Diagnosis Of Cardiogenic Shock Research Articles

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

Abstract Funding Acknowledgements None. Background Cardiogenic shock (CS) is a heterogenous, life-threatening disease burdened by a mortality up to 50%. An increasing incidence of the CS related to other etiological causes, including acute decompensated heart failure, has been reported. However, most of the epidemiological data are derived from patients admitted to dedicated acute cardiac care units. Epidemiology and management of CS patients admitted to general intensive care unit (ICU) in Italy is yet unexplored. Purpose To describe the epidemiology, patients feature, management and outcome of CS patients admitted to Italian general ICUs. Methods Prospective multicentric epidemiological study. Over 600 thousand patients admitted to 316 hundred Italian general intensive care units from 2011 to 2018 were screened trough PROSAFE software. The Margherita PROSAFE project is an observational project for the continuous electronic collection of data on patients admitted to ICUs; it is developed by the GiViTI (Gruppo italiano per la valutazione degli interventi in terapia intensiva - Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The primary outcome of the analysis was hospital mortality. Secondary outcomes included description of patients features and management. Results 11661 patients (72.1±12.1 years old.; 39.5% women) with a diagnosis of CS were included in the analysis. ICU and in-hospital mortality were respectively 45.5 % and 53.9%. Highest mortality was observed for pulmonary embolism (58.4%), right heart failure (56.3%) and acute decompensated heart failure (ADHF) (44.2%). 46.9% of patients presented with more than 3 organ failure (panel A). CS commonest aetiologies were ADHF (63,3%), acute myocardial infarction (19.8%) and right heart failure (11%). Invasive mechanical ventilation was used in the 88.6% of cases. Intra-aortic balloon pump was placed in 15.2%, with higher frequency in ischemic aetiologies (43.9%) and ADHF (13.7%); VA-ECMO was most frequently placed in the right heart failure (3.7%) and acute myocardial infarction (2.6%) groups. The factors independently associated with increased hospital mortality were increasing age (p <0.001), lower Glasgow coma scale (p <0.001), hypoxemia (PaO2 <100, OR: 1.91; 95% Cl: 1.58 – 2.3; p <0.001), bradycardia (OR: 1.84; 95% Cl: 1.49 – 2.26; p <0.001), hypotension (OR: 1.27; 95% Cl: 1.12 – 1.43; p <0.001), bilirubin above 12 mg/dl (OR: 7.90; 95% Cl: 2.56 – 24.3), increased creatinine (p <0.001) and reduced platelets (<50000 U/mL, OR: 2.43; 95% Cl: 1.78 – 3.31; p <0.001) (panel B). Curiously, in the predictive model a BMI above normal values was protective as well as tachycardia compared to severe bradycardia (panel C). Conclusions The etiology of CS in general intensive care units is heterogeneous with acute heart failure being the commonest. The mortality rate remains unacceptably high with right heart failure and acute heart failure being burden by the worst outcome.

The dual prevalence of advanced degrees of obesity and heart failure: a study from the National Inpatient Sample database

BackgroundNational prevalence rates for obesity and heart failure (HF) have been steadily increasing, which predisposes patients to higher morbidity and mortality rates. ObjectivesThe purpose of this study was to evaluate the prevalence of HF stages in hospitalized patients according to their body mass index (BMI). SettingAcademic institution. MethodsNational Inpatient Sample data from 2016 to 2018 were examined to identify patients with obesity, HF (presence or absence of advanced HF [AHF]), and cardiogenic shock (CS). The proportion of hospital admissions was determined for each category on the basis of the presence of AHF with/without CS. A comparative analysis was performed between patients with and without AHF, and multivariate logistic regression analysis was performed for the event of AHF. The same analyses were performed for the event of CS. ResultsA total of 3,354,970 hospital admissions were identified. The prevalence of hospital admissions with a diagnosis of AHF and class III obesity and a diagnosis of CS and class III obesity was 21% and .5%, respectively. The prevalence of AHF and other classes of BMI and CS and other classes of BMI was 17% and .5%, respectively. The univariate analysis showed that there were significant variations in 10 factors between hospital admissions with/without the diagnosis of both AHF and CS. Statistical analyses indicated the following findings: Hospitalized patients in higher obesity groups are more likely to have AHF, and they are less likely to have CS compared with those with a BMI of ≤29.9. ConclusionsThis study revealed that the prevalence of AHF was significantly higher in hospitalized patients with class III obesity. These findings have implications for clinical management, and it can be inferred that these patients are less likely to receive advanced cardiac replacement therapies and might benefit from innovative approaches to address severe dual morbidity.

Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey.

The epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units. A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1st-2nd versus 3rd). Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. 94.2% routinely uses a cardiac output monitoring device (pulmonary artery catheter more frequently in 3rd level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%). According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.

In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019.

Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS). Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients. The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05). We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints. These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.

ПРОГНОЗИРОВАНИЕ НЕБЛАГОПРИЯТНЫХ КЛИНИЧЕСКИХ ИСХОДОВ ПАЦИЕНТОВ С КАРДИОГЕННЫМ ШОКОМ ПОСЛЕ ОПЕРАЦИЙ НА ОТКРЫТОМ СЕРДЦЕ ПРИ ПОДКЛЮЧЕНИИ ВНУТРИАОРТАЛЬНОЙ БАЛЛОННОЙ КОНТРАПУЛЬСАЦИИ

Aim. To determine preimplantation risk factors and predictors of unfavorable outcome in patients with cardiogenic shock after open-heart surgery, who had an intraoperative system of mechanical circulatory support – intra-aortic balloon contrapulsation. Methods. A retrospective study was conducted at the Republican Scientific and Practical Center “Cardiology” for 2015–2020. It included 66 patients who underwent heart surgery on bypass and who intraoperatively developed cardiogenic shock, refractory to drug therapy, which resulted in the use of intra-aortic balloon counterpulsation. The diagnosis of cardiogenic shock was determined based on the generally accepted criteria, as well as based on the SCAI (Society for Cardiovascular Angiography and Interventions) classification of shock: systolic blood pressure &lt; 90 mmHg for &gt; 30 minutes or the need for infusion of vasopressors or inotropes to achieve the blood pressure of ≥ 90 mm Hg. The Pearson Chi-square test used for nonparametric analysis of qualitative characteristics. The predictors were identified based on logistic regression. Differences were considered significant at p &lt; 0.05 (5%).Results. Risk factors for adverse outcome in case of CS before the use of IABP were: age over 65 years OR = 6.04 [95% CI 1.73 – 21.06], p = 0.003; female gender OR = 3.24 [95% CI 1.064 – 9.873], p = 0.048; vasoactive and inotropic support of more than 42 points OR = 7.85 [95% CI 2.33 – 26.45], p = 0.001; blood lactate of more than 4.7 mmol/l OR = 4.12 [95% CI 1.27 – 13.37], p = 0.014; blood acidity pH &lt; 7.33 OR = 6.34 [95% CI 1.97 – 20.37], p = 0.003; base deficit BE &gt; –5.6 OR = 7.32 [95% CI 2.19 – 24.42], p = 0.001. According to the β-coefficients of the logistic regression equation, predictors were scored as follows: age &gt; 65 years = 2 points, VIP &gt; 42 = 2 points, lactate &gt; 4.7 mmol/L = 1 point. The cumulative probability of 30-day mortality was as follows: 9% when defined as 1 point, 20% – 2 points, 55% – 3 points, 60% – 4 points, 75% – 5 points (Chi-square 24.1; df = 5; p = 0.001). Conclusions. Cardiogenic shock is a fatal complication in cardiac surgery. The use of vasopressor and inotropic drugs has an important role in the treatment of CS; however, escalation of catecholamine doses leads to the progression of multiple organ failure due to hypoperfusion and hypoxia of target organs. Therefore, the use of intra-aortic balloon counterpulsation can improve the results of CS treatment. However, the effect of IABP is limited to increasing cardiac output by no more than 1 l/minute. Based on the calculator we developed, when determining a high risk of an unfavorable outcome of the IABP use, options for circulatory support should be considered including extracorporeal membrane oxygenation, ventricular assist device.

