The War on Shock: Is Industry Leading the Charge?

Jaya Mallidi, MD, MHS

2:00 AM on call. I wake up to the sound of my phone ringing. The emergency room (ER) physician is calling to evaluate a 93-year-old man, Mr Smith,* with ongoing chest pain. His ECG shows diffuse ST-segment depressions. His systolic blood pressure is low, at 80 mm Hg on pressor support. I hear this information and think cardiogenic shock (CS) and probable left main or multivessel coronary artery disease.

I walk toward the ER clutching my jacket closely in the chilly December night. My thoughts drift to the recent controversies in the management of patients with CS, specifically the use of the Impella (Abiomed; Danvers, MA)—the US Food and Drug Administration-approved, temporary, percutaneous mechanical circulatory support (MCS) device.

A few months earlier, I had attended a national conference on the management of CS. The mortality rate for this high-acuity, low cardiac output state often associated with multiorgan dysfunction has remained high, at about 40%-50% over the past several years. The conference focused on an algorithmic approach of early identification, activation of the cath lab for hemodynamic assessment, and early use of MCS, specifically Impella, before percutaneous coronary intervention (PCI). Implementation of these protocols led to survival rates as high as 72%