Sindhuja Ramarathinam, Product Manager-Cardiopulmonary, Getinge explains about cardiogenic shock and its management
Understanding and managing cardiogenic shock
Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in India, reflecting a significant public health challenge. The prevalence of heart diseases in India has been rising steadily, driven by factors such as urbanisation, sedentary lifestyles, unhealthy diets, tobacco use, and increasing rates of hypertension and diabetes.
Heart attacks (myocardial infarctions), coronary artery disease, heart failure, and arrhythmias are among the most common cardiac conditions affecting the Indian population.
Within this spectrum, cardiogenic shock is one of the most severe and life-threatening complications of heart disease. Cardiogenic shock occurs when the heart fails to pump enough blood to meet the body’s needs, leading to organ failure and, if untreated, death. It is commonly triggered by a heart attack, where the damage to the heart muscle is so extensive that it can no longer function effectively. Other causes include severe heart failure, cardiomyopathy, acute valvular disease, and arrhythmias.
In India, the incidence of cardiogenic shock is closely linked to the high burden of coronary artery disease, particularly heart attacks. Many patients develop cardiogenic shock after a severe heart attack, especially if there is a delay in receiving prompt medical treatment.
However, the management of cardiogenic shock in India faces several challenges in terms of healthcare infrastructure, resource access, awareness, and patient education. The availability of timely and advanced care, such as angioplasty, thrombolysis, and mechanical circulatory support, is crucial for improving survival rates in these patients.
The problem
Cardiogenic shock (CS) can present in many different stages. It ranges from those at high risk of developing shock to those critically ill with severe multisystem organ failure, hemodynamic collapse, and on-going cardiac arrest.
It can happen anywhere
Cardiogenic shock can present along multiple points in the pathway of care and develops more frequently after initial presentation to the hospital.
Clinicians must be ready to recognise the early signs and symptoms of cardiogenic shock, not only in the Emergency Room and Cath lab but throughout their patient’s course of treatment including the ICU setting.
Timing is everything
Any attempt to improve outcomes in CS should begin with early identification. In an aging population with increased comorbidity, hemodynamic monitoring has become even more critical today to optimise approach.
From blood pressure to blood flow, volume responsiveness, systemic vascular resistance, and cardiac contractility: Advanced hemodynamic monitoring enables the development of therapeutic strategies for volumetric, inotropic, and vasoactive drug management to optimise tissue perfusion. They also offer detailed insights into the patient’s hemodynamic status, support accurate diagnosis, and enable tracking of trends in vital signs. This will also guide decision making on use of pharmacological agents and escalation to use of mechanical circulatory support devices.
To avoid potential negative effects of high dose of pharmacological agents, its essential to escalate treatment modalities. Two advanced medical interventions that are critical in managing cardiogenic shock in India are the Intra-Aortic Balloon Pump (IABP) and Extracorporeal Membrane Oxygenation (ECMO).
IABP is one of the most used mechanical circulatory support devices in India. It works by inflating and deflating a balloon in the aorta (the main artery leaving the heart) in sync with the heartbeat, which helps reduce the workload on the heart and improve blood flow to the body. The IABP is often used as a first-line treatment in cardiogenic shock, particularly in patients who have just suffered a heart attack. Hospitals often have the necessary equipment and trained personnel to use IABP effectively including private, and government set up.
Straightforward insertion, ready availability and low cost have made Intra-Aortic Balloon Pump Therapy the predominant choice for temporary circulatory support in clinical settings.
ECMO is a more advanced and complex form of mechanical circulatory support. ECMO acts as a temporary heart and lung support system, essentially taking over the function of these organs to allow them to rest and recover. This technology is particularly valuable in severe cases of cardiogenic shock where other treatments, such as IABP are insufficient. ECMO is lifesaving but also resource intensive. ECMO requires specialised equipment and highly trained staff to manage. It has become a life-saving tool to support patients with severe and refractory cardiogenic shock, either after myocardial infarction, cardiac surgery, myocarditis, or intoxication. In India, ECMO is primarily available in large, tertiary-care hospitals in major cities.
While urban centers and semi urban centers have seen significant advancements in cardiac care, with state-of-the-art facilities and a growing number of specialised cardiologists and cardiac surgeons, rural and areas often lag. Despite these challenges, there are ongoing efforts to improve the situation. The Indian government, along with various healthcare organisations, is working to expand access to advanced cardiac care. Initiatives include increasing the number of cardiac care centers, improving training for healthcare professionals, and promoting the use of telemedicine to bridge the gap between urban and rural healthcare services.
In summary, while India faces significant challenges in managing cardiogenic shock due to disparities in healthcare infrastructure and access to advanced treatments like IABP and ECMO, ongoing efforts to improve healthcare delivery and public awareness offer hope for better outcomes in the future.