Sex Disparities in the Management, Outcomes, and Transfer of Patients Hospitalized for Cardiogenic Shock

BackgroundPrevious studies have shown that women have worse outcomes for cardiogenic shock (CS) than men. Patients who receive care in CS “hubs” have also been shown to have improved outcomes when compared to those treated at “spokes.” This study aimed to examine the presence of sex disparities in the outcomes of CS in relation to hospital type. MethodsHospitalizations of adults with a diagnosis of CS were identified using data from the 2016-2019 Nationwide Readmissions Database. CS “hubs” were defined as any centers receiving at least 1 interhospital transfer with CS, while those without such transfers were classified as “spokes.” Data were combined across years and multivariable logistic regression modeling was used to evaluate the association of sex with in-hospital mortality, invasive procedures, and transfer to hubs. ResultsThere were a total of 618,411 CS hospitalizations (62.2% men) with CS related to acute myocardial infarction comprising 15.3 to 17.3% of women hospitalizations and 17.8 to 20.3% of men hospitalizations. In-hospital mortality was lower at hubs (34.5% for direct admissions, 31.6% for transfers) than at spokes (40.3%, all P < .01). Women underwent fewer invasive procedures (right heart catheterization, percutaneous coronary intervention, mechanical circulatory support) and had higher mortality than men. Female sex was independently associated with decreased transfers to hubs (odds ratio, 0.93; 95% CI, 0.89-0.96) and increased mortality (odds ratio, 1.09; 95% CI, 1.05-1.12). ConclusionsWomen with CS were less likely to be treated at a hub or transferred to a hub, had higher in-hospital mortality, and had a lower likelihood of receiving CS-related procedures than men. Further research is needed to understand sex-specific gaps in CS outcomes.

Abstract 16217: Characteristics and Short-Term Outcomes of Patients With Cardiogenic Shock Secondary to Myocarditis

Background: The clinical profile and short-term prognosis of patients with cardiogenic shock (CS) secondary to myocarditis remains poorly defined. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of cardiogenic shock (CS) were retrospectively identified through electronic medical records. Patients were further categorized into those with CS secondary to myocarditis (myocarditis-CS) or other etiologies (non-myocarditis-CS). Only patients with confirmed myocarditis with an endomyocardial biopsy or cardiac MRI were included. Descriptive characteristics and short-term outcomes of this group were explored. Results: A total of 2775 patients were admitted to our CICU with CS of which, 26 patients (1%) had CS secondary to confirmed myocarditis. Compared to patients with non-myocarditis CS, patients with myocarditis-CS were significantly younger (median age of 49 vs 65, p&lt;0.001), had lower prevalence of known coronary artery disease (23% vs 62%, p&lt;0.001), and significantly lower prevalence of other comorbidities (diabetes- 12% vs 42%, dyslipidemia- 23% vs 49%, and hypertension- 31% vs 62, all p&lt;0.05). Amongst patients with myocarditis-CS, 23% (n=6) patients received a heart transplant during the same admission whereas 8% (n=2) were discharged on an LVAD. Viral myocarditis was the most common etiology (35%, n=9), followed by idiopathic myocarditis (23%, n=6), and lymphocytic (15%, n=4). The 30-day all-cause mortality of patients with CS-myocarditis was 8% compared to 22% for those with non-myocarditis CS (p=0.1). Conclusion: Myocarditis continues to remain an infrequent cause of CS in the contemporary era accounting for around 1% of all CS admissions. A third of these patients would require advanced therapies and so early consideration of a destination mechanical therapy or transplant is vital to ensure optimal care of these patients.

