When it comes to the survival rates of cardiogenic shock (CS), it’s been decades since anything has improved. For the last 20+ years, chances for surviving CS — the leading cause of death in heart attack patients — have hovered around 50 percent.
“We are the second hospital in the state of Washington to adopt the new protocol,” said Dr. David Zhang, who specializes in cardiac care for adult patients at St. Joseph’s.
This new protocol is the backbone of a groundbreaking clinical trial — funded by global leader in healthcare technology Abiomed — that focuses on implementing best practices to increase survival rates among patients with CS.
NCSI centers around standardized use of Abiomed’s Impella system, the world’s smallest heart pump. While the technology provided by Impella is impressive and helpful on its own, data collected by Abiomed revealed that the way in which Impella is implemented makes a huge difference in its ability to save a life.
“We collect data on more than 90 percent of our patients in the United States, and the data have given us the ability to understand what some of the predictors of better outcomes are,” said Dr. Seth Bilazarian, chief medical officer for Abiomed. “We noticed that at some centers, there were very good outcomes and at others, there were not. They’re all using the same device, so those outcomes don’t have to do with the device but rather with the way it’s being used.”
From this collected data, the physicians who started the cardiogenic shock initiative — which was originally based in Detroit — agreed on four steps to create a standard protocol for treating CS with Impella to improve outcomes for patients.
The pieces of the protocol, Dr. Bilazarian explained, are as follows:
- The earlier a patient gets identified as having CS, the more likely he is to survive. If a patient gets identified in less than 75 minutes, his survival is almost three times greater than if the diagnosis is not made for more than four hours. Early recognition is therefore critical.
- Once recognized, the Impella must be put in before any other procedure is done. The artery should only be opened after Impella has been inserted.
- Doctors should do everything possible to lower the use of toxic drugs and isotopes in the course of treatment. These have traditionally been used to build up heart rate and blood pressure, but recent studies show that these drugs actually increase risk of death.
- A right-heart catheter and hemodynamic monitoring should be used to determine the level of support a patient continues to need, as well as his ability to ween off of the support of Impella over time.
St. Joseph’s has been officially implementing this four-step protocol since October of 2018, when it signed on to be a part of NCSI. Dr. Zhang explained that the team at St. Joseph’s was following a similar protocol even before that, based on initial academic studies that had been published.
Since officially joining, six team members at St. Joseph’s have worked together to treat about 40 patients with CS.
“It’s not just the protocol that’s important — it’s also the team approach,” said Dr. Zhang. “The cardiogenic shock team is a combination (of doctors with) different specialties who collaborate to make quick decisions. In the past, each hospital did its own thing, and there was a huge variation of outcome. But once we adopt the same protocol and a consistent team approach, we can seriously impact outcomes.”
NCSI has seen a 50 percent increase in survival, bringing survival rates up to 72 percent with 98 percent native heart recovery. While these are promising results, there is more that needs to be done before the protocol is made standard beyond the hundred or so hospitals that will ultimately participate in NCSI.
“Right now, the protocol is not yet randomized,” said Dr. Zhang. “We’ll probably spend another year before we randomize it and have a control group, after which we would hope that the American Heart Association would eventually adopt it as a guideline for cardiologists to follow.”
Dr. Antonio Secaira, another doctor on the cardiogenic shock team at St. Joseph’s, explained why the process is so drawn-out and thorough.
“We need scientifically sound data to show that this is in fact the best approach,” he said. “The technology itself can be very expensive, so we need to be able to show that (the protocol with Impella) is the best approach for these patients in order to advise other institutions to get involved.”
Ultimately, Dr. Bilazarian said, the goal is to continually collect more information that will lead to improved patient outcomes for a condition that has long gone without an effective treatment.