Dr. Tehrani serves as Co-Director of Inova Heart and Vascular Institute's Cardiogenic Shock Program. He examines a standardized approach to improving team-based care to improve clinical outcomes in cardiogenic shock.
on behalf of Sentara Heart Hospital in Eastern Virginia Medical School. I would like to welcome dr venom to Ronnie. His talk today is entitled cardiogenic shock evolving paradigms and care. Dr Tehrani is the co director of the cardiac Cath lab at Inova Fairfax Medical Campus and co director of the Inova Heart and vascular institutes Cardiogenic Shock program is also intimately involved in a novas coronary, total occlusion, pulmonary embolism and chronic thrombosis, symbolic pulmonary hypertension programs as well nationally. He serves on american College of Cardiology and Society of Cardiovascular angiography and intervention committees regionally as its impact on advancing quality gains through his involvement with statewide Virginia Heart attack coalition and Virginia cardiac services quality initiatives. Dr Theron graduated from George Washington University School of Medicine. He then remained at GW for his internal medicine residency and cardiology and cardiac intervention fellowships. Benham is authored many important articles on cardiogenic shock going roles for coronary intervention, extracorporeal membrane oxygenation and perhaps most significantly promoting a standardized regionalized system of care for patients with cardiogenic shock. Ben, um we're looking forward to your talk this morning. Welcome. Thank you. Thank you very much Dr Bernstein for having me. It's obviously a it's always a privilege to be with all of you today and and to just share some of this work that we've been doing at a nova but also to learn more from you as well. So the following are my disclosures. So, you know, we'll talk briefly about some of the challenges and improving outcomes in cardiogenic shock, examine the merits of a standardized approach to doing cardiogenic shock and look at some opportunities for improvement and systems of care delivery models for this disease state. So many of you have seen this slide in um um in one iteration or another. But essentially you know as we've known now for the better part of almost 22 years that despite advances and systems of care strategies and uh and despite advances in early uh early revascularization and M. C. S. Devices outcomes in cardiogenic shock remain poor with short term survival rates that are just you know barely you know 50 55 60% and that's been that case despite a number of advances as I have discussed and this is also in the context that uh incidents and outcomes for this disease process are steady and moving in the wrong direction. Now. Part of it is because you know part of the reason why incidents continues to rise is because you know we have an aging population, we've gotten better at keeping people alive longer for chronic heart conditions, coronary disease cardiomyopathy. But it's not uncommon that the um that one of the outcomes of this long term is worsening heart failure and ultimately shock. And interestingly not only is the incidence of Am I shock on the rise in yellow as you'll see but in red the instance of non Am I shock which you're learning now is most likely the predominant cause of shock is also on the rise and these outcomes are consistently seen across the United States. This is also one of the most common causes of admission to go to modern and contemporary cardiac intensive care units. But it's also one of the most common causes of of morbidity and mortality. And this is data from the uh cardiology critical care Trials network from three years ago. Now we've evolved over the last 25 30 years in terms of how we define shock from the classic diamond Forrester classification of whether you were warm, uh cold or whether you were wet and you were dry. And we have now developed definitions that have gone beyond that and one of that is from the seminal sky shot classification staging system, which really breaks it down across the entire severity spectrum of shock from those that are at risk to those that are pre shock that have now developed a full minute or classic shock and those that are deteriorating because of failure response to therapies or those that are in extremists and they've also added a couple of modifiers. One of them is cardiac arrest with concern for anoxic brain injury because we know that cardiac arrest complicating shock only further heightens your risk for morbidity and mortality. And this classification system has gone through a number of iterations as we've discussed, but it's also been validated retrospectively from the Mayo register on the left for in hospitals. The ICU mortality retrospectively in the middle graph from german data With regard to 30 mortality. And then prospectively was published by Dr. Dave Baron and your team at Sentara. Um And it's been shown that the worsen sky stage translates into worsen outcomes now. Um we've learned a lot but we also know that there remain unresolved gaps in knowledge. Um and so these are a number of them that you that you'll see here and we'll address a number of these. But one of the roles that that you know, I've been fortunate to have have have