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Michelle M. Kittleson, MD, PhD: Welcome to Medscape InDiscussion: Heart Failure. I'm your host, Dr Michelle Kittleson. This is episode four of our 12-part series, in which we first look at the six core challenges and issues that affect patient care, and then turn our attention to tackling special concerns in the last six episodes. Today we'll discuss decompensated heart failure and cardiogenic shock. What are the diagnostic and treatment challenges? Which classification tools should we be using for our patients? How should we think about mechanical circulatory support? For expert guidance on these questions, we've invited advanced heart failure specialist Dr Jason Katz, associate professor of medicine at Duke University, where he directs both the mechanical circulatory support and durable left ventricular assist device programs, as well as the cardiac intensive care unit. Welcome, Jason.
Jason N. Katz, MD, MHS: Michelle, thanks so much for having me. It's an absolute honor to be here to speak with you and to have the opportunity to discuss a topic that I hope you'll see is something about which I'm incredibly passionate.
Kittleson: That's exactly why you're here. You're known for your expertise in the cardiac critical care arena. Tell us how you got started on this path and what keeps you engaged today.
Katz: I'll give you the Cliffs Notes version, although the young people today have no clue what Cliffs Notes are. I'll give you the abbreviated version. I can tell you that my pathway has been anything but straightforward. It was incredibly winding, and I think it continues to be winding. I started in medical school with the intention of being a community pediatrician. It took me, unfortunately or fortunately, about a week in a community pediatric practice to realize that there was some skill set, some intrinsic capability and attribute, that I did not possess that would make me an outstanding pediatrician. So, I pivoted. If there's one word that could describe my life and career to this point, it would probably be the word pivot. Have you ever seen that old Friends episode, where Ross and his buddies are taking this sofa up this winding staircase and he yells, "Pivot! Pivot!" I watched that recently with my daughter, and I just couldn't stop giggling at it. It really resonated with me because that's kind of what I've done to this point. After medical school at the University of North Carolina, I went to University of Texas (UT) Southwestern, with the intention of being an ER doctor. I loved the pace of the ER, the acuity, the breadth of disease and illness. But it was difficult for me to leave the ER after every shift and not go up to the intensive care units to see what happened to the patients whom I admitted. So, long story short, I completed an ER intern year at UT Southwestern, and then pivoted into internal medicine as a field and began as an intern again.
Initially, my plan was to be a pulmonary critical care physician, but because of selection for chief residency there, I had to postpone it for about a year. Then I did this senior rotation in the coronary care unit (CCU) at Parkland Hospital — something I honestly didn't want to do. I was ready to hate rounding in the CCU; it was the MICU [medical intensive care unit] where I really loved my time. But then, instead, I wound up falling in love with acute heart failure under the tutelage of two attending physicians whom I think you know very well: Clyde Yancy and Mark Drazner. How could you not love heart failure, especially acute heart failure, if you work with amazing mentors like them? I decided that heart failure was the career for me, and then I started my fellowship here at Duke University. There was constantly something about the unknowns of the CCU patient that kept drawing me back to critical care as a field. Ultimately, through a lot of blood, sweat, and tears, I was able to convince the folks here at Duke to help me train in critical care medicine, and that's ultimately what brought me here today.
You asked what keeps me engaged. It's lots of things. We're constantly learning. There is not a day that goes by that I don't learn something; it's humbling. There's not a day that goes by that I don't realize there are things I don't know. Probably my greatest inspiration in medicine was this gentleman named Dan Foster, who was a long-term chairman of medicine at UT Southwestern when I was there and when I was a chief resident. He told us that if we needed to remember one thing, it was to remember to be a lifelong learner, and he's right; it's what really keeps me engaged. I also really like asking questions that don't have answers. It turns out that our field — particularly, acute heart failure, cardiogenic shock, and critical care cardiology — is just the right place to work on answering questions that don't yet have answers. I love working with trainees, especially trainees who are interested in thinking outside the box, like I dared to try to do. I also love the community aspect of acute heart failure, cardiogenic shock, and critical care — of working with physicians in all sorts of different disciplines: consultants, advanced practice providers, pharmacists, bedside nurses, and others. I grew up playing team sports; it was something that I loved then and continue to love to this day. This is sort of the ultimate team sport in in our field, and that makes me happy.
