ESC HEART FAILURE REVIEW

ESC Heart Failure 2021; 8: 988–998

Published online 16 January 2021 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.13180

Cardiogenic shock teams and centres: a contemporary

review of multidisciplinary care for cardiogenic shock
Nima Moghaddam1 , Sean van Diepen2, Derek So3, Patrick R. Lawler4,5,6 and Christopher B. Fordyce1*
1
Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; 2Division of Cardiology, University of Alberta,
Edmonton, Alberta, Canada; 3University of Ottawa Heart Institute, Ottawa, Ontario, Canada; 4Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario,
Canada; 5Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; 6Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario,
Canada

Abstract
Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary me-
chanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis
and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic
approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a
standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasi-
bility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS
teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient iden-
tification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent
studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hur-
dles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.

Keywords Cardiogenic shock; Cardiogenic shock teams; Cardiogenic shock centres

Received: 19 July 2020; Revised: 16 November 2020; Accepted: 3 December 2020
*Correspondence to: Christopher B. Fordyce, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Email: [email protected]

Introduction (MCS) devices, such as ventricular assist devices (VADs)

and microaxial flow pump catheter (Impella), offering
Cardiogenic shock (CS) is characterized by reduced cardiac greater haemodynamic support than IABP.7–9 Despite the
output along with abnormal multi-organ blood flow and ox- superior haemodynamic profile of newer MCS devices, they
ygen delivery to meet metabolic demands. CS is the most have not been shown to improve clinical outcomes.10–12
common cause of death in patients with acute myocardial Therefore, new approaches to care of CS patients have fo-
infarction (AMI) with mortality rates as high as 50%1,2; cused on mechanisms beyond MCS and revascularization. A
however, CS-AMI constitutes only 30% of all patients pre- recent promising initiative has focused on establishing CS
senting with CS. The CS outcomes in non-AMI patients teams to provide rapid identification, early resuscitation,
are less established but remains similarly disappointing.3 and multidisciplinary management of this population. A
In CS-AMI, a survival advantage has been demonstrated multidisciplinary approach that encompasses all aspects of
for patients who undergo successful reperfusion with pri- CS care is sensible given the dynamic course of disease
mary coronary intervention (PCI) or coronary artery bypass with rapidly changing treatment targets. Preliminary studies
graft (CABG) surgery.4 Notably, other modern cardiac inten- have generated optimism that a team-based approach to
sive care unit (CICU) interventions such as vasopressor and CS can optimize treatment, from medical to invasive man-
inotropic drug infusions, haemodynamic monitoring, and agement, and improve clinical outcomes. In this article,
intra-aortic balloon pump (IABP) counterpulsation have we will review the rationale and current literature for de-
shown no improvement in CS outcomes.5,6 There has been veloping a multidisciplinary care for this critically ill
growing interest for use of mechanical circulatory support population.

© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any me-
dium, provided the original work is properly cited and is not used for commercial purposes.
 20555822, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ehf2.13180 by CochraneArgentina, Wiley Online Library on [12/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock 989

