CalShock: beyond the shock team, building on California's cardiogenic shock system of care.

Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams

Multidisciplinary Shock Teams have improved clinical outcomes for cardiogenic shock, but their implementation costs have not been studied. This study's objective was to compare costs between patients treated with and without a Shock Team and determine if the team's implementation is cost-effective compared with standard of care. We examined patients with refractory cardiogenic shock treated with or without a Shock Team at a tertiary academic hospital from 2009 to 2018. Real-world hospital data were used to compare costs and outcomes, including survival at discharge, 1-year survival, and quality-adjusted life years gained at 1 year. Incremental cost-effectiveness ratios were calculated over a 1-year time horizon, with parameter uncertainty evaluated through probabilistic sensitivity analysis using 1000 second-order Monte Carlo simulations. The study involved 244 patients, with 123 treated by the Shock Team and 121 receiving standard of care. Patients were predominantly male (77.5%), with a mean age of 58 (18-92) years. The Shock Team approach improved survival rates at hospital discharge and 1-year follow-up (61.0% versus 47.9%; P=0.04 and 55.0% versus 40.5%; P=0.03, respectively). The incremental cost-effectiveness ratio for increases in survival probability at discharge for the multidisciplinary Shock Team compared with standard of care was $102 088. The incremental cost-effectiveness ratio for increases in survival probability at 1-year was estimated at $96 152 and at $127 862 per 1 quality-adjusted life year gained. Probabilistic sensitivity analysis estimates showed that the Shock Team was cost-effective in the majority of simulations using a willingness-to-pay threshold of $150 000, while it was also dominant in almost one-third of the simulations. The Shock Team approach for treating refractory cardiogenic shock may be a cost-effective alternative to traditional standard of care. These findings can help prioritize the implementation of Shock Team initiatives to further improve cardiogenic shock outcomes.

Background: Multidisciplinary Shock Teams have improved clinical outcomes for cardiogenic shock (CS), but their implementation costs have not been studied. Objectives: To compare costs between patients treated with and without a Shock Team and determine if the team's implementation is cost-effective compared to standard of care (SoC). Methods: We examined patients with refractory CS, treated with or without a Shock Team at a tertiary academic hospital from 2009-2018. Real-world hospital data was used to compare costs and outcomes, including survival at discharge, 1-year survival, and quality adjusted life years (QALYs) gained at 1 year. Incremental cost-effectiveness ratios (ICER) were calculated over a 1-year time horizon, with parameter uncertainty evaluated through probabilistic sensitivity analysis using (PSA) 1000 second-order Monte Carlo simulations. Results: The study involved 244 patients, with 123 treated by the Shock Team and 121 receiving SoC. Patients were predominantly male (77.5%), with a mean age of 58 years (18-92). The Shock Team approach improved survival rates at hospital discharge and 1-year follow-up (61.0% vs 47.9%; p=0.04 & 55.0% vs 40.5%; p=0.03, respectively). The ICER for increases in survival probability at discharge for the multidisciplinary Shock Team compared to SoC was $102,088. The ICER for increases in survival probability at 1-year was estimated at $96,152 and at $127,862 per one QALY gained. PSA estimates showed that the Shock Team was cost-effective in the majority of simulations using a willingness-to-pay threshold of $150,000, while it was also dominant in almost one-third of the simulations. Conclusion: The Shock Team approach for treating refractory CS may be a cost-effective alternative to traditional SoC. These findings can help prioritize the implementation of Shock Team initiatives to further improve cardiogenic shock outcomes.

