Alastair G Proudfoot1,2,3,4, Antonis Kalakoutas4, Susanna Meade5, Mark J D Griffiths1,6,7, Mir Basir8, Francesco Burzotta9, Sharon Chih10, Eddy Fan11,12, Jonathan Haft13, Nasrien Ibrahim14, Natalie Kruit15, Hoong Sern Lim16, David A Morrow17, Jun Nakata18, Susanna Price6,19, Carolyn Rosner20, Robert Roswell21, Mark A Samaan5, Marc D Samsky22, Holger Thiele23, Alexander G Truesdell24, Sean van Diepen25,26, Michelle Doughty Voeltz27, Peter M Irving5,28. 1. Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (A.G.P., M.J.D.G.). 2. Clinic For Anaesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany (A.G.P.). 3. Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Germany (A.G.P.). 4. Queen Mary University of London, United Kingdom (A.G.P., A.K.). 5. Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (S.M., M.A.S., P.M.I.). 6. National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.D.G., S.P.). 7. William Harvey Research Institute, Queen Mary University of London, United Kingdom (M.J.D.G.). 8. Department of Cardiology, Henry Ford Health System, Detroit, MI (M.B.). 9. Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy (F.B.). 10. University of Ottawa Heart Institute, Ontario, Canada (S.C.). 11. Interdepartmental Division of Critical Care Medicine, Department of Medicine and Division of Respirology, University of Toronto, Ontario, Canada (E.F.). 12. Toronto General Hospital Research Institute, Ontario, Canada (E.F.). 13. Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor (J.H.). 14. Massachusetts General Hospital, Boston (N.I.). 15. Department of Anaesthesia, Westmead Hospital, Sydney, New South Wales, Australia (N.K.). 16. Department of Cardiology, University of Birmingham NHS Foundation Trust, Birmingham, United Kingdom (H.S.L.). 17. Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M.). 18. Division of Cardiovascular Intensive Care, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan (J.N.). 19. Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (S.P.). 20. Inova Heart and Vascular Institute, Falls Church, VA (C.R.). 21. Lenox Hospital, Northwell Health, New York, NY (R.R.). 22. Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.D.S.). 23. Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Germany (H.T.). 24. Virginia Heart, Falls Church, VA (A.G.T.). 25. Department of Critical Care Medicine (S.v.D.), University of Alberta, Edmonton, Alberta, Canada. 26. Division of Cardiology, Department of Medicine (S.v.D.), University of Alberta, Edmonton, Alberta, Canada. 27. Northside Cardiovascular Institute, Northside Hospital System Atlanta, GA (M.D.V.). 28. School of Immunology and Microbial Sciences, King's College London, United Kingdom (P.M.I.).
Abstract
BACKGROUND: Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS: An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS: There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS: While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
BACKGROUND: Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS: An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS: There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS: While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.
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