Cardiogenic shock teams to streamline mobilizing the proper units and earlier transfer of CS patients
to specialized centres can improve the outcomes of this
care highly morbid population. However, development of shock
teams should not replace the traditional network of STEMI
Team-based care for critical illness has been a fundamental activation, but instead complement existing STEMI systems
tenet in many areas of medicine. The implementation of code to address the needs of the sickest CS-AMI patient.
teams, in-hospital rapid response teams for decompensating A key reason for developing dedicated CS centres and
patients, stroke, and trauma teams have been paramount in streamlining systems of care is the considerable variation
improving outcomes in patients with acute and time-sensitive seen in practice patterns of CS patients with worse out-
conditions.13–15 Although having a multidisciplinary CS team comes in hospitals with lower CS volumes. The results from
has only recently garnered interest, a team-based ‘heart the National Cardiovascular Data Registry CathPCI of CS pa-
team’ approach has been commonplace in care of patients tients showed that IABP or MCS were more commonly
in other areas of cardiology. Multidisciplinary ‘heart teams’ employed in large hospitals (>600 beds) and university or
have been adopted in the management of complicated car- teaching hospitals (as compared with private or community
diac arrhythmia,16 heart transplant, complex coronary hospitals).30 Among over half a million patients admitted
revascularization,17 and structural heart interventions.18,19 with CS in the Nationwide Inpatient Sample database in
More recently, there has been a trend towards specialized the United States, a 5% reduction in mortality was ob-
cardiac arrest centres in patients with out-of-hospital cardiac served in the hospitals with the lowest volume quartile as
arrest to provide an all-encompassing and contemporaneous compared with the highest volume quartile of CS cases
evidence-based resuscitation and post arrest care.20,21 Bun- (odds ratio for inpatient mortality 1.27 vs. 1.12,
dled care at a cardiac arrest centre has been suggested to im- respectively).31 An important factor that may have contrib-
prove survival to hospital discharge with good neurological uted to the observed disparity was the significantly greater
outcome and increased 30 day survival compared with admis- use of early revascularization (36.4% vs. 20.6%) and MCS
sion at non-specialized centres.22,23 The 2019 American Heart (33.5% vs. 16.9%) in higher compared with lower CS vol-
Association focused update on cardiac-arrest systems of care ume centres, respectively. In a more recent analysis of
now provides a Class IIa recommendation for transfer of pa- 362 065 patients with AMI-CS, there was a serial decrease
tients to cardiac arrest centres.24 Given that cardiac arrest in mortality with increasing hospital size (42.4% and 39%
is commonly complicated by shock and the added hazard of between small and large hospitals, respectively).32 Com-
cardiac arrest in CS patients,25,26 it is conceivable that pared with smaller hospitals, larger centres had increased
implementing specialized CS centres could confer the same use of early coronary angiography (41.8% vs. 30.3%), PCI
benefits. (49.9% vs. 36.6%), and MCS (46.3% vs. 32.9%). Further-
Despite major breakthroughs in the fields of percutaneous more, appropriate patient selection for advanced therapies
and surgical revascularization and MCS devices, the outcomes may be a determinant of outcomes. Patient selection for
of CS have remained unacceptably poor, with a mortality MCS also differs in hospitals with different rates of MCS
range of 31% to 39% across a wide spectrum of CS in contem- utilization, which could affect variation in clinical outcomes
porary CICUs.27 The disappointing outcomes in patients with across hospitals.33
CS, despite these advancements, may be partly attributed to Overall, given the complexity of CS, dedicated training and
delays in recognition and subsequent timely deployment of experience is needed to maintain competency in delivering
appropriate resources for management of CS. Significant de- safe and effective non-invasive and invasive interventions. It
lays in offering guideline-directed interventions can occur is possible to build upon the volume–outcome relationship
due to additional time needed for initial stabilization of the by establishing multidisciplinary CS teams within specialized
critically ill CS patients. In the AHA Mission Lifeline System referral centres adept at providing comprehensive care for
Accelerator project, fewer than 40% of ST-Elevation Myocar- CS patients.34–36
dial Infarction (STEMI) patients complicated with CS achieved
the first medical contact-to-device time targets.28 The
multicentre Feedback Intervention and Treatment Times in
ST-Elevation Myocardial Infarction (FITT-STEMI) trial showed Structure of cardiogenic shock teams
that every 10 min treatment delay in first medical contact-
to-balloon time resulted in 3.3 additional deaths in 100 The earliest efforts to centralize CS care were focused on a
PCI-treated patients, with a 10-fold rise in mortality rate ‘travelling shock team’ concept where a group of physicians
within the early hours of infarction in CS patients as com- with expertise at managing CS was deployed to a spoke cen-
pared to haemodynamically stable patients.29 Similarly, by tre. The Mayo Clinic Arizona team included a cardiothoracic
decreasing the contact-to-balloon time to less than 90 min, surgeon or heart failure/transplant cardiologist, perfusionist,
one out of five CS patients could be saved. Therefore, and ICU nurses.37 The travelling team would focus on