Kittleson: I love that answer. I love that you referenced Cliffs Notes and Friends, because I am a child of the '80s and remember those things very fondly. I love that you showed us the power of mentors and those experiences that can change you that you might not anticipate. Incredible. Now we're going to take all that wisdom, everything you've learned, and we're going to start with everything you need to know about the care of the patient with decompensated heart failure. Let's start first by asking, how can you tell how sick the patient is when they're admitted to your service? What are the key clinical markers, the classification schemes, that you use to figure out whether this is going to be a humdrum easy admission or one that earns you more gray hairs?
Katz: I don't think it's possible to earn any more gray hairs, but this is a great first question. I love this as a first question because it's really the crux of what we do in acute heart failure and in critical care cardiology. It's differentiating a very sick patient who needs emergent or urgent intervention from the less ill patient. This is what I spend a lot of time working with nurses and trainees to try to figure out. I think that's probably one of the most important things we do. There are obviously innumerable ways to risk-stratify these patients, but I tend to take a more holistic approach. When we go in and round on patients, you can see me standing at the foot of the bed initially, because I just stare at the patient. I look at the patient; I watch how they look. What does their skin or body position say about their underlying pathophysiology or the severity of their illness? How are they breathing? Are they breathing rapidly? Is it because they're anxious or uncomfortable? Is it because they're hypoxic? Is it because they're compensating for some underlying metabolic acidosis? Are they sitting upright because they're trying to avoid a supine position? I feel their forearms and shins. It's kind of old-school. It's a little bit creepy, to be honest with you. Oftentimes, I will shake their hand and kind of run my hand up their forearms. I joke about this often with the house staff, but how their arms and forearms feel, and how their shins feel, can tell you a lot. Are they cool and hypoperfused and vasoconstricted? Are they warm? Can I feel their pulses? Is there anything about the character of their pulses that really helps me, including, but not limited to, the rate of pulsation? Are they tachycardic? Are they hypotensive? I look at their noninvasive vital signs. This is all before we even talk about things such as invasive hemodynamics and pulmonary artery catheters. I look at their blood pressure. Is it normal? Is it high? Do they have a wide pulse pressure? Do they have a narrow pulse pressure? I still have a fondness for the old stethoscope. My stethoscope has gotten a little fancier over the years, but I'm still fond of cardiac auscultation. That's a lost art when it comes to risk-stratifying or classifying these patients, as there are numerous classification schemes in heart failure and cardiogenic shock. They're all helpful, including, but not limited to, the more recent SCAI [Society for Cardiovascular Angiography and Interventions] classification scheme for the cardiogenic shock patient. I think about all of them, or at least components of all of them. I tend to use them more to communicate to others about the patients than I do in terms of my acute management of those patients. For me, I actually still go back to the old 2 x 2 table from Nohria, Lewis, and Stevenson. It was in the early 2000s when we just risk-stratified or classified patients based on their cardiac output and cardiac filling pressures. Are they cold or are they warm? Are they wet or are they dry? To this day, that still really helps me at least categorize the patients and think about what resources and management schemes I might have to try to employ. We're lucky in the critical care setting. I often say that it's difficult to be an ambulatory outpatient doctor because you're not blessed with all these data, but it's both a blessing and a curse. On the one hand, you've got all this information to help you figure out what's going on with a patient or how to manage them. On the other hand, you can be inundated with so much information that you can almost be paralyzed. Obviously, we get laboratory results: Electrolytes — sodium and potassium, in particular — help me. We also have hepatic biomarkers, renal biomarkers, and acid-base balance data. I use them all together to help understand the severity of an illness and to think about whether a patient is sick or is not sick.