Abstract 16254: Short and Long-Term Outcomes of Patients With Cardiac Amyloidosis Presenting in Cardiogenic Shock

Background: The characteristics and outcomes of patients with cardiac amyloidosis who present in cardiogenic shock (CS) remains poorly defined. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of cardiogenic shock (CS) were retrospectively identified through electronic medical records and confirmed via physician chart review. Patients were further categorized into those with CS with cardiac amyloidosis (C-Amyloid) and CS without cardiac amyloidosis. 30-day and 1-year all-cause mortality was compared between the two groups with Kaplan-Meier (KM) estimates. Results: During the study period, a total of 2775 were patients were admitted to our CICU with CS of which, 29 patients (1%) had confirmed cardiac amyloidosis (C-amyloid). Amongst patients with CS and c-amyloid, 18 patients (62%) had TTR amyloid, 8 (28%) had AL amyloid and 3 were undefined. Compared to patients with other forms of CS, patients with C-amyloid were significantly older (median age of 70 vs 65, p=0.024), had lower prevalence of prior myocardial infarction (21% vs 42%, p=0.037) or coronary artery bypass grafting, and a higher prevalence of chronic kidney disease (69% vs 39%, p=0.002). There were no significant differences in the utilization of right heart catheterization, mechanical circulatory support or mechanical ventilation between the two groups. Comparison of survival probabilities revealed that CS patients with amyloid had similar 30-day (17% vs 21%, p=0.56) and 1-year all-cause mortality (38% vs 31%, p=0.6). Conclusion: Amyloid cardiomyopathy is a rare but unique etiology of CS in the CICU. Observed mortality rates are similar to patients with other forms of CS. Given breakthroughs in therapeutics for this condition, the proportion of patients with this clinical entity is expected to rise.

Abstract 395: Outcomes Of Mechanical Circulatory Support for Cardiogenic Shock in the United States: An Analysis of the 2017-2020 National Inpatient Sample Database

Introduction: Mechanical circulatory support devices, such as Extracorporeal membrane oxygenation(ECMO), Impella, and intra-aortic balloon pump(IABP), play a crucial role in managing patients with cardiogenic shock(CS). This study aimed to compare the outcomes and patient characteristics of different mechanical circulatory support modalities. Methods: We utilized the National Inpatient Sample Database(NIS) data from 2017 to 2020 to identify patients with the diagnosis of CS who received mechanical circulatory support. The study population was categorized into six groups: ECMO, Impella, IABP, ECMO + Impella, and ECMO + IABP. The groups were compared based on patient characteristics, length of stay(LOS), complications, need for a heart transplant, mortality, and total charges. Results: A total of 715,470 patients were identified with CS, 17%(122,100) received mechanical circulatory support, 5,675 had ECMO therapy, 33,360 Impella, 79,540 IABP, 1,890 cases ECMO+Impella, and 1,635 cases ECMO+IABP. Age significantly differed, with ECMO patients being the youngest 54[36-65] years. There were higher proportions of females in the ECMO-only(37.4%) and males in the ECMO+Impella(76.7%). LOS was prolonged in the ECMO group(14 [5-28] days) compared to other groups(p&lt;0.001). Mortality rates were higher in the ECMO group(47.1%), followed by ECMO+Impella(45.8%) and ECMO+IABP (40.1%) (p&lt;0.001). Higher rates of stroke, disseminated intravascular coagulation, and continuous renal replacement therapy requirements were observed in the ECMO group. Bleeding requiring transfusion was more frequent with ECMO+IABP, and limb ischemia was more common in the ECMO+Impella group (p&lt; 0.001). Heart transplant rates were highest after ECMO+IABP therapy. Over the years, ECMO utilization increased, while Impella and IABP utilization remained stable. Notably, the ECMO+IABP had the highest total charges among all the therapy modalities evaluated (p &lt; 0.001). Conclusions: The rising utilization of ECMO and ECMO-IABP therapies indicates a changing treatment landscape. However, these approaches exhibit lower survival rates, potentially due to the severity of CS, heightened complications, and increased costs compared to standalone IABP or Impella therapies.