ESC Heart Failure 2021; 8: 988–998

DOI: 10.1002/ehf2.13180
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990 N. Moghaddam et al.

stabilizing the patient and deciding on initiation of MCS prior Role of cardiogenic shock team in early
to transfer. In their pilot study of 27 patients, 15 underwent
extracorporeal membrane oxygenation (ECMO) placement revascularization
prior to transfer, 25 patients survived transfer to the tertiary
CS centre, and 14 patients survived to discharge. In a similar A key objective of centralizing CS care is to obtain expedient
study of the cardiac-RESCUE programme, a mobile team access to a cardiac catheterization laboratory with expertise
consisting of cardiac surgeon, intensivist, perfusionist, and a in managing haemodynamically unstable patients. The role
nurse provided MCS with ECMO to non-tertiary centres in of early revascularization in CS complicating AMI is well
Paris.38 Their programme resulted in long-term survival in ap- established. In the landmark SHOCK trial, which included
proximately one-third of refractory CS patients (32 out of 75 302 patients with CS-AMI, although there was no 30 day sur-
patients). vival benefit with early invasive approach, the mortality rates
Contemporary CS teams generally comprise an advanced were significantly lower in the revascularization cohort in
heart failure cardiologist, a cardiothoracic surgeon, an inter- comparison with the medical therapy group at 6 months and
ventional cardiologist, and intensivist (including cardiac 1 year (50.3% vs. 63.1% and 46.7% vs. 33.6%, respectively).4,48
intensivist). Other members of the team include a critical A prospective observational study of the National Registry of
care nurse, perfusionist, and a respiratory therapist. Cardiac Myocardial Infarction supported these findings with de-
catheterization laboratory staff, critical care nurses, and per- creased in in-hospital mortality from 60.3% to 47.9% with
fusionists should be available as appropriate. Once acti- early revascularization in patients with CS following AMI.49
vated, all team members are expected to participate in The proficiency of medical staff, including the intervention-
the decisions surrounding patient management and thera- ists and cardiac surgeons, to provide acute PCI or CABG is in-
peutic options. Commonly, the CICU attending or heart fail- dependently associated with successful revascularization.50,51
ure specialist would activate the CS team after initial There appears to be a positive correlation between the vol-
assessment for appropriate criteria for team activation.39 ume of procedures and the outcomes of CABG or PCI. Multi-
The term ‘shock doc’ has been proposed for the physician ple studies have reported improved survival after primary PCI
in charge of coordinating with the other parties the critical for STEMIs in high-volume centres and by high-volume oper-
team-based decisions and interventions, such as urgent ators. A 5 year analysis of over 2 million PCIs in United States
MCS placement, streamlining care in CICU, and day-to-day showed a decrease in mortality and complication rates with
management of the patient.40 increasing quartiles of operator volume with mortality rates
A categorized level of care for CS has been suggested of 1.68%, 1.15%, 0.87%, and 0.59% in first (≤15 PCIs yearly),
based on the capability of the hospital.41 This is similar to second (16 to 44 PCIs yearly), third (45 to 100 PCIs yearly),
the three-tiered CICU classification system in which a Level and fourth (>100 PCIs yearly) quartiles of operator volume,
I CICU is assigned the ‘regional hub’, Level II the ‘secondary respectively.50 A meta-analysis of 15 studies (10 PCI and 7
referral centre’, and the Level III the ‘community CICU’.42 A CABG studies) revealed lower in-hospital mortality in
Level I CS centre implies a tertiary hospital with full-time large-volume (more than 600 cases annually) as compared
PCI and advanced MCS capabilities. After appropriate as- with lower volume (less than 600 cases annually) PCI [odds
sessment by the advance heart failure specialist, refractory ratio (OR) 0.89, confidence interval (CI) 0.83–0.91] and CABG
CS should trigger activation of the ‘shock team’, which in- (OR 0.85; CI 0.79–0.92) centres.51 The importance of proce-
cludes transferring from the spokes hospitals to the Level I dural competence is crucial in the management of CS pa-
hub centre with concurrent consultation with the cardiac tients who present with tenuous haemodynamics.
intensivist.43 The cardiac catheterization laboratory staff in- Accordingly, establishing systems of care with dedicated CS
cluding the interventionist and cardiac surgeon should also centres identified as hubs with proficiency in performing
be simultaneously notified for immediate angiography and high-risk interventions has the potential to improve out-
possible need for MCS support.41,43,44 In the INOVA Heart comes in CS patients and limit procedural complications.
and Vascular Institute (IHVI) cardiogenic shock pathway,
the shock team was activated via a ‘shock line’ prompting
a multidisciplinary discussion with the four specialists
involved.45,46 In the University of Ottawa Heart Institute Role of cardiogenic shock team in early
(UOHI) code shock protocol, a smartphone application was mechanical circulatory support
employed for code shock activation and subsequent online
virtual discussion among the CS team members.47 Irrespec- Despite haemodynamic advantages of MCS, large trials
tive of the initial management plan, there should be ongo- powered for efficacy and safety are lacking in CS.4,11,52,53 A po-
ing daily communication between all team members to tential limitation of these trials was a selection bias in choosing
discuss management strategies and timing for escalation patients who were either extremely sick with irreversible neu-
or de-escalation of care.39 rological injury (i.e. post-arrest CS patients in IMPRESS trial) or

