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Experts' Recommendations for the Management of Adult Patients With Levy et al. Annals of Intensive Care (2015) 5:17 DOI 10.1186/s13613-015-0052-1 REVIEW Open Access Experts’ recommendations for the management of adult patients with cardiogenic shock Bruno Levy1*, Olivier Bastien2, Karim Bendjelid3, Alain Cariou4, Tahar Chouihed5, Alain Combes6, Alexandre Mebazaa7, Bruno Megarbane8,PatrickPlaisance9, Alexandre Ouattara10, Christian Spaulding11,Jean-LouisTeboul12, Fabrice Vanhuyse13, Thierry Boulain14 and Kaldoun Kuteifan15 Abstract Unlike for septic shock, there are no specific international recommendations regarding the management of cardiogenic shock (CS) in critically ill patients. We present herein recommendations for the management of cardiogenic shock in adults, developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF)), with the participation the French Society of Anesthesia and Intensive Care (SFAR), the French Cardiology Society (SFC), the French Emergency Medicine Society (SFMU), and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV). The recommendations cover 15 fields of application such as: epidemiology, myocardial infarction, monitoring, vasoactive drugs, prehospital care, cardiac arrest, mechanical assistance, general treatments, cardiac surgery, poisoning, cardiogenic shock complicating end-stage cardiac failure, post-shock treatment, various etiologies, and medical care pathway. The experts highlight the fact that CS is a rare disease, the management of which requires a multidisciplinary technical platform as well as specialized and experienced medical teams. In particular, each expert center must be able to provide, at the same site, skills in a variety of disciplines, including medical and interventional cardiology, anesthesia, thoracic and vascular surgery, intensive care, cardiac assistance, radiology including for interventional vascular procedures, and a circulatory support mobile unit. Keywords: Cardiogenic shock; Myocardial infarction; Monitoring; Extracorporeal membrane oxygenation Review forms of CS in the latest international guidelines led our Introduction group to draw the following recommendations. The expert Contrary to septic shock, there are no international panel also deemed of interest to take into consideration the recommendations regarding the management of cardio- care spectrum for these specific patients, by emphasizing genic shock (CS) in intensive care. Reasons include the the notion of expertise. rarity of the disease, but also the fact that patients with CS often solely receive care in cardiology. Recent European Methodology Society of Cardiology (ESC) guidelines on the manage- These recommendations were drawn by an expert panel ment of acute heart failure include a section on CS [1]. convened by the French Intensive Care Society (SRLF). However, these guidelines are vaguefortheintensivistand The various disciplines contributing to the management at times obsolete (with regard to vasopressors, for example). of CS in adults were represented as follows: intensive The lack of a specific approach to the management of severe care, anesthesia, cardiac surgery, cardiology, and emer- gency medicine. The organizing committee first defined, * Correspondence: [email protected] with the coordinator of the expert panel, the issues to be 1 CHU Nancy, Service de Réanimation Médicale Brabois; Pôle Cardiovasculaire covered and then designated the experts in charge of et Réanimation Médicale, Hopital Brabois, 54511 Vandoeuvre-les-Nancy, France each issue. The GRADE (Grading of Recommendations Full list of author information is available at the end of the article Assessment, Development and Evaluation) system and a © 2015 Levy et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Levy et al. Annals of Intensive Care (2015) 5:17 Page 2 of 10 literature analysis were used to formulate the recom- Area 1: epidemiology mendations [2]. A level of proof was defined for each bibliographic reference depending on the type of study. 