in mortality with the streamlined systems of care [for cardiogenic shock] that coordinate transfer between centres with different capabilities and the use of potent mechanical circulatory support,” they suggested.

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