ESC Heart Failure 2021; 8: 988–998

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Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock 991

insufficiently sick to derive meaningful benefits from MCS (i.e. with improved outcomes when MCS was initiated within
mild to moderately severe CS patients in IABP-SHOCK II trial). 5 h of patient presentation.
Timing of MCS initiation is also thought to contribute to suc- Although more robust data are required before routine
cess of therapy. CS teams can play a crucial role to (1) evaluate adoption of MCS in CS, a strategy adopting rapid assessment
those that may derive benefit from MCS, (2) to provide more for MCS can be facilitated by establishing dedicated CS proto-
timely access for these patients, and (3) to prevent individual cols. A concern raised with CS teams is the potential delay in
biases and identify those that may be too sick to derive any care and execution of critical decisions with increasing num-
benefits. It is hoped that previous efforts failing to show con- bers of providers involved. However, in the Utah Cardiac Re-
sistent clinical improvements with MCS can be overcome by covery (UCAR) shock team experience, a multidisciplinary
optimization of MCS care with specialized CS teams. approach did not delay care with a shock-to-support time of
One potential role of having CS teams is earlier recognition 19 ± 5 h in shock team vs. 25 ± 8 h in control (P = 0.52) with
of refractory shock in order to expedite the initiation of MCS. an increased survival after establishing a dedicated multidisci-
For CS, a similar metric as STEMI’s door-to-balloon time, or plinary CS team.61
‘door-to-support’ time could be developed to reflect the time
between onset of CS and initiation of MCS.54 It has been pro-
posed that early identification of CS to rapidly implement MCS Patient selection and choice of mechanical
can improve clinical outcomes.55–57 In a study of 287 patients circulatory support device
with AMI-CS receiving an Impella less than 1.25 h from shock
onset, a 66% in-hospital survival was achieved compared with Patient selection for MCS is critical in obtaining a successful
37% and 26% survival in patients who received MCS within outcome. Given the high morbidity and substantial costs as-
1.25 to 4.25 h or exceeding 4.25 h of CS onset, respectively.55 sociated with MCS, its judicious use to carefully selected CS
In a non-randomized cohort from the USpella registry, among patients is critical.62 Given the lack of clear guidelines for ap-
patients with CS following AMI, Impella insertion prior to PCI propriate patient selection for MCS application, development
increased survival by 24.4% (number needed to treat of five) of CS teams can help in selecting the right patient for the
compared with insertion after PCI.56 A meta-analysis of three right device. In the IHVI and National Cardiogenic Shock Ini-
studies comprising a total of 370 patients indicated that early tiative shock team protocols, presumed more robust haemo-
initiation of Impella in CS following AMI leads to a 48% reduc- dynamic markers such as cardiac power output63 and
tion in 30 day mortality compared with late MCS initiation.58 pulmonary artery pulsatility index (PAPi)64 were used as hae-
Despite the strong physiological bases, these associations re- modynamic criteria for MCS patient selection, assessing re-
quire confirmation in randomized control studies. sponse to therapy and whether escalation/de-escalation of
The Detroit Cardiogenic Shock Initiative enacted a regional MCS was needed. It should be kept in mind that the use of
protocol for management of CS in AMI patients focusing these metrics is mostly based on observational data rather
around rapid insertion of MCS and use of pulmonary artery than randomized control trial evidence.
catheter haemodynamic monitoring to guide subsequent The appropriate MCS device for a given CS stage is of ut-
therapy.59 In this pilot protocol of 41 patients, a rapid door- most importance to maximize the survival benefit while
to-support time averaging 83 min was obtained, with 85% minimizing the risks. MCS devices should be tailored to pa-
survival rate until device explant and 76% survival rate to dis- tient profile to offer the highest chance of haemodynamic
charge; this was a marked improvement compared with con- augmentation, and this process can be facilitated by the
ventional expected outcomes. This study cultivated the emergence of CS teams. Different types of MCS devices
National Cardiogenic Shock Initiative where multiple US insti- have different efficacy in the management of CS, with the
tutions adopted the same CS protocol-based approach em- newer percutaneous VAD and venoarterial (VA)-ECMO pro-
phasizing on early initiation of MCS.60 About 98.9% of viding greater haemodynamic support that IABP.65–67 Also,
enrolled CS patients underwent Impella placement with MCS devices with dedicated right ventricular support may
74% of patients receiving it pre-PCI. Also, a striking rapid be used in patients with refractory right heart failure.68 In
door-to-MCS time of 85 ± 63 min was achieved. With an early the UCAR shock team study, there was a significant varia-
MCS approach, the number of inotrope infusions was re- tion in MCS-device type with increased use of Impella
duced in 51% of patients, a potential marker of improved out- and VA-ECMO in the shock team cohort as compared with
comes. In the UOHI code shock protocol, there was a trend controls, although no survival advantage was observed in
towards increased MCS utilization among patients treated relation to device type (Table 1).61 In the UOHI shock expe-
with adoption of a CS team approach (45%) as compared with rience, Impella—particularly the 5.0 L device—was used
a conventional treated group (28%).47 In the IHVI shock team more commonly in the CS team managed group in relation
study, 44% of patients presented to the hub CS centre had es- to the standard care cohort.47 In the INOVA-SHOCK registry,
calation of MCS.46 Every hour of delay in intensification of percutaneous VADs (especially Impella CP) either alone or in
therapy was associated with 10% increased mortality risk, combination to VA-ECMO were used more commonly than

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Table 1 Studies to date using dedicated cardiogenic shock teams and protocols

Study Number of patients Quality Measures/Goals Intervention(s) Outcome(s)