CE-452776-4 ATRIAL FIBRILLATION IS ASSOCIATED WITH HIGHER INPATIENT MORTALITY AS COMPARED WITH SINUS TACHYCARDIA IN PATIENTS WITH CARDIOGENIC SHOCK

Cardiogenic shock (CS) is commonly associated with a compensatory atrial stress response like sinus tachycardia (ST) or atrial fibrillation (AF). However, there is paucity of data comparing inpatient outcomes in patients with cardiogenic shock presenting with AF versus ST. To compare the impact of AF and ST on in-hospital outcomes in patients admitted with cardiogenic shock. We queried the National Inpatient Sample database to identify primary hospitalizations of CS using ICD-9/ICD-10 CM codes between 2009 and 2019. The study cohort was further divided into three groups based on the concurrent diagnosis of AF, ST, and a comparator group of no AF/ST. Our cohort included a total of 1,376,187 hospitalizations with a diagnosis of CS. Multivariate analysis showed CS hospitalizations with AF as compared with ST, had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.03-1.11) p=0.0005], CRT implantation [aOR 2.38 (1.88-3.03) p<0.001] and AV node ablation [aOR 3.22 (2.63-4.00) p<0.001]. Patients hospitalized with CS without concurrent AF/ST vs concurrent AF had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.06-1.08) p<0.001] and utilization of mechanical circulatory support [aOR 1.33 (1.31-1.34) p<0.001] but lower odds of CRT [aOR 0.76 (0.73-0.80) p<0.001] and AV node ablation [aOR 0.38 (0.37-0.40) p<0.001]. Our data suggest that patients admitted for CS and AF have worse outcomes including higher inpatient mortality, compared to those with CS and ST. However, compared to those without ST or arrhythmias, AF patients had a lower in-hospital mortality. These data are hypothesis generating and merit further study to better inform management of patients with CS and atrial arrhythmias.

