Instituting a Cardiogenic Shock Protocol to Improve Outcomes

Alexander Truesdell, MD, and Behnam Tehrani, MD, interventional cardiologists at Inova Heart and Vascular Institute discuss their experience implementing a cardiogenic shock protocol at Inova. Data from their experience was recently published in the Journal of the American College of Cardiology. After Inova instituted a best practice protocol that includes early use of percutaneous mechanical circulatory support, AMI cardiogenic shock survival at 30 days rose from 44% to 82% (p=0.0001).

Dr. Tehrani discusses the poor historical outcomes for cardiogenic shock and physiological characteristics of the cardiogenic shock “death spiral.” Dr. Truesdell discusses the need for a team-based approach to treating cardiogenic shock as well as the timeline of the Inova Heart and Vascular Heart Recovery Initiative. The group assembled a team, conducted service line outreach and education, and met each week to hold after action reviews to discuss patient outcomes and protocol improvements. The heart team involved physicians and care teams in the hub and spoke network of the Inova system.

In the team’s initial analysis, they found that the factors of fractured care, late detection, impaired access to care, and variations in care contributed to the opportunity to improve with their protocol. Dr. Truesdell details the need for identifying shock early to allow patients the best chance for survival. He also describes the short window to reassess patients for escalation of support.

Finally, Dr. Truesdell describes the outcomes with the use of their protocol over time. Interestingly, he provides a metric on the fact that under the new program, the team was able to save 60 patient lives who may not otherwise have been saved without the protocol.

Dr. Tehrani discusses the risk stratification score that the team used to predict survival including an assessment of variables and status after 24 hours. Another highlight of the team-based approach is the time dependency of treating cardiogenic shock. The team found that for every one-hour delay in initiation of mechanical circulatory support, there was a 9.9% increased risk of mortality.

Ingredients for a successful heart recovery program:

• One-call access
• Multi-disciplinary heart team
• Treatment protocols and validated risk scores
• Regional destination center utilizing a hub-and-spoke model