National Cardiogenic Total: 171 1. MCS use pre-PCI PCI: 171 of 171 patients MCS pre-PCI: 74%
60
Shock Initiative All patients with AMI-CS 2. Shock onset to MCS [Impella 2.5, CP, or RP]: RHC usage: 92%
Basir et al. 2019 *No control group device <90 min 169 of 171 pts Maintain CPO > 0.6 W: 62%
Prospective single-arm study 3. Establish TIMI 3 Flow • 74% pre-PCI Door to support time:
4. Complete • 7.1% during PCI 85 ± 63 min
revascularization • 18.9% post-PCI Survival to discharge: 72%
5. Maintain CPO > 0.6 W RHC: 154 of 171 pts
6. Maintain PAPi >0.9
7. Routine RHC use
Inova Heart and Vascular Total: 204 1. Rapid CS identification PCI: 82 of 204 patients 30 day survival:
Institute Cardiogenic AMI-CS: 81 2. Early MCS (LV and RV) MCS: 135 of 204 pts • Pre-shock team
46
Shock Initiative ADHF-CS: 122 3. RHC: Thresholds at 24 h: • 35.3% IABP implementation: 47%
Tehrani et al. 2019 *Control group not i. Lactate <3 • 44.9% Impella only • After 1 year of shock team
Prospective, pre-intervention presented ii. CPO >0.6 W • 6.4% VA-ECMO only implementation: 58%
and post-intervention study iii. PAPi >1.0 • 13.5% Impella + VA-ECMO • After 2 years of shock team
4. Minimize inotropes/ RHC: 167 of 204 patients implementation: 77% (P < 0.01)
vasopressors
5. Cardiac recovery
Utah Cardiac Recovery shock Total: 244 If STEMI: MCS: 123 of 123 in shock team Shock to support time: 19 ± 5
61
team N = 123 treatment; 1. Central arterial access (vs. control) (vs. 25 ± 8 h, P = NS)
Taleb et al. 2019 N = 121 control for LVEDP measurement • 30.2% IABP (vs. 62.8%) Mean length of MCS support:
Prospective, pre-intervention AMI-CS: 2. Consideration for • 33.3% Impella (vs. 9.9%) 121 ± 13 (vs. 104 ± 16 h, P = NS)
and post-intervention study Ntreatment = 75 MCS and simultaneous • 8.9% VA-ECMO (vs. 5%) In-hospital survival: 61% (vs. 47.9%;
Ncontrol = 85 angiogram-PCI • 27.6% combination of devices P = 0.04)
Non-AMI CS: 3. Urgent RHC (vs.. 22.3%) 30 day all-cause mortality HR 0.61
Ntreatment = 48 If not STEMI: P value for MCS type <0.001 [95% CI, 0.41–0.93]
Ncontrol = 36 1. Urgent RHC
2. Consideration for MCS
3. Possible LHC as needed
University of Ottawa Heart Total: 100 1. Confirmation of CS Revascularization: 12 of 100 Temporary MCS use: 45% (vs. 28%,
47
Institute code shock team Ntreatment = 64 2. Resuscitation patients—all AMI-CS (75% PCI, 8% P = 0.08)
Lee et al. 2020 Ncontrol = 36 3. Medical optimization CABG, 17% both) In-hospital survival: 69% (vs. 61%;
Retrospective, CPO, MCS, PAPi, AMI-CS: 4. Temporary MCS MCS: 29 of 64 in shock team (vs. P = NS)
RHC Ntreatment = 7 evaluation 10 of 36 in control) 30 day survival: 72% (vs. 69%;
pre-intervention Ncontrol = 6 5. Heart transplant, • 34% IABP (vs. 40%) P = NS)
and post-intervention study Non-AMI CS: LVAD evaluation • 28% Impella (vs. 10%) Long-term survival: 67% (vs. 42%;
Ntreatment = 57 • 7% VA-ECMO (vs. 10%) P = 0.04)
Ncontrol = 30 • 14% combination (vs. 11%) Cumulative survival: HR
P value for MCS type: 0.08 0.53 [95% CI 0.28–0.99]
RHC: 50 of 100 patients

AMI, acute myocardial infarction; CABG, coronary artery bypass graft; CI, confidence interval; CPO, cardiac power output; CS, cardiogenic shock; HR, hazard ratio; IABP, intra-aortic bal-
loon pump; LVAD, left ventricular assist device; MCS, mechanical circulatory support; NS, not significant; PAPi, pulmonary artery pulsatility index; PCI, primary coronary intervention;
RHC, right heart catheterization; VA-ECMO, venoarterial extracorporeal membrane oxygenation.

DOI: 10.1002/ehf2.13180
ESC Heart Failure 2021; 8: 988–998
N. Moghaddam et al.