have a part in at a nova is around systems of care and developing a team based approaches shock. Now, many of you have seen this slide in one iteration or another from the initial Holland Berg Diagram from 22 years ago. But this is a complex metabolically complex and then also um hemo dynamically very multi various disease state in which patients progress down this very rapid proverbial cycle of inflammation. A scheme you have as a construction volume overload And results and and and sustained worsening and organ failure. And as a consequence of that, 50% of patients die. And as I mentioned, not all shock is the same. This is data again from the cardiogenic from the cardiac uh cardiology critical care trials network that shows that what we thought was initially uh am I shock is not, is no longer the majority. There's non ischemic for forms of shock and those that are what we call mixed shock may have some distributive shock because of complexities in the intensive care units, But what we've learned is that in shock congestion translates into worsen outcomes. So the worst the congestion is, the worst the outcomes. And especially among those that develop right ventricular by ventricular shock, outcomes are significantly worse than those that develop classic LV dominant shock. And we've learned that this is data that was published six years ago from the group of Duke, in which they showed that a low index is bad. The low index coupled with the high wedge pressure is worse than all other forms of shock because not only low output, but also congestion. And this data from cardiogenic shock working group showed that worsen congestive profiles across the severity of of of shock translates into worsen outcomes. And as you'll see here that's seen particularly with LV and BV compared to RV shop and this is due to worse than kidney and liver failure. And this paper that was again published by the cardiogenic shock more of a deep phenotype ng analysis of cardiogenic shock, like those that cardio metabolic shock, those that have kidney um um and and hepatic dysfunction and what they showed was that those patients were less likely to survive and they were more more likely to require cardiac replacement therapies if they had a chance of survival. Now, one of the new paradigms in shock is knowing that there's a difference between am I shock and heart fair shock to separate disease states. The common final pathway may be the same. But in order to avoid getting to the final common pathway of mortality, it's important to understand that those that are walking around with heart fair have a low baseline output state have a higher based on congested profile state versus those that are Am I shocked that are healthy will then develop hypertension followed by congestion as a consequence of the acute coronary thrombosis and pump failure. We just published data recently last weekend circulation Heart Fair. Which we showed that those that have uh heart fair shock have higher based on wage pressures, lower output and index, higher pulmonary hostility index. Um And at the upfront phase in the 1st 30 days and in hospitalization the patients that have a cute am I do worse? But at one year There are similar rates of Mace between the two disease states. Now as we've talked about, just as not all shock is the same. Not all temporizing M. C. S. Devices are the same. This is a paper that was published just a year ago. And as you'll see here 2012 was an important year with regard to you know, utilization of devices. Obviously iterative advances with a cutaneous ventricular assist devices, ECMO and whatnot. But that was also the year the publication of the iBP shock to study by by paul martin and his team in which they showed that there was clinical equipoise in AM I shock between balloon pump and standard of care and as a result of a downgraded to a three A classy recommendation in europe and a class two A in the United States. And just as I mentioned, you know, not all devices are the same. They come in different platforms that come in different of varieties and iterations. Um and in order to use these devices appropriately. It's important to understand how they interact with the pressure volume loop. Important understand how much flow they provide what their mechanism of of of unloading the heart There is if there may be and also making sure to do them in a way which is safe with best practices for vascular access to mitigate the risk for bleeding and vascular complications. So again, as I mentioned, you know the understanding pressure volume loops and how these devices plus or minus drugs can can interact with them. As you'll see here on the top right balloon pump provides a modest reduction after load and maybe about a half a liter, maybe three quarters of a leader. And some new variations a leader of cardiac output. Whereas the other devices like the impel a. They changed a configuration of the pressure volume loop from Trapasso triangular and that obviously obviates the need for vice volume ventricular contraction and relaxation and that unloads the heart tandem unloads the heart indirectly by taking blood from the left atrium to the femoral arterial circuit. But it does provide a modest increase and after load an