Kittleson: I think that's incredible. I love the fact that what you say starts with the patient, because as Osler said, "Just talk to the patient; they'll tell you the diagnosis." Or, "Look at the patient; they'll show you the diagnosis." That was initially the Forrester classification, which then was expanded by Drs Nohria, Stevenson, and others in a review in JAMA in the early 2000s. Warm, wet, cold, dry — those initial hemodynamic profiles based just on your history, physical, and initial labs can tell you which way the patient's headed. Now, let's take it a step further. The patient's getting sicker, or you think the patient is not heading on the right trajectory. Maybe they used to have a stable heart rate, blood pressure, creatinine, but now things are getting a little murkier. Your trajectory check shows you they're not heading in the right direction. When do you need a PA [pulmonary artery] catheter? Do you ever need a catheter? Do you always need a catheter? Guide us on your approach.
Katz: There are so many controversies and so many things we could talk about for hours and hours — this is one of them that I love. No, obviously not every patient needs a PA catheter. I think the ESCAPE [Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness] trial in acutely decompensated heart failure patients showed us that it's not always necessary or necessarily always helpful. I consider the PA catheter one of many tools that we have in our armamentarium, including our brain and our hands, to help manage the patient with acute heart failure and cardiogenic shock. The PA catheter is a helpful tool in patients, particularly those with worsening acute heart failure and cardiogenic shock. There's obviously an increasing evidence base suggesting that data from the PA catheter, when used appropriately, can help by profiling these patients and guiding therapeutics. These are obviously largely observational studies with different designs and patient populations. We accrued our own data from the Critical Care Cardiology Trials Network — a network of high-volume cardiac intensive care units across the US and Canada — to focus on this question from a descriptive standpoint or from a landscape perspective: Who's using PA catheters, and for what reason? What are the real triggers for using PA catheters? The findings that we presented, at least in abstract form and a paper likely coming soon, were incredibly enlightening. The only factor that was significantly and independently associated with PA catheter use in cardiogenic shock was clinical site. So, that meant that there is great individual within-site bias in the use and utility of the tool. I'm pleased, as I'm sure you are, that there are people trying to tackle this in a randomized, controlled, prospective fashion. Shashank Sinha, Navin Kapur, those from the Cardiogenic Shock Working Group, they've asked this question. They've initiated the PACCS [Pulmonary Artery Catheter in Cardiogenic Shock] trial, which will randomize patients to early vs delayed or no PA catheter use in de novo acute decompensated chronic heart failure or cardiogenic shock. I worry a little bit about the trial because of what we found in the Critical Care Cardiology Trials Network — that equipoise is going to be a big enrollment challenge. Now, you clearly have people who are strong believers in the utility of the PA catheter in all cardiogenic shock patients. There are others on the opposite end of the spectrum who suggest that perhaps there's no benefit.
I tend to use the PA catheter when my routine management isn't working, when patients aren't responding effectively to intensified decongestive strategies — particularly when, as you mentioned, the end-organ function starts to worsen. I use it frequently when IV vasoactive medications or the use of temporary MCS [mechanical circulatory support] is involved, because I think patients respond quite differently, for a variety of reasons, to these drugs and technologies. I also use it — as someone who spends a lot of time rounding and running a cardiothoracic surgical ICU, where many of these patients come in on ECMO [extracorporeal membrane oxygenation] support or following definitive surgeries, such as heart transplant and LVAD [left ventricular assist device] — when I'm considering that transition from a temporary support strategy to a more durable exit strategy. To be honest, I think I use it a little bit more than some of my colleagues in the cardiac ICU, because I want the trainees and nurses to understand how and how not to use it in management decisions. I can tell you — and you've seen this, I'm quite certain, following ESCAPE and on the heels of a number of observational studies in critical care, noncardiac critical care populations — critical care physicians, nurses, and trainees stopped using this tool entirely for a long period of time. It was left for dead, and it was only with the emergence of our understanding of cardiogenic shock and temporary MCS that this technology started to "rise from the dead," if you will. But experience and expertise were lost for sure; familiarity was lost. Because of COVID and several other factors, we've had lots of nursing turnover. So, experienced nurses with great knowledge on the use of invasive hemodynamics and PA catheters left the field. I think it's important to continually educate the team so that people understand how to potentially use this tool.
