Management of Cardiogenic Shock During COVID-19

In 2017, the Inova Heart and Vascular Institute (IHVI) in Falls Church, Virginia implemented a systemwide cardiogenic shock (CS) initiative using a “one-call” activation and management system (1). Our program has emphasized early CS recognition and has used a standardized treatment algorithm, multidisciplinary decision making, and selective use of mechanical circulatory support (MCS) tailored to shock severity and phenotype. This approach improved access to care and has been associated with increased survival for patients presenting at our hospital and at 34 regional transferring facilities (1). From its inception, our policy has been to accept all CS transfers in the absence of compelling contraindications.

The recent coronavirus disease 2019 (COVID-19) pandemic significantly affected our CS team’s care processes. Anticipating a strain on finite resources, we recalibrated our program to optimize outcomes while ensuring patient and staff safety and managing resource capacity (2). The following 5 measures were enacted: 1) universal rapid testing to identify COVID-19–positive patients with CS at the time of index presentation to the health care system; 2) real-time intensive care unit (ICU), ventilator, and MCS capacity dashboards; 3) standardized donning and doffing protocols for personal protective equipment (PPE) according to the recommendations of the Centers for Disease Control and Prevention; 4) daily systemwide dissemination of resource availability; and 5) modification of our CS transfer policy to be more restrictive toward accepting patients when critical care resources were limited.

To expedite the cohorting of patients with COVID-19 in our rapidly expanded negative-pressure ICU beds, COVID-19 status was determined, whenever possible, during the initial CS activation call. An ICU capacity dashboard provided updates on the number and location of available ICU beds, negative-pressure–ventilated rooms, mechanical ventilators, MCS devices, and ICU staffing. All CS activations were reviewed by our multidisciplinary team, and decisions were rendered on a case-by-case basis, taking into consideration IHVI resources, medical futility, and the perceived ability to provide care at the current location (with ongoing support from IHVI). At the pandemic’s peak, this resulted in fewer transfers being accepted, with transferring centers forced to manage more patients with CS within their own facilities. To support our referral centers, our CS team provided enhanced remote consultative support with more frequent communication and technical guidance.

From March 1 to June 30, 2020, 7,809 patients were tested for suspected COVID-19 at our hospital. Of these, 3,096 patients tested positive for the virus, and 1,468 required hospitalization at IHVI. To the best of our knowledge, there were no cases of transmission from patients to health care providers. Compared with the same period in 2019 (Table 1 ), there were fewer CS activations (67 vs. 93) and a higher proportion of transfer patients declined (42% vs. 11%; p < 0.001). The in-hospital survival of declined transfer patients was numerically less than those accepted for transfer (47% vs. 67%; p < 0.098). In addition, patients with CS who were treated during the pandemic presented with greater hemometabolic acuity (Table 1). Despite this, MCS use and in-hospital survival were comparable to the previous year. Consistent with national and international trends (3,4), we experienced a significant decline (∼25%) in the number of patients treated for ST-segment elevation myocardial infarction and an increase in mechanical complications resulting from late presentations (4 acute ventricular septal defects in 2020 vs. 1 in 2019). Data were obtained by retrospective review of electronic medical records under previously obtained internal Institutional Review Board approval.

Table 1.

Characteristics of Patients With CS During the COVID-19 Pandemic Compared With the Previous Year

	March 1 toJune 30, 2020	March 1 to June 30, 2019	p Value (2020 vs. 2019)
COVID-19 patients hospitalized	1,468	0	N/A
Number of CS team activations	67	93	N/A
Declined for transfer to IHVI	28 (42)	10 (11)	<0.001
In-hospital survival	12∗ (46)	6 (60)	0.46
Treated at IHVI	39 (58)	83 (89)	<0.001
In-hospital survival	26 (67)	59 (71)	0.62
CS phenotype
AMI-CS	16 (41)	40 (48)	—
ADHF-CS	23 (59)	43 (52)	0.46
Median lactate, mmol/l	5.6 (2.5–8.9)	2.3 (1.6–5.0)	<0.001
SCAI shock scores			—
Stage A	0 (0)	0 (0)	—
Stage B	0 (0)	0 (0)	—
Stage C	14 (36)	45 (54)	—
Stage D	17 (44)	24 (29)	—
Stage E	8 (20)	14 (17)	0.03
Cardiac arrest at presentation	17 (44)	25 (30)	0.14
MCS use	20 (51)	34 (41)	0.28

Values are n, n (%), or n (interquartile range).

ADHF-CS = acute decompensated heart failure complicated by cardiogenic shock; AMI-CS = acute myocardial infarction complicated by cardiogenic shock; COVID-19 = coronavirus disease 2019; CS = cardiogenic shock; IHVI = Inova Heart and Vascular Institute; MCS = mechanical circulatory support; N/A = not applicable; SCAI = Society for Cardiovascular Angiography and Intervention.

^∗Final disposition was undetermined for 2 of the 28 patients declined for transfer; therefore, the denominator was 26.

In summary, the COVID-19 pandemic substantially disrupted IHVI’s established regional system of care delivery for CS. Acute shortages in resources resulted in fewer accepted transfers. We also noted a shift toward higher patient acuity during this time. Although IHVI’s CS survival rates remained favorable, mortality was high for those patients declined for transfer. Our PPE policy appeared to be effective at preventing patient-to-staff virus transmission. The 5 key interventions noted earlier were instrumental in allowing our program to assess, adjust, and adapt in real time to the crisis. Although primarily descriptive, these observations may inform future strategies aimed at optimizing access, resources, and outcomes for patients with CS who are treated within regional systems of care affected by a worldwide pandemic.