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Published on: August 16, 2021
Definitions of Cardiogenic Shock and Indications for Temporary Mechanical Circulatory Support: Joint Consensus Report
Michael C Grant1, Charles Scott Brudney2, Jaime Hernandez-Montfort3
1Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Standardizing cardiogenic shock (CS) assessment with early evaluation of severity, cause, and phenotyping improves patient outcomes. Timely initiation of temporary mechanical circulatory support (tMCS) can minimize organ injury and mortality.
Area of Science:
- Cardiology
- Critical Care Medicine
Background:
- Management of cardiogenic shock (CS) is complex, especially with increasing use of temporary mechanical circulatory support (tMCS) devices.
- A structured approach to CS assessment is needed for early and targeted therapies.
Purpose of the Study:
- To establish a consensus-based approach for assessing CS.
- To guide early and targeted therapies, including tMCS, based on severity, etiology, and phenotype.
Main Methods:
- An international expert panel used literature appraisal and a modified Delphi method.
- Consensus was derived on assessing CS severity, etiology, and phenotypic clustering.
Main Results:
- Early, continuous assessment of shock severity and etiology is crucial for guiding care escalation and triage.
- Phenotypic clustering aids prognosis.
- tMCS is most beneficial for refractory congestion before organ injury, requiring interdisciplinary discussion and informed consent.
Conclusions:
- Standardizing CS characterization by severity, etiology, and phenotyping is an opportunity.
- Early monitoring, triage, and timely escalation of care, including tMCS, can reduce organ injury and mortality.
Background:
The management of patients with cardiogenic shock (CS) is complex and resource intensive, particularly given the recent surge in temporary mechanical circulatory support (tMCS) devices. This document was created to establish an approach to the assessment of CS to provide early and targeted therapies, including tMCS.
Methods:
An interdisciplinary, international panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus regarding the assessment of CS based on pathophysiologic severity, etiology, and phenotypic clustering to guide escalation of care as well as identify those patients who might benefit from tMCS.
Results:
Key principles included early and continuous assessment for the evolution of shock severity to guide the escalation of care as well as establishment of the cause of CS to facilitate triage and assignment of initial therapies. Phenotypic clustering is complementary and aids in prognosis. tMCS provides the greatest benefit in CS for relief of congestion refractory to medical therapy, ideally when initiated before the development of organ injury. The use of tMCS should be preceded by an interdisciplinary discussion as part of the informed consent process to establish therapeutic goals, including exit strategies.
Conclusions:
Based on the available literature and expert consensus, there is an opportunity to further standardize the approach to CS, including characterization based on the severity of the shock state, etiology, and further enhancement by phenotyping. Monitoring, early triage, and timely escalation of care, including the targeted initiation of tMCS, can minimize organ injury and in-hospital mortality.
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