As Dr. Debbie A. Rinde-Hoffman discusses contemporary recognition and initial management of cardiogenic shock in 2022, listeners will be able to identify when to consider shock as the diagnosis, recognize how to diagnose the etiology, and discover the management options available.
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Target Audience: cardiologists, internal medicine, and/or APPs with a cardiology interest
Release Date: June 14th, 2022
Expiration Date: June 14th, 2023
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Selected Podcast
Contemporary Recognition and Initial Management of Cardiogenic Shock 2022
Featuring:
Debbie Rinde-Hoffman, MD, FACC, FACP, FHFSA
Debbie A. Rinde-Hoffman, MD, FACC, FACP, FHFSA, completed her medical training, including medical school, internal medicine internship, residency and fellowship in cardiology at the University of South Florida in Tampa, Florida. Dr. Rinde-Hoffman has completed special training and proficiency in nuclear cardiology, cardiac transplantation, echocardiography, diagnostic cardiac catheterization, percutaneous transluminal angioplasty, excimer laser angioplasty and intracoronary stent placement. She is a fellow of the American College of Cardiology and is board-certified in internal medicine, cardiovascular disease, advanced heart failure and heart transplant by the American Board of Internal Medicine. In addition, she served as chief of the Department of Internal Medicine at Tampa General Hospital and is the medical director of the cardiac transplantation mechanical circulatory support team. She is also an affiliate associate professor at the USF Health Morsani College of Medicine. Dr. Rinde-Hoffman has had numerous articles published in the area of cardiac transplantation. She is a sought-after speaker on issues related to women with heart disease, congestive heart failure, transplantation and mechanical assist devices. She is a member of numerous professional and scientific societies, including the American Medical Association, American College of Physicians and Florida Medical Association.
Transcription:
Maggie McKay (Host): Cardiogenic shock is a life-threatening condition in which your heart suddenly can't pump enough blood to meet your body's needs, but not everyone who has a heart attack has it. Also, what if it's not treated early? And how do you recognize it to begin with? These are just some of the questions we'll get answers to as we discuss contemporary recognition and initial management of cardiogenic shock. Joining me today is Dr. Debbie Rinde-Hoffman, Medical director of Advanced Heart Failure and Mechanical Circulatory Support. Welcome, doctor.
Dr Debbie Rinde-Hoffman: Thank you very much.
Maggie McKay (Host): I'm your host, Maggie McKay. Welcome to MD cast by Tampa general hospital, a go-to listening location for a specialized position to physician content and a valuable learning tool for world-class health.
Doctor, what are the clinical signs?
Dr Debbie Rinde-Hoffman: So typically, we talk about patients who have low blood pressure, who have signs of poor circulation, be it cold clammy legs, be it an altered sensorium, they can't think clearly. They're short of breath, they're tachycardic, and either this is happening in the threat of an acute MI or can be happening if somebody has chronic congestive heart failure that acutely worsens.
Maggie McKay (Host): And when do you consider temporary mechanical support?
Dr Debbie Rinde-Hoffman: So we typically consider temporary mechanical support when the patients are either not responsive to a little bit of fluid hydration and they remain hypotensive when we put them on low doses of ionotropic support medications to help the heart do a little bit better and/or if they continue to show evidence of hypoperfusion, mainly by having elevated lactate levels, elevated filling pressures and low cardiac output.
Maggie McKay (Host): So how do you determine which device to use?
Dr Debbie Rinde-Hoffman: So that's the $64,000 question because these days we have several devices available for use. So part of it is determined based on, A, what's available at anybody's institution, B, what device is familiar to that operator and then, C, the degree of cardiogenic shock and does it involve just the left side of the heart, does it involve just the right side of the heart or does it involve both sides of the heart? And that helps us to determine which devices we should go for.
Maggie McKay (Host): Wow. That sounds like a lot of decisions in a short amount of time, right? Because don't you have to act fast?