Kittleson: That's the perfect response. If I may, I have rules about things in life. Some might call them "Kittleson rules" — maybe someone's heard of them. I would say that's how I think of it. Let's see if you, as a critical care guru, approve. I like to say that there's the holy trinity of decompensated heart failure: If you have volume overload plus either hypotension or renal dysfunction, you need a PA catheter because what you're doing isn't working either in the volume overload — meaning, their creatinine is rising; maybe they're not really wet, or maybe their index is so low that your diuretics aren't having an impact. That's the first Kittleson rule. My second rule is that you must remember a PA catheter is a diagnostic, not a therapeutic, maneuver. I can't remember how many times as a medical student I'd be hanging out with some awesome surgeons and they'd say, "Patient's not doing well; throw in a Swan [-Ganz catheter]. "Throwing in a Swan" — the act of it doesn't do anything. You framed it so beautifully. Know when you need the information and know what to do with the information. That was perfect. Now we're going to pick your brain a little further. We're going to close with a very challenging question. Now it's time to consider temporary mechanical support. When do you say when, and which one for which patient?
Katz: This one's an easy one — no, I'm just kidding.
Kittleson: Oh, no — let me make it harder.
Katz: I love it, and I was fortunate to participate in this recent AHA Scientific Statement on the escalation and de-escalation of temporary MCS. It got me thinking a lot about this question — a lot about what we don't know about this question. I'm not sure that we have enlightened the field in any way, but we certainly pointed out where there are data missing, where we need to be thinking about this. I think it was a call to action to bring the field together to really understand this better. There's not a lot of evidence to support how we utilize temporary MCS, and in what population and for which patients. But whether I use it or not, whether I intend to use it or not, I think about it for every acute heart failure or cardiogenic shock patient who's wheeled into my cardiac ICU. If you don't think about it — I don't remember who said this — but if you don't think about it, then you'll never consider it or you might consider it when it's far too late. But as you allude to, it's not for everyone. There is, fortunately or unfortunately, a veritable alphabet soup of current and emerging temporary MCS technologies. It can be overwhelming for all of us, and there are no real guidelines to turn to. Most of what we use, from a guideline perspective, we've adopted from other clinical conditions. The field is filled largely with scientific statements and key opinion pieces that I mentioned earlier.
I often highlight this funny figure when I talk about cardiogenic shock and temporary MCS. It's this graph on which the x-axis includes several choices and the y-axis contains the chances of getting anything done. It won't surprise you that the chances of getting anything done go down exponentially with the increased number of choices in many cases. I don't believe it's necessary for every physician or institution to be great at all the available devices. To have an understanding is very important, but to be great and to be good at using it isn't necessary. I think a team — and I emphasize team — needs to get together to decide what supportive technologies they want to use. Then, everyone should become familiar with and experts on the use of those technologies. How do I decide which one and for which patient? I think about a lot of factors. Obviously, I consider the patient's hemodynamic and phenotypic presentation because that can be quite varied, as you mentioned. I think about whether I believe that the patient can tolerate univentricular support or instead needs biventricular support. Even if I go in with a strategy of univentricular support — let's say I send the patient to the cardiac catheterization lab for a left-sided Impella device — I'm prepared to wait after that device goes in to see how well they tolerate it. I don't tend to rush them back to the ICU. I want to know, then and there, and I give the patient some time to adapt to that technology.