752 CARDIOGENIC SHOCK AS THE FIRST PRESENTATION OF ACUTE ANTRACYCLINE CARDIOTOXICITY: A CLINICAL CASE

Abstract Background Several therapeutic strategies are available for cancer patients, leading to a longer life expectancy; however, each drug might have different side effects, which increase morbidity and mortality. Cardiovascular diseases are one of the most frequent and dramatic of these side effects, leading to interruption of a potentially lifesaving treatment or hesitating into heart failure. Clinical Case A 50 year-old female with recent diagnosis of breast cancer presented to our Emergency Department (ED) for asthenia, vomiting and dyspnea. A first dose of epirubicin and cyclophosphamide as neoadjuvant chemotherapy (CT) was administered three days before the onset of symptoms. Screening echocardiogram performed before starting the CT showed normal systolic ejection fraction, normal diastolic function and no valvular disease. At ED admission, the patient presented hypotension, tachycardia, sweating and mental confusion. The ECG showed sinus tachycardia with diffuse ST segment elevation and diffuse low QRS voltages. Echocardiogram proved severe left dysfunction (LVEF 15%) with low cardiac output (LVOT VTI 6 mm) and elevated ventricular filling pressure (E/e’ 26). EAB showed severe hyperlactacidemia. The diagnosis of cardiogenic shock was done and high doses of dobutamine and noradrenaline were started. Laboratory values confirmed multiorgan involvement, in absence of any signs of inflammation and infection. The coronary angiography performed revealed normal coronary arteries and elevated left ventricular end-diastolic pressure (LVEDP 29 mmHg). Despite pharmacological therapy, the patient's condition worsened so we proceeded to IMPELLA CP implantation and started methylprednisolone 10 mg/kg for three days with subsequent tapering doses. After 24 hours, we obtained hemodynamic stability and hyperlactacidemia clearance. Unfortunately, myelotoxicity and marked piastrinopenia (until 16 000*10 9/L) complicated the clinical course; for this reason, we stopped unfractionated Heparin (UHF) and no anticoagulant therapy, other the one in purge solution, was performed. CMR revealed diffuse signal enhancement during the T2w sequences associated with a global enhancement of T2 Mapping values due to general edema, a global intramyocardial strengthening, a significant enhancement of the T1 mapping values and extracellular volume were described at the delayed enhancement sequences. The hemodynamic conditions progressively improved during the hospitalization and the IMPELLA pump was removed. Serial echocardiograms documented an improvement of the ejection fraction and further mild reduction of ventricular filling pressure (E/e’ 8) normal right ejection fraction and initial inferior vena cava collapsibility. All the inotropic supports were suspended; we introduced beta-blocker, ACE-inhibitors, subsequently replaced with sacubitril/valsartan, well tolerated. Conclusion Acute cardiotoxicity with possible life-threatening conditions regardless of the basal cardiovascular risk class is a rare clinical condition, but needs further investigation. Future researches are warranted to determine the molecular mechanisms underlying cardiotoxicity to contain the side effects, maximize the benefit of the oncological therapy and, when necessary, select the best therapeutic option.

Abstract 13382: Outcomes of Patients With Valvular Cardiogenic Shock Stratified by Treatment Strategy

Background: No prior studies have compared the outcomes of patients with valvular cardiogenic shock (VCS) depending on the treatment received. Our study aimed to assess this. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of cardiogenic shock (CS) were retrospectively identified through electronic medical records and confirmed via physician directed chart review. Patients with CS were subsequently categorized into those with valvular cardiogenic shock (VCS) and non-valvular CS depending on the primary etiology responsible for hemodynamic instability. The impact of treatment strategy on 1-year all-cause mortality in patients with VCS was assessed with Kaplan-Meier (KM) estimates. Results: Overall 511 patients were admitted to our CICU with VCS during the study period. Out of these patients, 188 patients (37%) underwent surgery, 76 patients (15%) underwent percutaneous structural intervention, and 247 patients (48) % underwent conservative management. Comparison of baseline characteristics (Table 1) revealed that patients with VCS who underwent surgical treatment were significantly younger (median age 64 yrs vs 72 and 76 yrs, p&lt;0.001), and less likely to have coexisting comorbidities such as diabetes, dyslipidemia, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). KM survival analysis revealed that VCS patients who underwent conservative management had the highest all-cause mortality at 1 year, whereas those patients who underwent surgery had the lowest all-cause mortality at 1 year (p&lt;0.001) (Figure 1). Conclusion: Patients with VCS remain a high-risk cohort who are most likely to be conservatively managed. Of the patients who received a specific therapy, surgical management was associated with the best outcomes. The impact of early intervention in patients with VCS needs to be further explored.

Abstract 11340: Characteristics of Patients Admitted to a Contemporary Cardiac Intensive Care Unit With Valvular Cardiogenic Shock

