Cardiogenic shock, the poor relation of septic shock – are we missing a trick? - Susanna Price
•
1 like•710 views
Dr Susanna Price trained in both cardiology and intensive care medicine in the UK, and completed a fellowship at the Thorax center with Jos Roelandt. She was awarded a PhD from Imperial College London, and following completion of her training was awarded the two-year BHF Jill Dando GUCH Fellowship in order to train further in critical care and imaging in congenital heart disease. She is a consultant at the Royal Brompton Hospital where she is Clinical Lead for Critical Care, Honorary Senior Lecturer at National Heart & Lung Institute, Imperial College London. Dr Price is President-elect of the European Society of Cardiology (ESC) Acute Cardiovascular Care Association, and sits on numerous committees including the ESC Education Committee, ESC Press & Media Committee, ALS subcommittee of the RCUK and SCCM US guideline committee. She is an Associate Editor of the European Heart Journal of Acute Cardiovascular Care, and an invited reviewer for a number of other journals. She has been a member of a number of Task Forces relating to international guidelines including VA-ECMO, acute cardiovascular care, the management of cardiovascular diseases including valvular disease, endocarditis, non-cardiac surgery, pulmonary hypertension, pericardial disease, cardiovascular disease in pregnancy and grown-up congenital heart disease. Dr Price has authored numerous papers and book chapters on cardiology, echocardiography and intensive care, and lectures regularly globally
Recommended
More Related Content
Similar to Cardiogenic shock, the poor relation of septic shock – are we missing a trick? - Susanna Price
Similar to Cardiogenic shock, the poor relation of septic shock – are we missing a trick? - Susanna Price (20)
More from Intensive Care Society
More from Intensive Care Society (20)
Recently uploaded
Recently uploaded (20)
Cardiogenic shock, the poor relation of septic shock – are we missing a trick? - Susanna Price
- 1. CARDIOGENIC SHOCK, THE POOR RELATION OF SEPTIC SHOCK: ARE WE MISSING A TRICK? Susanna Price Royal Brompton Hospital, NHLI, Imperial College, London, UK Intensivist? Cardiologist?
- 2. Declaration of interest • I have no disclosures
- 3. Outline • Cardiogenic shock: background • Septic shock: lessons to be learned? • Key messages
- 5. USA: >5 million citizens, incidence 825,000 per annum •2030: >8 million citizens with HF •1 million hospitalisations per annum •Cost >30 billion USD per annum (70 billion USD by 2030) •5-year mortality 50 •Most expenditure attributable to AHF: - high rates hospitalisation/OP visits/medical therapy • STEMI shock cost (USA) $41,774+45,252 • IABP-SHOCK II trial IABP arm (€ 33 155+14 593) Resource evaluation last 180 days of life, Medicare with HF: - 80% hospsitalised in last 6/12 life - Cost from 28,766 – 36,216 USD per patient Background: heart failure & cardiogenic shock
- 6. 90,000 people in the UK affected – increasing Acute heart failure: • 11% die in hospital • 30% dead in one year Cardiogenic shock: • 27-51% die in hospital • ACS-related: if survive to discharge, 62-87% of these alive at 6 years • Non-ACS-related: ? Background: heart failure & cardiogenic shock
- 7. CS incidence AMI cause in 80% CS complicates AMI in 5-15% (60-70,000/annum, EU, 40- 50,000, USA) Thiele et al., Eur Heart J. 2015, Jeger et al., Ann Intern Med. 2008
- 8. IHD-related CS: mortality Increased: PCI MCS Transcatehter interventions Resynchronisation/pacing
- 10. Key challenges to address • Diagnosis and recognition of CS challenging (criteria, investigations, logistics) • Rapidly changing interventions for underlying cause • Lack of high-quality studies for critical care interventions • Lack of long-term data (particularly non-ACS) • Lack of clinical pathways • Management recommendations: disease-specific statements/guidelines • Comprehensive clinical resources lacking • International/National/Regional disparities in evidence-based care
- 11. Septic shock?