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Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock 993

IABP (45% vs. 27%), with frequent escalation of IABP to VAD CS teams, using protocol-based approaches (Table 1
after activating the CS team.46 Until there are convincing data and Figure 1). Basir et al., based on their experience
from randomized studies demonstrating a survival benefit with the Detroit Cardiogenic Shock Initiative, established
based on MCS type, a CS team-based approach can streamline the National Cardiogenic Shock Initiative, a regional protocol
eligibility for different types of MCS to choose accordingly. for CS in patient with AMI.59,60 The investigators developed
Lastly, development of multidisciplinary CS teams can help in a CS protocol focused on best practices including early
excluding patients from invasive therapies with advanced co- activation of catheterization laboratory, early use of MCS
morbidities or impending futility.69 preferably within 90 min of presentation, and routine use
of invasive haemodynamic monitoring. A total of 171
patients from 35 US centres were enrolled in which 167
(97.7%) survived the index procedure and 123 (71.9%)
Association of cardiogenic shock teams survived to discharge.
with outcomes The IHVI investigators developed a shock team protocol
for management of patients with CS.45,46 The team-based
Four published observational studies from North American approach demonstrated a 30 day survival among patients
centres have evaluated the role of multidisciplinary with CS at 57.9%, which was a marked improvement from

Figure 1 Survival outcomes pre-shock and post-shock team/protocol implementation in the (A) National Cardiogenic Shock Initiative, (B) INOVA Heart
and Vascular Institute Shock Team Protocol, (C) Utah Cardiac Recovery shock team, and (D) University of Ottawa Heart Institute Code shock team.
12
*Data from the IMPRESS in Severe Shock Trial. **No baseline institutional survival outcomes or controls reported in the National Cardiogenic Shock
Initiative.

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994 N. Moghaddam et al.