In many cases, we must consider concomitant pulmonary pathologies and the need for both cardiac and pulmonary support. It turns out that there is, obviously, a large percentage of patients who have concomitant cardiac arrest, which needs to be considered as well. Then when a patient comes in, I immediately think about temporary MCS strategies. I immediately start thinking about what my exit strategy is. What's the downstream plan for this patient? What resources will ultimately be available for them? Because once you put that temporary device in, the clock of potential complications starts ticking down. The longer you use these devices and the longer they're in place, the greater the risk for complications. In general, this is not a Kittleson rule; this is a Mrs Katz — a mom — rule. She told me two things when I went off to medical school. She said, one, "Jason, know your role." In this case, I think about my role as a member of the team and that I may be helping to sort of orchestrate some of this, but I think we're better as a team with different influences and perspectives. Then the second thing that she told me is, "Jason, it's important to have goals." I want to know what the goal is for my patient. How do I hope to ultimately alter the patient's acute pathophysiology? What are my metrics of success or failure, and what's my exit strategy? Then we could talk for hours about specific devices, but we don't have time for that. If you want to get controversial, we can talk about what we know, what we don't know, and maybe what we don't want to know about balloon pumps in cardiogenic shock and other interesting questions. I personally believe that there's a role for all these different technologies.
Kittleson: I think your perspective is extraordinary. The lessons you've taught us are that the art of medicine is not dead. There is a heterogeneous patient population. At this point in the history of critical care cardiology, you must use your judgment and experience more than anything to guide your strategy. One rule I throw in there is that tachycardia is bad. So, when I have a patient who is tachycardic on inotropic support and it's not working with the goals I want for their hemodynamics, when I think medical solutions aren't working, I think I need something mechanical. I think your mom is awesome because you must remember where you're going. You gave us so many incredibly important lessons today. So, what have we learned? We've learned, number one, that it's important to look at the patient, to stratify their hemodynamic profiles when they're admitted with decompensated heart failure: warm, wet, cold, dry. Second, when thinking about a PA catheter, you must remember what you are looking for and what you're going to use it for. Finally, when it comes to temporary mechanical support, trust your instincts, because currently, the trials don't offer us clear guidance. As Dr Katz taught us, pivot — pivot in life, pivot with your patient if what you're doing isn't working. I can't thank you enough. It's been such a pleasure to brainstorm with you. Thank you for being here today.
Katz: The pleasure was all mine. This was a lot of fun. Thanks for taking the time to speak with me.
Kittleson: Thanks for joining our discussion with Dr Jason Katz. There's much more ahead in the coming episodes, so be sure to check out the Medscape app, and share, save, and subscribe if you enjoyed this episode. I'm Michelle Kittleson for Medscape InDiscussion.
Resources
Are Unselected Risk Scores in the Cardiac Intensive Care Unit Needed?
Cardiac Auscultation: A Glorious Past—but Does It Have a Future?
SCAI Clinical Expert Consensus Statement on Cardiogenic Shock
Medical Management of Advanced Heart Failure
Correlative Classification of Clinical and Hemodynamic Function After Acute Myocardial Infarction
Cardiogenic Shock Working Group Registry (CSWG)
Pulmonary Artery Catheter in Cardiogenic Shock Trial (PACCS)
Critical Care Cardiology Trials Network (CCCTN): A Cohort Profile
Equipoise and the Ethics of Clinical Research
The Swan-Ganz Catheters; Past, Present, and Future
Experience With Univentricular Support in Mortally Ill Cardiac Transplant Candidates
Durable Biventricular Support Using Right Atrial Placement of the HeartWare HVAD
The Impella Device: Historical Background, Clinical Applications and Future Directions
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Cite this: How to Mix Touch and Tech in Advanced Heart Failure - Medscape - Mar 09, 2023.
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