SCAI/EAPCI/ACVC Expert Consensus Statement on Cardiogenic Shock in Women-Dr. Alasnag slides

Dr. Alasnag slides

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This case-based discussion focuses on cardiogenic shock (CS) in women, illustrated by a 31-year-old female smoker presenting with acute chest pain and hypotension (BP 80/40 mmHg, HR 120 bpm) at a wedding. Initial workup included EKG, point-of-care ultrasound (POCUS), echocardiogram, and coronary angiogram revealing a dissection with elevated left ventricular end-diastolic pressure (LVEDP 32 mmHg) and elevated lactate (2.5). Management involved mechanical circulatory support with an Impella CP device, wiring both vessels, proximal segment stenting using drug-eluting stents (Zotarolimus), and intravascular imaging to guide intervention. The Impella was weaned over five days, and guideline-directed medical therapy (GDMT) for left ventricular dysfunction was initiated along with dual antiplatelet therapy. Follow-up included echocardiography and outpatient reassessment focusing on smoking cessation, genetic screening, and titration of heart failure medications.<br /><br />A referenced study of 167 cardiogenic shock patients (22% women) highlighted sex differences: women more frequently received Impella CP versus larger devices like Impella 5.0/5.5 or VA-ECMO, which were more common in men. Although women showed trends toward higher bleeding, neurologic, and limb complications, these were not statistically significant. In-hospital mortality rates were similar between sexes (~43%), and discharge to home among survivors was comparable.<br /><br />Regarding future pregnancies after spontaneous coronary artery dissection (SCAD), current guidelines (AHA 2018) generally discourage pregnancy due to uncertain prediction and prevention of SCAD recurrence, which ranges from 2.1% to 22% over 30 months. Pregnancy-associated SCAD tends to be more severe, with multivessel involvement and cardiogenic shock. Comorbid fibromuscular dysplasia elevates obstetric risks such as gestational hypertension, pre-eclampsia, and preterm delivery.<br /><br />In summary, tailored mechanical support and interventional strategies are pivotal in managing CS in women, with careful long-term follow-up and risk management including consideration of pregnancy-related risks in SCAD patients.

Keywords

cardiogenic shock

women

spontaneous coronary artery dissection

Impella CP

mechanical circulatory support

drug-eluting stents

left ventricular dysfunction

dual antiplatelet therapy

fibromuscular dysplasia

pregnancy risks