Background: Cardiogenic shock (CS) is a heterogeneous clinical entity associated with poor outcomes. Patients with CS primarily due to an acute valvular dysfunction (valvular cardiogenic shock; VCS) constitute a unique cohort who remain poorly defined. We sought to define the prevalence and underlying patient characteristics of patients with VCS. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of CS were retrospectively identified through electronic medical records and confirmed via physician directed chart review. Patients with CS were subsequently categorized into those with VCS and non-VCS depending on the primary etiology responsible for CS. Characteristics of patients with VCS were analyzed to descriptively define this entity. Patients with mixed shock and those with incomplete variables were excluded. Results: Overall, 2754 patients were admitted to our CICU with CS of which 511 (18.6%) were determined to have VCS. The median age of patients with VCS was higher than those with non-VCS (70 yrs vs 64yrs, P&lt;0.001). Patients with VCS were also more likely to be females (40.5% vs 31.8%, P&lt;0.001), have higher prevalence of atrial fibrillation (56.9% vs 48.5%, p=0.001), chronic obstructive pulmonary disease (26.4% vs 20%, p=0.002), and prior history of valve replacement or repair (29.7% vs 7.9%, p&lt;0.001) (Table 1). Patients with VCS were also significantly less likely to have prior MI (19.4% vs 46.6%, p&lt;0.001). The aortic valve was most commonly implicated; with more native valve dysfunction as compared to prosthetic valve dysfunction (73% vs 27%, p&lt;0.001). (Figure 1). Conclusion: One in 5 patients admitted with CS has VCS with native valves and the aortic position being the common culprit. The availability and impact of emergent percutaneous structural-interventions on clinical outcomes in this population warrants investigation.

Abstract 14677: Therapeutic Outcomes in Concomitant Cardiogenic Shock and Severe Aortic Stenosis: Insights From the National Inpatient Sample

Introduction: Cardiogenic shock (CS) in patients with concomitant severe aortic stenosis (AS) is a critical combination of pathologies that has been associated with a 43% to 77% in-hospital mortality. There is scant data regarding outcomes after medical management (MM), transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in this high risk population. Methods: The National Inpatient Sample was queried from 2011-2019 for relevant ICD-9 and ICD-10 codes to identify patients with AS and CS who underwent MM, TAVR or SAVR. Binary logistic regression was used to adjust outcomes for significantly different baseline characteristics. Results: We identified a weighted sample of 4,663,000 patients with AS, of which 26,101 had a concurrent diagnosis of CS and did not meet exclusion criteria. Medical management was associated with increased mortality compared to treatment with TAVR or SAVR (aOR 2.231, 95% CI 2.032-2.448, p&lt;0.001). SAVR was associated with decreased mortality when compared to TAVR, although the difference was not statistically significant. Patients that underwent intervention, and specifically SAVR, had lower odds of cardiac arrest than patients that underwent medical management (SAVR aOR 0.514, 95% CI 0.386- 0.685, p&lt;0.001, TAVR aOR 1.946, 95% CI 1.461-2.592, p&lt;0.001). Medical management was associated with decreased risk of complete heart block (aOR 0.402, 95% CI 0.341-0.473, p&lt;0.001), length of stay (8.4±9.9 days versus 9.6±8.5 for TAVR and 11.4±9.7 for SAVR, p&lt;0.001) and cost of stay ($151,605±200,268 versus $352,936 ±297,495 for TAVR and $325,485 ±281,422 for SAVR, p&lt;0.001). Conclusions: Patients with concomitant CS and severe AS have increased mortality with MM as compared to patients that undergo TAVR or SAVR, however there is no significant difference between TAVR and SAVR mortality despite SAVR patients generally having a lower incidence of comorbidities. These patients may benefit from AVR as opposed to MM.

Feasibility of Very Early Identification of Cardiogenic Shock by Semi-automated Ultrasound Exam in the Emergency Department.