ECMO as we know, it just takes blood on the right side, back into the left side. And because the retrograde flow that significantly increases after loading patients can develop worsening pulmonary edema, absence of aortic valve opening aortic rhombus. And some mechanisms have to be looked at to then the L. V. Uh And as we talked about, you know these devices are very helpful. They can certainly reduce intra critic filling pressures, improve stroke work but over a long period of time they can be associated with complications. Um P. A. Catheters as you know, we're not too long ago more than a decade and a half ago written off. And this was after initial papers by Dr. Connors and team in the late 90s at the medical critical care population but also subsequently the escape trial which is purely a heart fair patient population, not a shock patient population and suggested that there may be more harm than benefit. But we've known now for the almost 18 years that there are important thermodynamic variables garnered from the catheter That can really translate into prognosis. One of these is the cardiac power output which is your map times your cardiac output divided by 451 and when that number is less than .6 in hospital mortality shoots up. So it's important to use the p. a catheter to recognize shock early and then to implement tailored therapies. And this paper that was published by the cardiogenic shock Working group a year and a half ago is very important because it showed that doing comprehensive hemo dynamic assessment to not only get your wedge but your P. A pressure, your cardiac output to look at signs of RV. Dysfunction early can translate into early application of tailored therapies and as a result, reduced mortality across all sky stages including D and E. That was in the context of this data. That this paper was published by the group out of Duke. Talking about standardized approach to shock with the rationale being that's a complex disease process. There's a lot of these practice pattern variations. There are no randomized controlled trials to guide management and this precedent for managing complex diseases like shock and a team based approach trauma sepsis tumor boards. Now we're having data around management of pulmonary embolism, aortic syndromes and the concept is to identify the team members, develop protocols, mechanisms or risk stratify these patients and take this information and this model of care first within your hospitals and then to disseminate across the community to ensure adequate disease recognition. Um and then obviously appropriate utilization of contemporary resources. We published our initial data back in 2019 and this paper the right was what we had discussed as being one of the ways in which one can develop a contemporaneous approach to shock. Now in 2016, when we looked at our own internal disease management process, we identified four opportunities for improvement, one was fractured care, which was no process for multidisciplinary evaluation. Communication was not standardized. Oftentimes patients were detected late and they were thus too sick to benefit from therapies, there was impaired access to care as a result of late recognition and as a result of that there was inconsistent uh practice patterns and the utilization of therapies. Our process began in the summer of 2016. Over six months, we brought together service lines and we identified what who these were interventional cardiology, critical care heart fair cardiac surgery. We put together protocols and we did outreach to our service lines in the hospital and ultimately in the community. And as you can see here In the middle of last year and I should update this to January of this year. We've had now 1100 patients with cardiogenic shock that we followed. We are here at Inova Fairfax Medical Campus, that's our main flagship hospital and we partner with 34 hospitals in our community in Washington, D. C, northern Virginia, Western Virginia, West Virginia itself down all the way to folk here in Warrenton and fredericksburg and even into parts of southern Maryland where we work with these hospitals to identify these patients early to use standardized protocols and to get them to, you know, to the level one Center for standardized and team based care and the goal that we've set out is to identify the shock state earlier. The level of not only you know with the admitting doctor in the er but also the emergency room physician and the P. A. S. And a P. P. S. But also the E. M. S. To get them to where they need to be offered them revascularization. If it's am I shocked early invasive hemo dynamic assessment, tailored and tailored and applied M. C. S. Therapies and ultimately multidisciplinary care. We we then institute a number of interventions to address these opportunities. So um robust participation of all the service lines. Um We we undertook a health system sprint in which we identified what the key stakeholders were and we created a laminated cards which will show you across the hospital but the community for who to call and how to treat the disease early to get them where they need to be. We created a one call access line to get everybody on the phone early and the algorithms that I'll share with you