47% the year prior to the shock team implementation. One patients with CS following AMI showed significant underutili-
year after implementation of the programme, about 76.6% zation of palliative care services despite the high mortality
of patients with shock treated in the IHVI pathway survived associated with CS.73 Therefore, CS team can help with
to 30 days (P < 0.01). The survival benefit of this treatment de-escalation, earlier incorporation of palliative
team-based shock care was more pronounced in CS care measures, and facilitate transition to comfort care if
following AMI (44% in 2016, 63% in 2017, and 82% in necessary.
2018) as compared with CS following acute decompensate
heart failure (60% in 2016, 63% in 2017, and 72% in 2018).
In the latest proof of concept study, the UCAR shock team Challenges in implementing
compared 123 consecutive patients with refractory CS
between 2015 and 2018 managed through a ‘shock team’ cardiogenic shock teams
approach with 121 control patients treated with traditional
algorithms.61 After institution of a shock team, there was A number of hurdles exist in establishing CS teams and
13.1% absolute risk reduction in in-hospital death and a centres. To implements successful CS protocols, multiple
reduction in 30 day all-cause mortality with an adjusted cross-specialists, and personnel with adequate expertise and
HR of 0.61 (95% CI, 0.41–0.93). More recently, the UOHI competence in managing the most critically ill patients are
code shock protocol displayed an improved long-term required. Frequent training and quality improvement should
survival with establishing an interdisciplinary CS team be incorporated for the members of the CS teams to sustain
compared with standard care (HR 0.50; 95% CI 0.28–0.99) adequate clinical and procedural proficiency. This is specifically
over a median follow up of 240 days.47 Notably, there were important for centres where CS cases are sporadic. It is also
no in-hospital or 30 day survival benefit. This may in part be quite burdensome at an institutional and individual level to
accounted by the lower incidence of AMI-CS and ischemic maintain a 24 h/7 day CS programme. In addition to the
cardiomyopathy, two CS phenotypes with higher inherent funding required to run CS teams, the costs associated with
mortality. Although the outcomes in CS is still discouraging temporary MCS74 can be prohibitive for single payer health
despite the use of various interventions, emergence of CS care systems.
centres with staffed multidisciplinary ‘shock teams’ offers Expediency is also imperative in establishing CS teams
an encouraging vision in CS care with potential to improve where critical decisions and interventions are needed but
survival. might be delayed with the increasing number of stake-
holders involved. These challenges could be mitigated by
designating a ‘shock doc’ who could triage the initial calls
and ensures appropriate activation of the rest of the team
Cardiogenic shock teams in managing and also coordinate the care to avoid delays. The extensive
‘beyond shock’ resources needed to maintain CS teams require constant
institutional administration support, sufficient funding and
The understanding of CS has shifted away from a ‘haemody- staffing, and ongoing cost-effective analysis. It also needs
namic’ aberration towards a ‘haemometabolic’ insult that to be a regional buy in from health authorities into a
might not respond to treatment of the underlying haemody- hub-and-spoke model for CS management similar to STEMI
namic problem alone.54,70 This requires a multifaceted ap- systems of care. Design of CS teams requires consideration