- 12. • Expensive and deadly (30% mortality) • Diagnosis and treatment challenging: • No consensus • Little adequate training • Many cases missed • 2002: launch Surviving Sepsis • 2004: first edition • 2008, 2012, 2016: previous revisions • 2018: updated version (1-hour bundle) • Targeted education + bundled evidence-based care • Association with bundle compliance and improved survival • USA mandated public reporting • Concept of time to treatment 0 2 4 6 8 10 coronary sepsis stroke LRTI DM Global deaths/annum (million)
- 13. Infection/sepsis • Globally: primary cause of death = infection • Developing world 60-80% lives lost • Admissions increasing
- 16. Lessons from sepsis/septic shock • Beware the drivers • Quality of evidence: individualised vs bundled, protocolised care • Unintended consequences
- 18. ‘Cognitive dispositions to respond’? 1. Over-attachment 2. Failure to consider an alternative diagnosis 3. Inheriting someone else’s thinking 4. Prevalence perception 5. Patient presentation characteristics 6. Physician affect, personality or decision style
- 19. Cognitive dissonance and EBM 1. Personal experience and observation less reliable than controlled scientific study (evidence vs eminence-based medicine) 2. New evidence may challenge pre-conceived ideas/what previously taught – reveal inadequacy of current practice – and result in dissonance (IABP) 3. Particularly challenging where large amounts of evidence emerging Thiele et al. NEJM 2015
- 20. The literature Cardiogenic shockSeptic shock Myocardial infarction
- 22. UK coronary disease Mortality (age adjusted) CAD Coronary interventions Age-standardised mortality: CVD, CHD and stroke – declined by 70% over 30 years BHF, November 2018
- 23. Primary, secondary prevention and evidence-based intervention 95,000 members, 28 subspecialty communities,
- 24. Publicity campaigns to enhance awareness/implementation? Data: WHO 2017, BHF 2018 0 20000 40000 60000 80000 100000 120000 140000 160000 CV deaths per annum CAD deaths per annum OOHCA per annum Sepsis deaths per annum anaphylaxis deaths per annum UK mortality
- 26. If develop CS….
- 27. Concept of time to treatment in CS Chain of survival: cardiogenic shock
- 28. vs
- 29. Pathways and Processes of care 47.0% - 57.9% - 81.3% CS survival
- 30. • Hoffman • IABP shock II • CULPRIT-SHOCK • EuroShock • HT ECMO • Reduction iatrogenic harm • Device therapies The cardiology triallists are coming…
- 31. Integrated physiological and biological pathway research
- 35. Conclusion • Many parallels with septic shock – lessons to be learned • Much high quality evidence already exists for many cardiovascular interventions • Rapid implementation of evidence-based investigations and therapies should be increased in systematic manner (cf pPCI pathway success, STEMI quality indicators…) • Must not prematurely implement non-evidence-based therapies
- 36. CARDIOGENIC SHOCK, THE POOR RELATION OF SEPTIC SHOCK: ARE WE MISSING A TRICK? NOT REALLY Susanna Price Royal Brompton Hospital, NHLI, Imperial College, London, UK
- 37. CARDIOGENIC SHOCK, THE POOR RELATION OF STEMI Susanna Price Royal Brompton Hospital, NHLI, Imperial College, London, UK STEMI CS
Editor's Notes
- Short answer – NCEPOD – 1 year 2016 AHF deaths – has a number of suggestions – come back to it at the end of my short presentation
- HF is expensive – high rates of hospitalisation Large amount spent near end of life In particular in intensive care
- Who are these patients? Mostly AMI – huge numbers of patients per annum Majority have LV failure – later study confirmed fewer mechanical complications – Know that CS sesn on admission is now beginning to rise, as are the number of interventions – but the amount is now increasing significantly – as are the ages and co-morbidities of these pateints
- Huge strides in interventions – but AMI complicated by CS mortality remains high – around 30-46% depending on the data you lok at – and in terms of where the RV is involved, worse than many very significant causes of critical care mortality
- Have heard from HT regardign revascularisation – going to look now at device therapy….
- Much discussion in the literature – why the mortality so high – diagnosis and recognition is challenging for a number of reasons, what we do changes, evidence is not high quality, little long term data. Logistically we see that there is a lack of clinical pathways, explain…
- APC – went in 2003 when subsequent trials were negative, and company allegedly were trying to market and access clinicans on the back of the guidelines Emerging evidence that individualised care, phenotyping and in future more, may be superior to bundled, protocolised care, especially wehre based on eminence-based medicine rather than evidence-based – in particular with the latest 1 hour bundle in the 2018 guidelines Beware the unintended consequences: infantalising doctors, taking away their ability for independent thought, stopping them challenging their own assumptions
- Interesting in what was seen in debriefing terms…. Cognitive dispositions to respond (there are 42 of them - but grouped as): 1. Error of over-attachment 2. Error due to failure to consider a diagnosis 3. Error due to inheriting someone else’s thinking 4. Errors in prevalence perception 5. Errors involving paitnet presentation characteristics 6. Errors associated with physician affect, personality or decision style
- Interesting in what was seen in debriefing terms…. Cognitive dispositions to respond (there are 42 of them - but grouped as): 1. Error of over-attachment 2. Error due to failure to consider a diagnosis 3. Error due to inheriting someone else’s thinking 4. Errors in prevalence perception 5. Errors involving paitnet presentation characteristics 6. Errors associated with physician affect, personality or decision style
- What this translates into in terms of mortality – anaphylaxis 20 – all aware of the campaigns – and dangers of what you eat – sepsis – 17K – of which more later, OOHCA – all aware of footballers – and latest data suggesting that they are at risk - but by far and away the biggest cause is cardiovascular diseas e- 1:7 men, 1:12 women will die from cardiovascular diseae – of which around 80% of premature deaths are thought to be preventable.