Acute on Chronic Heart Failure and Cardiogenic Shock

When it comes to cardiogenic shock in the setting of acute decompensation in patients with chronic heart failure, explains Claudius Mahr, DO, “we do not have a system in place that is cohesive and universal.” In this interview, Dr. Mahr discusses his paper titled “Outcome differences in acute vs acute on chronic heart failure in cardiogenic shock” published in ESC Heart Failure. Dr. Mahr is professor of medicine and medical director of mechanical circulatory support at the University of Washington Medical Center and a founding member of the Cardiogenic Shock Working Group.

Dr. Mahr’s work explores the nuances between acute de novo cardiogenic shock without a prior history of heart failure and chronic heart failure deteriorating to shock. His paper presents results from a single-center, retrospective, observational study of 235 patients, 51 with acute shock and 184 with acute decompensation of chronic heart failure.  

In this study, patients had significant differences in baseline characteristics. Dr. Mahr highlights that the comorbidity burden (eg, atrial fibrillation, chronic kidney disease, cerebrovascular disease) was higher for patients with chronic heart failure developing cardiogenic shock. Yet cardiac indices were relatively similar between the groups.

“Interestingly the use of MCS devices was more frequent in the acute heart failure patient as opposed to the chronic counterparts,” Dr. Mahr states, noting that there is an inherent selection bias between established patients with chronic heart failure and known comorbidities and patients with no track record at an institution. “Part of this is that the patients who are obvious, desirable, advanced heart failure therapy candidates are more likely to receive those therapies before they fulminantly deteriorate to cardiogenic shock. And what you’re left with is a sicker and more virulent cohort, and frequently those patients may not be candidates for durable advanced heart failure therapy.”

“The outcomes, in some sense, speak for themselves,” Dr. Mahr states. “Acute heart failure had a higher percentage of death and less successful bridge-to-VAD, bridge-to-next therapy, than acute on chronic HF.”

Dr. Mahr explains that this research speaks to opportunities in the heart failure field. In addition to the need for standardized approaches to managing cardiogenic shock in chronic heart failure, Dr. Mahr highlights issues related to patient access to care. Only a small minority of patients with advanced heart failure, he emphasizes, get referred to an expert in heart failure care. In addition, he explains “if you want to, ideally, stratify a patient with cardiogenic shock, you have to have invasive hemodynamics.” Yet many patients with heart failure are receiving care at institutions without access to PA catheters and ICU beds. “That hemodynamic risk stratification is imperative but it’s still not happening in the majority of patients.”