proach to management of the multi-organ dysfunction that of local infrastructure, including involvement of referral
ensues CS. The role of CS teams thereby extends beyond op- centres and EMS for expedient triage and transport of
timizing revascularization and advanced MCS therapies. CS patients. In addition, designing a system to address all
teams can help in consolidating cardiac-related medical ther- stages of shock, rather than just those at more advance
apy from choice and titration of vasoactive agents to the stages continues to be a challenge. Lastly, consistent data
need for non-cardiac interventions including renal replace- collection is needed to follow outcomes and provide
ment therapy and neurological prognostication. Timely initia- a framework for quality improvement feedback for CS
tion of mechanical ventilation and mode of ventilation could teams.
attenuate multi-organ dysfunction in CS patients.71 A multi-
disciplinary shock team approach can take advantage of sub-
specialists with expertise in intensive care and ventilation Future directions
strategies.72
Lastly, a multidisciplinary approach to CS can integrate The increasing treatment complexity of CS creates new
advanced diagnostics and therapeutics with non-medical opportunities for dedicated multidisciplinary CS teams to
and palliative aspect of care. A retrospective analysis of gain traction. Since the initial inception of the formalized
national inpatient sample database from almost half a million team-based CS protocols however, our knowledge about

ESC Heart Failure 2021; 8: 988–998

DOI: 10.1002/ehf2.13180
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Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock 995

CS and different advanced therapies has grown. There is Conclusions

significant heterogeneity in the CS definition, patient
selection, treatment protocols, and outcome measures in Despite revascularization and MCS advancements, the out-
these studies. The new SCAI CS definition has added more comes of CS have remained poor largely due to fragmentation
granularity in the severity of shock and allows for better of care and disparity of practice patterns. There is now in-
multidisciplinary communication.25 It also helps to refine creasing evidence from observational registries supporting
our MCS selection based on the CS stage, as each MCS the establishment of a hub-and-spoke care system for CS.
device can have a variable outcome at different acuity Multidisciplinary shock teams utilizing protocol-driven care is
stages.26,75 Given the time-sensitive nature of managing feasible and can improve survival in patients with CS. The role
patients with CS and dynamic need for escalation or of CS teams is to facilitate timely diagnosis, appropriate use of
de-escalation of treatment, dedicated CS teams can help invasive haemodynamics, revascularization strategies, and im-
in efficiently navigating different therapies and optimizing plementation of MCS. CS teams should systematically include
outcomes. There needs to be further randomized cardiovascular specialists with dedicated expertise in different
evidence—perhaps generated by pragmatic, multi-centred, arrays of CS care and respond to the evolving advancements
stepped wedged strategy trials—evaluating the clinical and in this field. Given the observational nature of the current
cost effectiveness of the CS teams in relation to standard studies, further prospective large-scale randomized trials are
care before routine adoption in the critical care cardiology required to determine the clinical efficacy and cost effective-
landscape. ness of standardized team-based approach to CS.

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