now. And so the goal was to you know, in order to say that, you know, what is this team here for? Is that are there criteria that are meant for shock? Are there any absolute contraindications to therapy that's obviously important. We want to provide compassionate care which is um really in line with patients health values and goals of care to ensure that we have the adequate resources and that was obviously a big deal during covid and to make sure that the patient is safe for transfer. This was the initial protocol that he published three years ago. Again standardized clinical criteria identify whether they're am Earhart fair shock. Um apply the therapies, use chemo dynamics and then follow on care and the cardiac intensive care unit. And we showed that there was steady transit improvement in outcomes. And we'll show that with some upcoming papers that will be in the pipeline. Over the next 6 to 8 weeks we developed a risk score based on variables that we felt were important in their data. Um And as you can see here um not only baseline variables such as age whether they're um dialysis or they're diabetic also presser duration as we know now that worsening uh increasing pressures, translated worsening outcomes But also lactate and markers of RV dysfunction in 24 hours. Can um all these are present as you can see with this risk score 30 day mortality worsens. And again this was validated against the card sharks from europe and you can see the area under the curve was adequate. And so these are the cards that we created again to identify um you know the clinical criteria for shock to identify the one call number for for uh referring centers to send these patients over and to really develop upfront um triage mechanisms for large bore I. V. S. Uh to check labs and to utilize pressures at a minimum dose but at least at the appropriate just to stabilize the patient before following therapies. These are the this is the protocol that we created for what happens afterwards when they met the criteria. And they've had him oh dynamics and they're in a C. I. C. U. And ultimately once they're in the C. I. C. U. To use tailored therapies I'm sorry to apply tailored therapies based on utilization of invasive chemo dynamics. So if their cardiac powers improving the right side functions improving, they're not congested to win the Pressers and tropes that's for heart recovery. And then the the same applies whether if they have by V. L. V. R. V. But if they're deteriorating to use those therapies and to apply tailored when appropriate and then obviously engage advanced heart failure and transplant. Our data was in line with those published out of Utah and the University of Ottawa And similar data from National Cryogenic Shock Initiative around developing standardized protocols and team based Care for Shock. This was published last year from the Critical Care cardiology Trials network in which had looked at 14 centers Over 1224 centers with 1400 patients. 14 shock team 10 did not. And what they showed was that centers of had shock teams had improved the mortality and that that may have been due to the earlier utilization of P. A catheters. Um more advanced. M. C. S. Strategies and also better um better follow on him. Oh dynamics as a consequence of that. So in conclusion cardiogenic shock should be a team sport in which all these members come together. So this book was published by general Stanley McChrystal um a decorated four star general in which he identified the concept of command and control but also the command of the teams. So while it's important to have support from above ultimately comes down to the team of teams to come together to bring everybody on the same page and then really work in such a way that really no one knows who the team leader is but everybody's working together uh in a coordinated fashion to apply to standard therapies. This paper is gonna this is gonna be a clinical trial starting out out of cryogenic shock working group looking at the utilization of P. A. Catheters for cardiogenic shock and this will be the first randomized controlled trial looking at that and this should be seminal and very improvement. So how do we you know match the right patient the right device at the right time. It comes down to him. Oh dynamics and and then a team based approach and to really do that across the region in a way which patients are recognized early at the level two and level three shock centers and transferred to A level one center their ongoing studies and M. C. S. Um And and part of that's because we currently are in a state of clinical equipoise and M. C. S. And those should hopefully inform our knowledge and our treatment opportunities. So lessons that we've learned in Unova is the team commitment is a participation, participation. It's crucial. Early recognition of shock has improved, is associated with improved survival. Communication is key. The process needs to be reviewed and refined. Standardized care is important, but it's also important to have mechanisms for quality control and to really strengthen partnerships with all members of the community positions, a PBS, administrative stakeholders and other leaders. So on behalf of our team at a nova, thank you very much for having me.