Dr Debbie Rinde-Hoffman: We have to act fast. That's right. But that's what acute care cardiology is all about. So yes, those things are done fairly quickly with a multidisciplinary team. So in our institution, we are just formalizing our shock program so that whenever somebody presents with cardiogenic shock, we get a multidisciplinary team together quickly on a phone line, including an interventional cardiologist, a heart failure cardiologist, a cardiac surgeon and an intensivist and together we decide which machine, if the patient needs the machine, and where we go from there.
Maggie McKay (Host): How do you determine futility?
Dr Debbie Rinde-Hoffman: That's the other $64,000 question. So I think that's one of the hardest areas for doctors to come to grips with. We're all taught in medical school that we go to medical school to save lives and to try to have patients live as long as possible, but we all know that that's not reality. We try to give patients at least a good 24 to 48 hours of support to look to make sure that the organs have some degree of recovery, especially the brain.
If the shock has been so significant that the patient has had low blood pressure for such a long time or not enough oxygen running around for long enough that the brain suffered an ischemic event, I think that's the telltale sign of futility. If the patient has significant other comorbidities that has not allowed them to respond to therapy, that helps us to determine futility. And I think that one area that we all need to do better at is prepping the family that although our best efforts were made, it does not look like the patient's going to have an opportunity to improve or survive. And there is data out there that tells us that if patients don't start turning the corner by the first 24 to 48 hours, the likelihood of doing well is significantly diminished. So as part of our program, we have a palliative care team involved so that they can help us with some of those difficult discussions.
Maggie McKay (Host): Wow. What is the survival rate?
Dr Debbie Rinde-Hoffman: Well, there's different degrees of cardiogenic shock. So the survival rate these days with acute MI and cardiogenic shock, if the patients are intervened upon quickly and appropriately, the historic rate of survival is about 50% and we have not been able to really breakthrough that barrier until more recently with some of the newer contemporary devices and the idea that we support patients mechanically sooner. The newest data tells us that we can improve survival rates from 50% to the mid to high 70% range, which is a huge improvement over the last 40 to 50 years of stable survivals.
Maggie McKay (Host): Well, that's good news and encouraging.
Dr Debbie Rinde-Hoffman: It is encouraging.
Maggie McKay (Host): Is there anything else you'd like to add?
Dr Debbie Rinde-Hoffman: I'd like to say that in Hillsborough County, we are trying right now to develop a countywide program for cardiogenic shock so that patients can get recognized early in the field and then directed to the institutions that are best served to take care of those patient populations. Similarly to what we did with heart attack care, what we do with stroke care, this will be another level of sending patients to the right institution, and it's an exciting area that we're presently working on.
Maggie McKay (Host): That's wonderful. Thank you so much, Dr. Hoffman, for your time. We appreciate it.
Dr Debbie Rinde-Hoffman: Oh, my pleasure.
Maggie McKay (Host): That's Dr. Debbie Rinde-Hoffman, Medical Director of Advanced Heart Failure and Mechanical Circulatory Support.
Thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand, videos and local events offered to you by Tampa general hospital, please visit CME dot T G h.org.
I'm your host, Maggie McKay. Be well.
Maggie McKay (Host): Cardiogenic shock is a life-threatening condition in which your heart suddenly can't pump enough blood to meet your body's needs, but not everyone who has a heart attack has it. Also, what if it's not treated early? And how do you recognize it to begin with? These are just some of the questions we'll get answers to as we discuss contemporary recognition and initial management of cardiogenic shock. Joining me today is Dr. Debbie Rinde-Hoffman, Medical director of Advanced Heart Failure and Mechanical Circulatory Support. Welcome, doctor.
Dr Debbie Rinde-Hoffman: Thank you very much.
Maggie McKay (Host): I'm your host, Maggie McKay. Welcome to MD cast by Tampa general hospital, a go-to listening location for a specialized position to physician content and a valuable learning tool for world-class health.
Doctor, what are the clinical signs?
Dr Debbie Rinde-Hoffman: So typically, we talk about patients who have low blood pressure, who have signs of poor circulation, be it cold clammy legs, be it an altered sensorium, they can't think clearly. They're short of breath, they're tachycardic, and either this is happening in the threat of an acute MI or can be happening if somebody has chronic congestive heart failure that acutely worsens.
