What is the best next step in managing an 87-year-old woman with cardiogenic shock, cardiac arrest, and worsening acute kidney injury?

Management of Cardiogenic Shock with Worsening Acute Kidney Injury

Discussing goals of care with the family is the best next step for this 87-year-old woman with cardiogenic shock, cardiac arrest, and worsening acute kidney injury.

Patient Assessment and Risk Factors

This patient presents with multiple high-risk features that portend an extremely poor prognosis:

• Advanced age (87 years)
• Prolonged cardiac arrest (24 minutes of CPR)
• Severe cardiogenic shock with significantly reduced ejection fraction (15%)
• Multiple comorbidities (HFrEF, T2DM, CKD stage 3B)
• Worsening acute kidney injury (creatinine 3.50 mg/dL, eGFR 15 mL/min)
• Multiple organ failure despite maximal medical therapy

Evidence-Based Rationale

The 2021 AHA Scientific Statement on invasive management of cardiogenic shock specifically addresses patients with unfavorable prognostic features, which include:

• Age >85 years
• End-stage renal disease
• Prolonged CPR (>30 minutes to ROSC)
• Multiple organ failure 1

This patient meets several of these criteria, placing her at extremely high risk for mortality regardless of intervention.

Analysis of Treatment Options

Option A: Discuss goals of care with family

• RECOMMENDED based on patient's age, comorbidities, and multiple unfavorable prognostic features
• Aligns with AHA guidelines that emphasize the importance of "close communication with family to provide regular updates and reassessment of prognosis and goals of care" 1
• The 2024 AHA Scientific Statement on cardiogenic shock in older adults emphasizes that "patient wishes regarding mechanical ventilation should be considered" and that "potential advantages and disadvantages of dialysis therapy, including associated morbidity and QOL, should be considered" 1

Option B: Initiate vasopressin

• While vasopressin can be useful in vasodilatory shock 2, it would not address the underlying severe cardiogenic shock and multiorgan failure
• Adding another vasopressor is unlikely to improve outcomes given the patient's severe cardiac dysfunction (EF 15%)

Option C: Consult cardiology for mechanical circulatory support

• The 2022 AHA/ACC/HFSA Heart Failure Guidelines state that "the risk of vascular, bleeding, and neurologic complications should generally be considered in the calculation to proceed with such support" 1
• The patient's advanced age, prolonged cardiac arrest, and severe renal dysfunction make her a poor candidate for mechanical circulatory support
• Studies show extremely high mortality (>75%) in patients with cardiogenic shock requiring both mechanical support and renal replacement therapy 3

Option D: Initiate renal replacement therapy

• While CRRT is preferred over intermittent dialysis for management of acute renal failure in cardiogenic shock 1, studies show that AKI requiring RRT in cardiogenic shock is associated with significantly higher in-hospital mortality (75.74% vs 51.58%) 3
• The 2024 AHA Scientific Statement notes that "older adults in CS requiring RRT in particular are at high risk of in-hospital mortality" 1
• A Danish cohort study showed that AKI-RRT following myocardial infarction-related cardiogenic shock was associated with 62% in-hospital mortality 4

Management Algorithm

1. First step: Discuss goals of care with family

   • Review patient's overall prognosis given multiple unfavorable features
   • Discuss patient's values and wishes regarding aggressive interventions
   • Consider palliative care consultation

2. If decision is made to continue aggressive care:

   • Consider CRRT for refractory volume overload and metabolic derangements
   • Optimize current inotropic/vasopressor support
   • Consider mechanical circulatory support only if patient is deemed a candidate for advanced therapies (unlikely given age and comorbidities)

3. If transition to comfort-focused care:

   • Adjust medications to prioritize comfort
   • Withdraw interventions that do not contribute to comfort
   • Provide appropriate end-of-life care

Key Considerations and Caveats

• The mortality rate for patients with cardiogenic shock and AKI requiring RRT is extremely high (>75%) 3
• Age >85 years is specifically mentioned as an unfavorable prognostic feature in the AHA guidelines 1
• The 2023 WSES guidelines emphasize that "a palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach" 1
• Even with aggressive interventions, the likelihood of meaningful recovery is extremely low given the patient's age, prolonged cardiac arrest, and multiple organ failure

This case highlights the importance of balancing potentially life-sustaining interventions with quality of life considerations, particularly in elderly patients with multiple unfavorable prognostic features.