1- In cardiogenic shock, a coronary cause should This level of proof could be reassessed taking into ac- routinely be sought (strong agreement). count the methodological quality of the study. The bib- liographic references common to each assessment In over 70 % of cases, CS is related to acute myocardial criterion were then combined. An overall level of proof infarction (MI) with ST-segment elevation, with or without was determined for each assessment criterion taking into mechanical complications (rupture of the septum, of the account the levels of proof of each of the references, the ventricular wall or of chordae tendineae). However, shock consistency of the results between the different studies, rarely occurs during MI (4.2 to 8.6 % of cases, depending the direct or indirect nature of the proof, the cost ana- on the study) and is declining [3]. ECG, troponin assay (re- lysis, etc. A “strong” level of proof enabled formulation peated if necessary), and natriuretic peptide assay should of a “strong” recommendation (should be performed, be performed routinely, and coronary angiography should should not be performed, etc.). A “moderate”, “weak”,or be considered. Patients in shock or with a high risk of CS “very weak” level of proof led to the formulation of an should be hospitalized, preferably in intensive care. Except “optional” recommendation (should probably be per- for patients with ventricular assistance, CS is associated formed, should probably not be performed, etc.). The pro- with an immediate mortality of approximately 40 % [4]. posed recommendations were presented and discussed Survivors have a very good prognosis, with a very good one by one. The aim was not necessarily to reach a single quality of life. and convergent opinion for all proposals, but rather to highlight points of agreement and points of disagreement or indecision. Each recommendation was then scored by Area 2: cardiogenic shock in acute myocardial infarction each of the experts on a scale of one (complete disagree- ment) to nine (complete agreement). The collective scoring 1- Predictors of progression to cardiogenic shock, in was established using a methodology derived from the particular a heart rate >75 beats/min and signs of RAND/UCLA appropriateness method; after elimination heart failure, should be sought in all patients with of the extreme values (outliers), the median of values at- myocardial infarction (strong agreement). tributed to each proposed recommendation defined agreement between the experts when the median value In two-thirds of cases, shock is not present at admission was between seven and nine, disagreement between and occurs in the first 48 h following admission for MI [5]. one and three, and indecision between four and six. The predictors of ischemic CS are age, heart rate on admis- The agreement, disagreement, or indecision was sion above 75 beats/min, diabetes, history of MI, coronary “strong” if all values were within one of the following artery-bypass surgery, the presence of signs of heart failure three ranges, (1–3), (4–6), or (7–9), and “weak” if the at admission, and anterior location of the infarction [6]. range of values straddled two ranges. In the absence of strong agreement, the recommendations were reformu- 2- Coronary angiography, followed by coronary lated and again scored with the purpose of achieving a revascularization using angioplasty or exceptionally better consensus. coronary artery-bypass surgery, is required in cardiogenic shock secondary to acute myocardial infarction irrespective of the time interval since the Cardiogenic shock definition onset of pain (strong agreement). Cardiogenic shock (CS) is defined as a state of critical end-organ hypoperfusion due to reduced cardiac output. The SHOCK trial conducted from April 1993 to Notably, CS forms a spectrum ranging from mild hypo- November 1998 in 30 centers, and the associated regis- perfusion to profound shock. try assessed the effects of early revascularization (angio- Established criteria for the diagnosis of CS are as plasty or coronary artery-bypass surgery performed in follows: (1) systolic blood pressure less than 90 mmHg the first 6 h) compared with stabilization by medical for 30 min or mean arterial pressure less than 65 mmHg treatment in patients hospitalized for post-myocardial for 30 min or vasopressors required to achieve a blood infarction CS. Whereas mortality at 30 days did not pressure ≥90 mmHg; (2) pulmonary congestion or elevated differ significantly in the early revascularization group left-ventricular filling pressures; (3) signs of impaired organ compared with the control group (46.7 vs. 56 %) [7], perfusion with at least one of the following criteria: (a) early revascularization reduced mortality at 1 year (50.3 altered mental status; (b) cold, clammy skin; (c) oliguria; vs. 63.1 %, p = 0.027) [8] and 6 years [9]. The SHOCK (d) increased serum lactate. trial showed no benefit of revascularization in the over- Levy et al. Annals of Intensive Care (2015) 5:17 Page 3 of 10 75 age group, although this subgroup study was limited with blood. DAP is influenced by peripheral arterial tone, by the small number of patients. (Certain, Some) regis- heart rate,
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