Abstract 4371662: Sex-Specific Differences in Outcomes of Cardiogenic Shock Among Patients with Diabetes Mellitus: A Systematic Review

Cardiogenic Shock: Searching for a Better Lifeboat.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French Nationwide Registries

Comparison of Incidence and Outcomes of Cardiogenic Shock Complicating Posterior (Inferior) Versus Anterior ST-Elevation Myocardial Infarction

There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD). Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates. A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range,IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval,CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support. In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

Long-term trends of the incidence and outcome of cardiogenic shock (CS) patients are scarce. We analyze for the first time trends in the incidence and outcome of CS during a 20-year period in Switzerland. The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry enrolls patients with acute myocardial infarction from 83 hospitals in Switzerland. We analyzed trends in the incidence, treatment, and in-hospital mortality of patients with CS enrolled between 1997 and 2017. The impact of revascularization strategy on outcome was assessed for the time period 2005 to 2017. Among 52 808 patients enrolled, 963 patients were excluded because of missing data and 51 842 (98%) patients remained for the purpose of the present analysis. Overall, 4090 patients (7.9%) with a mean age of 69.6±12.5 years experienced acute myocardial infarction complicated by CS. Overall, rates of CS declined from 8.7% to 7.3% between 1997 and 2017 ( P for trend, <0.001; 1997-2006 versus 2007-2017). We observed a decrease in CS developing during hospitalization from 7.8% to 3.5% in the period 1997 to 2006 compared with 2007 to 2017 ( P for trend, <0.001), which was partially offset by an increase in CS on admission between 2006 and 2017 (2.5% [1997-2006] to 4.6% [2007-2017]; P for trend, <0.001). In-hospital mortality declined from 62.2% in 1997 to 36.3% in 2017 ( P<0.001 for temporal trend). Percutaneous coronary intervention was the strongest independent predictor for survival (odds ratio, 0.36; CI, 0.28-045; P<0.001). Among patients with acute myocardial infarction and multivessel disease, multivessel percutaneous coronary intervention was associated with an increased risk of in-hospital mortality (odds ratio, 1.88; 95% CI, 1.59-2.21) and was an independent predictor for the development of CS during hospitalization (odds ratio, 1.93; 95% CI, 1.62-2.30). Rates of CS declined between 1997 and 2017 driven by a reduction of CS developing during hospitalization. In-hospital mortality from CS declined from 62.8% (1997) to <40% (2017). Multivessel percutaneous coronary intervention was associated with an increased risk of mortality and the development of CS during hospitalization.

The intra-aortic balloon pump (IABP) was first introduced into clinical practice in 1968.1 Early experimental and clinical trials suggested that intra-aortic balloon counterpulsation could provide circulatory assistance to a failing left ventricle.2,3 Counterpulsation—balloon inflation during diastole and deflation in systole—augments the intrinsic Windkessel effect, whereby potential energy stored in the aortic root during systole is converted to kinetic energy with the elastic recoil of the aortic root. Counterpulsation leads to a decline in afterload, a reduction in cardiac work, and therefore myocardial oxygen requirements of the ventricle. Augmentation of diastolic pressure when the balloon is fully inflated together with reduction in left ventricular (LV) filling pressures contribute to improved coronary perfusion (Figures 1 and 2).4 This proposed improvement in myocardial energetics has been further supported by a significant reduction in systemic lactate.5 These physiological enhancements are thought to be of particular benefit after acute myocardial infarction (AMI), supported by animal studies, which have shown a reduction in infarct size when counterpulsation is used.6,7 Figure 1. Coronary perfusion. Coronary flow is predominantly diastolic and further enhanced by counterpulsation, which augments diastolic blood flow and thus coronary perfusion. In addition, aortic recoil during diastole further improves efficiency of the left ventricle. Figure 2. Systemic arterial pressure waveform on introduction of intra-aortic balloon pump–assisted diastolic augmentation. The intra-aortic balloon pump inflates at the dicrotic notch, leading to peak-augmented diastolic pressure. As the balloon deflates, assisted end diastolic pressure is seen to be lower than unassisted end diastolic pressure and assisted systolic pressure is lower than unassisted systolic pressure. Peak diastolic augmentation should be greater than the unassisted systolic pressure and both assisted pressures should be less than the unassisted pressures. Intra-aortic balloon counterpulsation was initially used as a means of supporting patients undergoing surgical revascularization. Percutaneous delivery …

Association of Mechanical Circulatory Support and Cardiac Catheterization Laboratory Procedural Volumes With Outcomes of Cardiogenic Shock.

