Clinical and Hemometabolic Status Impact Transitions in Acute on Chronic Heart Failure Shock: Insights from the CSWG Registry

Abstract

Cardiogenic shock remains a complex global health entity associated with high mortality despite increased utilization and availability of acute mechanical circulatory support (AMCS) as a bridge to replacement, recovery and/or palliation. We sought to determine the disease trajectory of patients with chronic heart failure complicated with cardiogenic shock and the impact of surrogates related to clinical severity and impaired hemometabolic status. 712 cardiogenic shock patients with acute-on-chronic heart failure as cause of shock were identified from the CSWG Registry and were evaluated by treatment, metabolic indicators of renal and liver dysfunction and hemodynamics with respect to outcome. Treatment parameters analyzed across the duration of in-patient hospitalization included the use of more than 1 AMCS device, the use of more than 1 vasopressor/inotrope, and the use of mechanical ventilation. Metabolic indicators were measured prior to any AMCS usage and included elevated INR, serum creatinine, and total bilirubin. Elevated right atrial pressure (RAP), wedge pressure and cardiac index at baseline was used to evaluate hemodynamic status. Recovery (discharge w/o replacement), replacement (bridge to VAD or OHT) and in-hospital mortality were the primary outcomes of interest. Out of 712 HF CS patients, 255 (35.81%) recovered, 277 (38.90%) bridged to either a VAD or OHT, and 180 (25.28%) did not survive their hospitalization. The variation in hemometabolic status and clinical severity across outcomes is summarized in the figure below. Specific surrogates of worsening clinical (mechanical ventilation/increased inotropes/vasoactives), hemodynamic (increased RAP) and metabolic (increased SCr and Total Bilirubin) status in HF-CS were associated with impaired survival. Our findings support the value of studying dedicated system-based strategies for early clinical and hemometabolic situational awareness in HF-CS.