Maggie McKay (Host): And when do you consider temporary mechanical support?
Dr Debbie Rinde-Hoffman: So we typically consider temporary mechanical support when the patients are either not responsive to a little bit of fluid hydration and they remain hypotensive when we put them on low doses of ionotropic support medications to help the heart do a little bit better and/or if they continue to show evidence of hypoperfusion, mainly by having elevated lactate levels, elevated filling pressures and low cardiac output.
Maggie McKay (Host): So how do you determine which device to use?
Dr Debbie Rinde-Hoffman: So that's the $64,000 question because these days we have several devices available for use. So part of it is determined based on, A, what's available at anybody's institution, B, what device is familiar to that operator and then, C, the degree of cardiogenic shock and does it involve just the left side of the heart, does it involve just the right side of the heart or does it involve both sides of the heart? And that helps us to determine which devices we should go for.
Maggie McKay (Host): Wow. That sounds like a lot of decisions in a short amount of time, right? Because don't you have to act fast?
Dr Debbie Rinde-Hoffman: We have to act fast. That's right. But that's what acute care cardiology is all about. So yes, those things are done fairly quickly with a multidisciplinary team. So in our institution, we are just formalizing our shock program so that whenever somebody presents with cardiogenic shock, we get a multidisciplinary team together quickly on a phone line, including an interventional cardiologist, a heart failure cardiologist, a cardiac surgeon and an intensivist and together we decide which machine, if the patient needs the machine, and where we go from there.
Maggie McKay (Host): How do you determine futility?
Dr Debbie Rinde-Hoffman: That's the other $64,000 question. So I think that's one of the hardest areas for doctors to come to grips with. We're all taught in medical school that we go to medical school to save lives and to try to have patients live as long as possible, but we all know that that's not reality. We try to give patients at least a good 24 to 48 hours of support to look to make sure that the organs have some degree of recovery, especially the brain.
If the shock has been so significant that the patient has had low blood pressure for such a long time or not enough oxygen running around for long enough that the brain suffered an ischemic event, I think that's the telltale sign of futility. If the patient has significant other comorbidities that has not allowed them to respond to therapy, that helps us to determine futility. And I think that one area that we all need to do better at is prepping the family that although our best efforts were made, it does not look like the patient's going to have an opportunity to improve or survive. And there is data out there that tells us that if patients don't start turning the corner by the first 24 to 48 hours, the likelihood of doing well is significantly diminished. So as part of our program, we have a palliative care team involved so that they can help us with some of those difficult discussions.
Maggie McKay (Host): Wow. What is the survival rate?
Dr Debbie Rinde-Hoffman: Well, there's different degrees of cardiogenic shock. So the survival rate these days with acute MI and cardiogenic shock, if the patients are intervened upon quickly and appropriately, the historic rate of survival is about 50% and we have not been able to really breakthrough that barrier until more recently with some of the newer contemporary devices and the idea that we support patients mechanically sooner. The newest data tells us that we can improve survival rates from 50% to the mid to high 70% range, which is a huge improvement over the last 40 to 50 years of stable survivals.
Maggie McKay (Host): Well, that's good news and encouraging.
Dr Debbie Rinde-Hoffman: It is encouraging.
Maggie McKay (Host): Is there anything else you'd like to add?
Dr Debbie Rinde-Hoffman: I'd like to say that in Hillsborough County, we are trying right now to develop a countywide program for cardiogenic shock so that patients can get recognized early in the field and then directed to the institutions that are best served to take care of those patient populations. Similarly to what we did with heart attack care, what we do with stroke care, this will be another level of sending patients to the right institution, and it's an exciting area that we're presently working on.
Maggie McKay (Host): That's wonderful. Thank you so much, Dr. Hoffman, for your time. We appreciate it.
Dr Debbie Rinde-Hoffman: Oh, my pleasure.
Maggie McKay (Host): That's Dr. Debbie Rinde-Hoffman, Medical Director of Advanced Heart Failure and Mechanical Circulatory Support.
Thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand, videos and local events offered to you by Tampa general hospital, please visit CME dot T G h.org.
I'm your host, Maggie McKay. Be well.