Four years of expertise in shock team management of cardiogenic shock

IMPLEMENTATION OF STANDARDIZED SCREENING OF CARDIOGENIC SHOCK (CS) FOR ALL PATIENTS ADMITTED TO THE CCU AT THE NEW BRUNSWICK HEART CENTRE

BackgroundThe development and implementation of a Cardiogenic Shock initiative focused on increased disease awareness, early multidisciplinary team activation, rapid initiation of mechanical circulatory support, and hemodynamic-guided management and improvement of outcomes in cardiogenic shock.ObjectiveThe objectives of this study are (1) to collect retrospective clinical outcomes for acute decompensated heart failure cardiogenic shock and acute myocardial infarction cardiogenic shock, and compare current versus historical survival rates and clinical outcomes; (2) to evaluate Inova Heart and Vascular Institute site specific outcomes before and after initiation of the Cardiogenic Shock team on January 1, 2017; (3) to compare outcomes related to early implementation of mechanical circulatory support and hemodynamic-guided management versus historical controls; (4) to assess survival to discharge rate in patients receiving intervention from the designated shock team and (5) create a clinical archive of Cardiogenic Shock patient characteristics for future analysis and the support of translational research studies.MethodsThis is an observational, retrospective, single center study. Retrospective and prospective data will be collected in patients treated at the Inova Heart and Vascular Institute with documented cardiogenic shock as a result of acute decompensated heart failure or acute myocardial infarction. This registry will include data from patients prior to and after the initiation of the multidisciplinary Cardiogenic Shock team on January 1, 2017. Clinical outcomes associated with early multidisciplinary team intervention will be analyzed. In the study group, all patients evaluated for documented cardiogenic shock (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) treated at the Inova Heart and Vascular Institute by the Cardiogenic Shock team will be included. An additional historical Inova Heart and Vascular Institute control group will be analyzed as a comparator. Means with standard deviations will be reported for outcomes. For categorical variables, frequencies and percentages will be presented. For continuous variables, the number of subjects, mean, standard deviation, minimum, 25th percentile, median, 75th percentile and maximum will be reported. Reported differences will include standard errors and 95% CI.ResultsPreliminary data analysis for the year 2017 has been completed. Compared to a baseline 2016 survival rate of 47.0%, from 2017 to 2018, CS survival rates were increased to 57.9% (58/110) and 81.3% (81/140), respectively (P=.01 for both). Study data will continue to be collected until December 31, 2018.ConclusionsThe preliminary results of this study demonstrate that the INOVA SHOCK team approach to the treatment of Cardiogenic Shock with early team activation, rapid initiation of mechanical circulatory support, hemodynamic-guided management, and strict protocol adherence is associated with superior clinical outcomes: survival to discharge and overall survival when compared to 2015 and 2016 outcomes prior to Shock team initiation. What may limit the generalization of these results of this study to other populations are site specific; expertise of the team, strict algorithm adherence based on the INOVA SHOCK protocol, and staff commitment to timely team activation. Retrospective clinical outcomes (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) demonstrated an increase in current survival rates when compared to pre-Cardiogenic Shock team initiation, rapid team activation and diagnosis and timely utilization of mechanical circulatory support.Trial RegistrationClinicalTrials.gov NCT03378739; https://clinicaltrials.gov/ct2/show/NCT03378739 (Archived by WebCite at http://www.webcitation.org/701vstDGd)

Recently, shock teams have been introduced to optimize cardiogenic shock (CS) care; however, their clinical benefits remain unclear. We conducted a systematic review and meta-analysis to assess whether management by a shock team improves outcomes in patients with CS. This meta-analysis was conducted according to the PRISMA guidelines. Studies comparing adults with CS managed with or without a shock team were identified from the PubMed, Web of Science, and Cochrane Library databases. The primary outcome was short-term mortality (cardiac intensive care unit, in-hospital, or 30-day mortality); the secondary outcome was bleeding. Of the 7 retrospective cohort studies that met the inclusion criteria, 3 without a critical risk of bias were included in the analysis. Shock team management was significantly associated with lower short-term mortality (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.32-0.85; P=0.010) and bleeding complications (OR 0.62; 95% CI 0.43-0.91; P=0.010). Sensitivity analysis using crude data also supported the mortality benefit (OR 0.68; 95% CI 0.54-0.85; P<0.010). However, no randomized trials were included, and the certainty of evidence was rated very low owing to the risk of bias and inconsistency. Shock team management may improve short-term outcomes in patients with CS; however, the level of evidence is very low. Further prospective studies are needed to evaluate optimal shock team composition and roles.

