Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative

Mir B. Basir, Henry Ford Health System
Navin K. Kapur, Tufts Medical Center
Kirit Patel
Murad A. Salam
Theodore Schreiber, Ascension St. John Hospital
Amir Kaki, Ascension St. John Hospital
Ivan Hanson, Beaumont Hospital, Dublin
Steve Almany, Beaumont Hospital, Dublin
Steve Timmis, Beaumont Hospital, Dublin
Simon Dixon, Beaumont Hospital, Dublin
Brian Kolski, St. Joseph Hospital, Orange
Josh Todd, Regional Medical Center
Shaun Senter, Washington Regional Medical Center
Steven Marso, Overland Park Regional Medical Center
David Lasorda, Allegheny General Hospital
Charles Wilkins, Regional Medical Center
Thomas Lalonde, Ascension St. John Hospital
Antonious Attallah, Ascension St. John Hospital
Timothy Larkin, Edward & Elmhurst Hospitals
Allison Dupont, Northeast Georgia Medical Center
Jeffrey Marshall, Northeast Georgia Medical Center
Nainesh Patel, Lehigh Valley Hospital and Health Network
Tjuan Overly, University of Tennessee Medical Center
Michael Green, Northwest Orthopedic Center
Behnam Tehrani, Inova Heart and Vascular Institute
Alexander G. Truesdell, Inova Heart and Vascular Institute
Rahul Sharma, Carilion Roanoke Memorial Hospital
Yasir Akhtar, Regional Medical Center
Thomas McRae, Centennial Medical Center
Brian O'Neill, Temple University Hospital
John Finley, Mercy Fitzgerald Hospital
Ayaz Rahman, Parkwest Medical Center
Malcolm Foster, Turkey Creek Medical Center


© 2019 Wiley Periodicals, Inc. Background: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). Methods: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the “SHOCK” trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. Results: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12–24 hr reliably predicted overall mortality postindex procedure. Conclusion: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.