Funding Acknowledgements Type of funding sources: None. OnBehalf Netherlands Heart Registration Background It is important to gain more insight into cardiogenic shock (CS), as currently little is known on how to improve outcomes. The aim of this study was to assess the incidence, clinical outcome and predictors for mortality of CS in acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI). Methods The Netherlands Heart Registration (NHR) is a nationwide registry on all cardiac interventions. We used NHR data of ACS patients treated with PCI between 2015 and 2019. CS was defined as shock present at admission. Cox regression analysis was used to calculate hazard ratios (HR) with 95% confidence intervals (CI). Results Among 75,407 ACS patients treated with PCI, 3,028 patients (4.1%) were identified with CS. The incidences of CS were respectively; 4.3%, 3.9%, 3.5% and 4.3% per year. Median follow-up duration was 9 months (IQR 0-26) for patients with CS and 22 months (IQR 12-36) for patients without CS. Thirty-day mortality was 36% for patient with CS and 3% for patients without CS (p &amp;lt; 0.001). Factors independently associated with mortality in CS were: age (HR 1.02, 95%CI 1.02-1.03), estimated glomerular filtration rate (eGFR) (HR 0.98, 95%CI 0.98-0.99), diabetes mellitus (DM) (HR 1.25, 95%CI 1.08-1.45), multivessel disease (HR 1.22, 95%CI 1.06-1.39), prior myocardial infarction (MI) (HR 1.24, 95%CI 1.06-1.45) and out-of-hospital cardiac arrest (OHCA) (HR 1.71, 95%CI 1.50-1.94) (Table 1). Conclusion In this Dutch nationwide registry-based study of ACS patients treated by PCI, the incidence of CS was 4.1% over the 4-year study period. Predictors for mortality in CS were higher age, renal insufficiency, presence of DM, multivessel disease, prior MI and OHCA. Multivariable Cox regression analysisHR95% CIp-valueAge (years)1.021.02-1.03&amp;lt;0.001MaleNSDiabetes mellitus1.251.08-1.45&amp;lt;0.01Multivessel disease1.221.06-1.39&amp;lt;0.01CTONSPrior MI1.241.06-1.45&amp;lt;0.01Prior CABGNSeGFR (ml/min/1.73 m2)0.980.98-0.99&amp;lt;0.001OHCA1.711.50-1.94&amp;lt;0.001STEMINSIntervention yearNS

Management of Acute Coronary Syndromes

Teamwork in Acute Heart Failure: The Role of the Cardiac Anesthesiologist

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Background: Patients with cardiogenic shock (CS) have high in-hospital mortality. Regionalized systems of care, modeled after trauma and ST-segment-elevation myocardial infarction networks, have been proposed to improve outcomes. Expert consensus frameworks classify CS centers based on mechanical circulatory support (MCS) capabilities, but national outcome data remain limited. This study assessed the association between hospital shock center designation and clinical outcomes. Methods: Adults (≥18 y) hospitalized with a primary or secondary diagnosis of CS were identified from the Nationwide Readmissions Database (2016–2022). Hospitals were stratified annually into four CS center levels using procedural codes: Level 1 (≥1 durable left ventricular assist device or cardiac transplantation [LVAD/HTx] transplant case), Level 1A (extracorporeal membrane oxygenation, Impella 5.5 or TandemHeart capable without durable LVAD/HTx), Level 2 (percutaneous coronary intervention [PCI]-capable hospitals offering intra-aortic balloon pump [IABP] or Impella CP/RP), and Level 3 (non-PCI, non-MCS hospitals with ICU-level care only). Outcomes included in-hospital mortality, 30-day readmissions, MCS use, length of stay (LOS), and cost. Multinomial overlap propensity and hierarchical regression models were used to adjust and analyze outcomes. Results: Among 623,835 CS hospitalizations, 33.8% occurred at Level 1, 49.5% at Level 1A, 11.8% at Level 2, and 4.8% at Level 3 centers. After propensity weighting, baseline characteristics were well balanced across shock center levels. In-hospital mortality increased across levels: unadjusted 29.5% at Level 1, 38.4% at Level 1A, 41.1% at Level 2, and 45.2% at Level 3; adjusted analyses vs. Level 1: odds ratio 1.33 [95% CI, 1.29–1.38] for Level 1A; 1.44 [95% CI, 1.38–1.50] for Level 2; 1.63 [95% CI, 1.54–1.71] for Level 3; all p&lt;0.001 (Figure 1). MCS use was highest at Level 1 centers (26.1%) and lowest at Level 2 centers (10.4%). Thirty-day readmission rates were lower at lower-level centers compared to Level 1. LOS and costs were highest at Level 1 centers. Pre-specified subgroup analyses showed consistent survival benefit favoring higher-level centers. Conclusion: In a large national study, higher tiers of CS centers were associated with improved short-term outcomes independent of patient comorbidity and acuity supporting the need for regionalization of CS care.

It is important to gain more insight into the cardiogenic shock (CS) population, as currently, little is known on how to improve outcomes. Therefore, we assessed clinical outcome in acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI) with and without CS at admission. Furthermore, the incidence of CS and predictors for mortality in CS patients were evaluated. The Netherlands Heart Registration (NHR) is a nationwide registry on all cardiac interventions. We used NHR data of ACS patients treated with PCI between 2015 and 2019. Among 75,407 ACS patients treated with PCI, 3028 patients (4.1%) were identified with CS, respectively 4.3%, 3.9%, 3.5%, and 4.3% per year. Factors associated with mortality in CS were age (HR 1.02, 95%CI 1.02–1.03), eGFR (HR 0.98, 95%CI 0.98–0.99), diabetes mellitus (DM) (HR 1.25, 95%CI 1.08–1.45), multivessel disease (HR 1.22, 95%CI 1.06–1.39), prior myocardial infarction (MI) (HR 1.24, 95%CI 1.06–1.45), and out-of-hospital cardiac arrest (OHCA) (HR 1.71, 95%CI 1.50–1.94). In conclusion, in this Dutch nationwide registry-based study of ACS patients treated by PCI, the incidence of CS was 4.1% over the 4-year study period. Predictors for mortality in CS were higher age, renal insufficiency, presence of DM, multivessel disease, prior MI, and OHCA.

Early Mechanical Circulatory Support is Associated with Improved Outcomes in Cardiogenic Shock Due to End-Stage Heart Failure