Call early, call often: When is the right time to transfer a patient in cardiogenic shock?
Inova MD leads creation of ACC’s concise clinical guidance
The first step in solving any problem is recognizing there is one. And in the case of cardiogenic shock, that is a difficult task. Cardiogenic shock is a heterogeneous, multifactorial syndrome. While the classic acute myocardial infarction (AMI) can result in cardiogenic shock, non-AMI etiologies of cardiogenic shock – particularly heart failure – can be far more insidious and difficult to appreciate.
For example, a patient presenting with an acute heart failure exacerbation may be admitted for intravenous diuretics and failing to improve. Clinically, the patient may still be interactive and have normal or mildly low blood pressure, but the clinical exam may belie the fact that the patient is in a low-output state. The patient may show early signs of hypoperfusion including rising lactate, worsening kidney function, cool extremities or persistent fatigue. However, without clear signs of hemodynamic instability, it’s often hard to know when to escalate, especially in the absence of invasive hemodynamics. The uncertainty around how quickly these patients may deteriorate adds to the difficulty in deciding when to act.
New concise clinical guidance, led by an Inova physician, simplifies cardiogenic shock evaluation
To help address this uncertainty, the American College of Cardiology (ACC) convened the Heart House Roundtable on Evaluation and Management of Cardiogenic Shock, a virtual roundtable of top international experts across various disciplines. Shashank S. Sinha, MD, MSc, FACC, FAHA, FHFSA, Director of Inova’s Cardiogenic Shock Program, Medical Director of the Cardiac Intensive Care Unit, Inova Fairfax Hospital and Director of the Cardiovascular Critical Care Research Program at Inova, served as the roundtable’s chair and led the development of the ACC’s first concise clinical guidance that resulted from its proceedings and was published in JACC just before the ACC.25 Scientific Sessions.
Although the field as a whole is continuing to gather rigorous randomized and registry-based evidence to support cardiogenic shock evaluation and treatment, this concise clinical guidance lays out the state of the art in 2025, with practical concepts providers can implement and incorporate in their day-to-day practice. It incorporates a one-hour roadmap and a 24-hour roadmap that gives providers step-by-step instructions on what to do and when to do it.
Review the concise clinical guidance.
How do you know when to transfer a cardiogenic shock patient to a referral center?
Providers do not need to go it alone. “We want providers to call early and often, so that our multidisciplinary cardiogenic shock team can come together in the ‘golden hour’ of acute shock and help determine whether the patient is in cardiogenic shock, how severe the shock is, what may have caused it, and what treatment the patient needs. This may include advanced temporary mechanical circulatory support to help restore perfusion to vital organs,” Dr. Sinha said.
Another tool that providers should use when assessing cardiogenic shock was developed by the Society for Cardiovascular Angiography and Intervention (SCAI). SCAI developed staging categories, from A to E, to reflect that cardiogenic shock exists across a spectrum. It progresses from SCAI stage A, which covers individuals at risk of cardiogenic shock, to SCAI stage E, the sickest of the sick.
“The challenge, and the message I have for referring providers, is that a patient may go from SCAI B, where the patient has hypotension but not hypoperfusion, to SCAI C or D within 12 to 24 hours, unbeknownst to providers or despite their best efforts,” Dr. Sinha said. “Our goal is to help providers recognize patients at earlier stages of disease, so we can make interventions earlier in the disease course, thereby improving the patient’s chances of survival. It’s never too early to call us.”
What happens when a provider calls Inova Schar Heart and Vascular’s cardiogenic shock team?
Inova is a regional cardiogenic shock referral center for > 40 hospitals in Washington, DC; Maryland; Virginia; and West Virginia. When its cardiogenic shock team is activated, it mobilizes a multidisciplinary group including heart failure, interventional cardiology, ECMO specialist, cardiothoracic surgery, and critical care. The team quickly reviews the clinical information, including vitals, labs, imaging, and current therapies.
“From there, we provide immediate recommendations, help stabilize the patient and assess if transfer is needed. If so, we coordinate the logistics and stay involved through the process,” said Inova advanced heart failure and transplant cardiologist Vanessa Blumer, MD. “Importantly, the referring team stays fully involved. We’re here to support and collaborate, not replace local care.”
“Once the team decides on an initial course of therapy, the part that really makes a big difference is that we then serially reassess the patient and reactivate the shock team six, 12 and 24 hours later to review the data, analyze the patient’s trajectory to determine whether the patient is getting better, and if not, determine how best to course-correct,” said Dr. Sinha.
How does a provider activate Inova’s cardiogenic shock team to discuss a patient or arrange a transfer?
Call 703-776-8000 and dial 5 to activate the cardiogenic shock team for a multidisciplinary, real-time consultation.
The shock team will need the following clinical information:
- History and physical examination
- EKG
- Bedside ultrasound
- Blood work (CBC, CMP, Mg, troponin, lactate, BNP or NT-pro BNP)
- SCAI stage (to risk stratify)
- Etiology identification (SHARC classification)
“I would encourage our referrers to get comfortable with contacting our shock team,” said Edward Howard MBChB(Hons), PhD, FACC, Director of Interventional Cardiology, Virginia Heart; Director of Cardiac Catheterization Lab, Inova Alexandria Hospital. “We have achieved a rapid and dramatic drop in mortality with our shock team approach, with published and globally recognized results. We are always available and willing to help either to accept patients for transfer or to assist and guide clinical management in this increasingly common, and increasingly treatable disease.”
Downloadable PDFs for reference:
Learn more about Inova Schar Heart and Vascular’s world-class cardiogenic shock program.