Purpose/Background: The implementation of a protocol-based, multidisciplinary shock team approach in tertiary centers can lead to an organized approach to care and early implementation of temporary mechanical circulatory support (tMCS) in the appropriate patient. The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019. We have reviewed our data to demonstrate the utility and viability of the PMCST model by highlighting improved outcomes in our patient population compared to published outcomes in the literature. Methods: We collected data on our shock team since its inception from 11/2019-1/2023. These data include review of patient profiles, tMCS use, and outcomes of our shock patients, including overall disposition as well as disposition after tMCS. Results: From 11/25/2019-1/15/2023, our team had 498 total shock calls. Three hundred and forty-three (69%) were accepted by our shock team (“Go”) and included in our analysis. One hundred and sixty did not meet criteria (“No Go”), most commonly because they were not candidates for advanced support. All patients were characterized by SCAI and Intermacs classifications as well as shock etiology. The largest number of accepted patients were SCAI D (131), followed by SCAI C (105) and E (83), respectively. Eighty-nine percent of patients fell into Intermacs classifications 1-3, with the highest number of Intermacs 2 patients at 132. The predominant diagnosis was Acute Decompensated Heart Failure-Cardiogenic Shock (ADHF-CS) in 111 patients (32%), with 67 patients (20%) diagnosed with Acute Myocardial Infarction Cardiogenic Shock (AMI-CS). Our team also accepted 17 patients with diagnoses related to ventricular tachycardia (VT storm, recurrent VT). Shock team calls were predominantly outside hospital (OSH) referrals (93%), and the remaining 7% were internal consults to the PMCST. Of accepted OSH patients, 143 had tMCS present on arrival, with the majority being intra-aortic balloon pump (IABP) and Impella CP, while 183 patients utilized tMCS during admission. Multiple tMCS devices were used concomitantly in 61 patients, the majority of whom with either ECPella (Impella CP and VA-ECMO) or IABP with VA-ECMO at 37% and 28%, respectively. In patients requiring tMCS, 104 (57%) remain alive, 91 (69%) of whom have since been discharged. With regard to our 343 accepted shock team patients, 240 (70%) remain alive, while 230 (67%) of whom were discharged alive. Summary: Our results show that a multidisciplinary shock team model represents a successful strategy leading to a multidisciplinary approach to care and timely deployment of tMCS. These data suggest the PMCST model leads to improved outcomes in patients with cardiogenic shock.Figure 1. Disposition of PMCST Shock PatientsFigure 2. Types of Concomitant tMCS Utilized in PMCST Patients

Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams. To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limitedavailable data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.

Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.

Short-term mechanical circulatory support (STMCS) may be used as an intentional escalation strategy to treat refractory cardiogenic shock (rCS). However, with growing technical possibilities, making the right choice at the right time can be challenging. We established a shock team in January 2013 comprising a cardiac anaesthetist-intensivist, an interventional cardiologist, and a cardiac surgeon. Since then, a diagnosis of rCS has triggered a multidisciplinary team meeting based on a common algorithm. This study aimed to compare the decision-making process for STMCS for rCS before (2007-2013) and after (2013-2019) the creation of the shock team. This before-and-after cohort study was conducted over a 156-month period. Post-cardiotomy rCS were excluded. The primary outcome was a 1-year survival rate. In total, 250 consecutive adult patients were included in the analysis (84 in the control group and 166 in the shock team group). At baseline, the CardShock score was not different between the two groups (5[3-5] vs. 5[4-6], P = 0.323). The 1-year survival rate was significantly higher in the shock team group compared with the control group (59% vs. 45%, P = 0.043). After a Cox regression analysis, the shock team intervention was independently associated with a significantly improved 1-year survival rate (HR: 0.592, 95% CI: 0.398-0.880, P = 0.010). A multidisciplinary shock team-based decision for STMCS device implantation in rCS is associated with better 1-year survival rates.

