Moving the Needle in AMI Cardiogenic Shock Survival

“We haven’t moved the needle in 40 years in the management of acute MI cardiogenic shock,” William O’Neill, MD, emphasizes in his presentation on the quest for heart recovery at the SCAI 2022 Scientific Session.

Dr. O’Neill states that from 1988 to 2018, AMI cardiogenic shock mortality in patients who do not have an out-of-hospital cardiac arrest has hovered around 50% and that this mortality occurs early on. “What we’re going to have to do in designing programs to improve outcome for these patients is identify them and get them treated and supported as soon as possible.” 

“If we want to do better, we’re going to have to come up with a different algorithm and a different program,” O’Neill explains. He challenges each institution to “look in the mirror” and identify what the community’s AMI cardiogenic shock mortality is and find a way to change the program to improve it. He cites the example of the INOVA® Heart and Vascular Institute in northern Virginia, which had 43% AMI cardiogenic shock survival before implementing a protocol which raised survival to over 80%.

Dr. O’Neill shows improved survival and native heart recovery in 3 large, published registries since 2018—INOVA, the National Cardiogenic Shock Initiative (NCSI) study, and the J-PVAD registry in Japan— highlighting, “with this, we’ve moved the needle.” In these 3 registries survival ranges from 70% to over 80%. This was achieved through the best practices of early identification of cardiogenic shock and use of Impella® pre-PCI within 90 minutes. The protocols also entail aggressive down-titration of inotropes, early identification and support of RV dysfunction, identification of inadequate LV support and escalation of support, and systematic use of right heart catheterization (RHC) to guide therapy.

Dr. O’Neill also shows that lactate levels and cardiac power output (CPO) at 12-24 hours after PCI are predictors of survival, with survival of 95% in patients with lactate <4 and CPO > 0.6. He explains that this is where the heart team’s role is important. If patients are doing well by these predictors, the team will be able to rapidly explant Impella. If, however, patients are not doing well, the heart team needs to discuss escalation options such as Impella 5.5®, ECMO, or ECpella (a combination of ECMO and Impella support).

To summarize, Dr. O’Neill shows the NCSI algorithm that he and his team have developed. “I think that this algorithm is working very well,” he states. Other lectures from the SCAI 2022 Scientific Session delve into the algorithm and management of AMI cardiogenic shock in more detail.