On World Heart Day 2023, Dr Jumana Haji, ECMO Program Director, Fortis Hospital, Mulund explains about cardiogenic shock and need for its timely intervention
Cardiogenic shock is a fatal condition in which the heart cannot pump sufficient blood to meet the human body’s needs. A severe heart attack most often causes the situation, although not everyone with a heart attack has cardiogenic shock. In most cases, a heart attack causes cardiogenic shock, but sometimes the heart depression is not because of Ischemia. Besides ischemic cardiac events, cardiogenic shock can also be caused by other conditions like Viral Myocarditis, drug overdose, poisoning, Arrhythmias, Takotsubo, cardiac depression due to Sepsis and Pulmonary Embolism. People who suffer from these conditions require immediate medical attention as they have a very narrow survival window with conventional therapies. Additionally, as cardiogenic stunning can lead to a multi-organ shutdown, reaching a hospital promptly is of prime importance for such patients.
What kind of treatments do patients who have suffered from cardiogenic shock require?
Patients who have suffered cardiogenic shock require immediate medical intervention. In most cases, treatment will involve reducing the damage caused by lack of oxygen to the heart muscle and other organs. These can include emergency life support through mechanical circulatory support devices such as Intra-Aortic Balloon Pump Therapy (IABP), Extracorporeal Membrane Oxygenation (ECMO), IMPELLA or definitive treatments like Percutaneous Coronary Intervention, and TAVI Mitraclip, among others.
In most cases, there is a golden window period of intervention beyond which all efforts may be futile. To make the most of this golden period, it is essential to activate the correct team of medical professionals so that they can quickly come up with a plan. They can deploy a team to report at the referring center to safely transport patient with the help of ECMO or other Mechanical Circulatory Support (MCS) devices, or to be ready on arrival of the patient to the Emergency Medicine department. Take, for instance, the case of a 20-year-old boy who was admitted to the Emergency Department in a hypotensive state with low peripheral pulses and low blood pressure. He suffered from a cough, cold and fever for more than a week, and initial examination and investigations revealed a meagre ejection fraction and stunned Myocardium, which led him to go into a cardiogenic shock state.
In the ER, various teams, including the ECMO, Intensive Care, Infectious Disease, and hospital administration, came together to decide his treatment plan. Within twenty minutes, a final plan involving probable causes of heart failure, treatment course, financial implications, and prognosis was conducted. The decision dilemmas included the potentially infectious nature of the disease, the need for isolation, and the need to initiate extracorporeal membrane oxygenation or ECMO, a life support system in the ER itself, as the patient could become too sick to transfer to the ICU or OT. As a result of quick treatment, the patient was successfully saved, and he was removed from the ECMO machine after four days and extubated after seven days. The probable cause for his cardiogenic shock was Myocarditis or inflammation of the heart muscles, accompanied by infection.
In another instance, a 40-year-old lady was presented in the ER after consuming rat poison. Rat poison contains Aluminium Phosphide toxin which can severely depress the heart. She had been admitted to a nursing home 12 hours after ingesting the poison with profoundly low blood pressure. Although she was managed at the nursing home for another 12 hours, she was eventually shifted to our hospital 30 hours after the incident. There was some time delay on arrival to hospital, as there was no intimation of her condition from the referring center before the transfer. By the time the ER, ECMO and Intensive Care team could discuss the option of ECMO, the treatment window was lost, and the patient succumbed despite reaching an ECMO center.
How can fatality related to such cases be brought under control?
Both these cases show that timely treatment of patients suffering from cardiogenic shock is vital. Unfortunately, due to the delay in reaching a hospital or receiving treatments, patient succumb to their condition. These cases can be tackled effectively by having a special shock team in the hospital. This team can play a vital role in ensuring that when a patient with this condition is brought to the hospital, their clinical condition and likely treatment options are decided at the earliest & without any delay.
The optimal composition of the ‘cardiogenic shock team’ would include a Cardiac Critical Care Physician, ECMO Specialist, Interventional Cardiologist, Cardiac Critical Care Nurses, Advanced Heart Failure Cardiologist, Cardiac Surgeon, Cardiac Anesthetist, Emergency Physician, and hospital administration. A referring physician, the hospital console, or any shock team specialties can activate this team.
This team can prove to be an asset to facilitate optimal treatment, in the following manner:
- They will be able to diagnose and treat patients in a timely & knowledgeable manner
- Quick decision making even if the patient is coming from another place or in the ER
- Potential to catch cases for interventions in the ‘Golden Hour’
- The load of decision-making and counselling is distributed among the medical team
- Enable quick mobilisation of resources (equipment and skilled manpower)
Recent studies have also shown that hospitals with shock teams had better outcomes, and more patients were managed with suitable conventional therapies, which also helped to avoid requirement of invasive heart support therapies altogether.