OR2-4 | Impact of the Shock Team on Institutional use of VA-ECMO for Cardiogenic Shock

BackgroundDespite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown. MethodsThis retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality. ResultsThe outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization. ConclusionsThis analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Background Cardiogenic shock is a critical cardiac condition characterized by low cardiac output leading to end-organ hypoperfusion and associated with high in-hospital mortality rates. It can manifest following acute myocardial infarction or acute exacerbation of chronic heart failure. Despite advancements, mortality rates remain elevated, prompting interest in multidisciplinary approaches to improve outcomes. This manuscript presents a review focused on the concept of a cardiogenic shock team and its potential impact on patient management and outcomes. Methods A comprehensive search was performed on March 19, 2023, covering PubMed, Web of Science, Scopus, Embase, and Cochrane Library. We included primary studies (prospective and retrospective) only and evaluated their quality using the Newcastle–Ottawa Quality Scale. This review was registered in PROSPERO (CRD42023440354). Results Six relevant studies with 2066 cardiogenic shock patients were included, of which 1071 were managed by shock teams and 995 received standard care. Findings from the reviewed studies indicated the favorable outcomes associated with implementing cardiogenic shock teams. Patients managed by these teams exhibited higher 30-day and in-hospital survival rates compared to those without team intervention. The implementation of cardiogenic shock teams was linked to reduced in-hospital and intensive care unit mortality rates. Additionally, shock team involvement was associated with shorter door-to-balloon times. Conclusion The findings suggest that cardiogenic shock teams play a crucial role in improving patient outcomes through earlier detection and timely interventions. Despite challenges in team implementation, their potential to reduce mortality and improve efficiency in patient care warrants further research and greater integration of multidisciplinary strategies into clinical practice.

Introduction: Cardiogenic shock (CS) is a high-mortality clinical syndrome, with reported rates between 40–50%. Multidisciplinary shock teams have emerged to streamline care and improve outcomes. In our non-LVAD center, we implemented a structured shock team model involving interventional cardiology, advanced heart failure, and critical care physicians, with early decision-making led primarily by an interventional and transplant cardiologist. Standardized protocols guided management and mechanical circulatory support (MCS) selection. Methods: We performed a retrospective review of adult patients with cardiogenic shock admitted between 2024–2025. Inclusion required ≥2 of the following: MAP &lt;60 mmHg or a ≥30 mmHg drop from baseline, SBP &lt;90 mmHg or ≥30 mmHg drop from baseline, HR &gt;100 bpm, cardiac index less than 2.2 L per min per m2, PAPI &lt;1.0, cardiac power output &lt;0.6 W, or vasopressor/MCS requirement. Clinical, hemodynamic, and echocardiographic data were extracted from electronic records. The primary outcome was in-hospital mortality; secondary outcomes included MCS use, escalation timing, and transfer rate. Results: A total of 40 patients were included (mean age 59.3 ± 13.6 years). The leading etiology was acute decompensated heart failure (51.2%), followed by NSTEMI (20.9%) and STEMI (16.3%). Most patients presented in SCAI Stage E (50%), followed by C (30%), D (17.5%), and B (2.1%). Vasopressors were used in 97.5%, and 36.5% were transferred from outside facilities. Temporary MCS was utilized in 50%, with Impella CP (34.6%) most common, followed by Impella 5.5 (30.8%), IABP (26.9%), Impella RP (3.8%), and VA-ECMO (3.8%). The mean lactate level across the cohort was 4.2 mmol/L, and the mean ALT was 285.57 U/L, suggesting evidence of systemic hypoperfusion and hepatic congestion. The average left ventricular ejection fraction (EF) was 28.7%, consistent with moderate systolic dysfunction. Notably, 50% of patients underwent pulmonary artery (PA) catheter placement during their evaluation. Despite high transfer rates, in-hospital mortality was 35.7%, below national averages for non-LVAD centers. Conclusion: Implementation of a structured, interdisciplinary shock team protocol at a resource-limited center led to favorable outcomes in cardiogenic shock. Timely escalation, protocol-driven MCS use, and coordinated care can enable non-LVAD centers to deliver high-quality shock management.