Background Cardiogenic shock (CS) is critical end-organ hypoperfusion due to reduced cardiac output. Early therapy, such as vasoactive agents or the initiation of mechanical circulatory support (MCS), requires early diagnosis and is associated with better outcomes. A novel ultrasound platform (GE Healthcare, Milwaukee, WI) has semi-automated imaging software (SAIS), which could simplify the point-of-care ultrasound (POCUS) diagnosis of CS. We assessed the feasibility of using POCUS with SAIS in patients in shock, determined the ability of SAIS to identify the subset of patients with CS, and described the process and outcome of care of patients with vs. without CS after presenting to Emergency Department (ED) with hypotension. Methods This prospective case-control study was conducted at an urban ED. Physicians with prior POCUS education received one hour of training with the study device. The qualitative ejection fraction was determined by visual assessment. SAIS measurements of hemodynamics were made with the study device and included left ventricle outflow tract velocity time integral (LVOT VTI), inferior vena cava collapsibility or distensibility indices, and pulmonary B-line assessment.ED patients with a systolic blood pressure ≤ 90 mmHg or need for a vasopressor initiation in the ED were enrolled. The diagnosis of CS was determined by a medical record review. All data were summarized descriptively. Results Twenty-ninecases underwent POCUS, and 87 controls did not. Baseline characteristics, process, and outcome of care were similar between groups. Seventy-nine percent (79%) of cases had a complete POCUS with SAIS. Of these, 55% had reduced LVOT VTI, 38% had IVC collapsibility <50%, and 48% of cases had a B-line pattern consistent with pulmonary edema. The mean LVOT VTI for cases with CS was 9.4± 5.4 cm; the mean LVOT VTI for cases without CS was 15.2 ± 6.0 cm. Among patients who did not undergo POCUS, 31 (36%) had a formal echocardiogram, and eight (9%) had a final diagnosis of cardiogenic shock during hospitalization. Conclusion Physicians with one hour of platform-specific training were able to implement POCUS with SAIS among patients who present with shock. POCUS with SAIS may aid in the early recognition of CS.

The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure.

Heart failure affects >6 million people in the United States aloneand is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program. A retrospective single-center cohort study was conducted at a single high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1, 2013 and 12, 2017 with a left ventricular ejection fraction < 30% and inotropic dependence or need for mechanical circulatory support were included. Patients with contraindications to durable LVAD were excluded. An adjusted logistic regression model for durable LVAD implantation within 90 days of the index admission was used to determine the effect of race on durable LVAD implantation. Among the 702 study patients (60.9% White, 34.1% Black), durable LVAD implantation was performed within 90 days of the index admission in 183 (26%) of the cohort. After multivariate analysis, Black patients were not found to have a statistically significant difference in durable LVAD implantation rates compared to White patients in our study (OR: 0.68 [95%confidence interval: 0.45-1.04; p: .074]). Black patients in our study did not have a statistically significant difference in the rate of durable LVAD implantation compared with White patients after adjustments were made for age, sex, socioeconomic, and clinical covariates. Larger prospective studies are needed to validate these findings.

The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design.

Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients. The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies. The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.

Mechanical ventilation in patients with cardiogenic shock complicating acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Invasive mechanical ventilation (IMV) provides up to a 30% reduction in cardiac output requirements and is frequently used in patients with cardiogenic shock following acute myocardial infarction (AMICS). However, practice of IMV in the setting of AMICS is sparsely described. Purpose The aim was to evaluate the use of IMV in a contemporary cohort of patients with AMICS. Methods Between 2010 and 2017, all adult AMICS patients admitted to two tertiary heart centres, providing AMICS care for two thirds of the Danish population, were individually identified through patient records. Temporal changes in application of IMV were registered as well as patient characteristics. Real-time electronic ICU data were available for a subset of mechanically ventilated ICU patients (n=566), and were retrieved for the first 24 hours of IMV, following ICU admission, and described in relation to 30-day survival and the presence of out-of-hospital cardiac arrest (OHCA). Results A total of 1716 AMICS patients were retrospectively identified, of which 1274 (74%) received IMV during ICU admission (IMV-ICU). The proportion of IMV increased from 70% in 2010 to 78% in 2017. IMV-ICU patients were younger (67 vs 76 years), more frequently male (79% vs 61%), and more likely to have OHCA (54% vs 3%) and higher lactate at diagnosis of cardiogenic shock (5.8 vs 4.1 mmol/L) compared with non-intubated patients (p for all&amp;lt;0.001). Among IMV-ICU patients, 69% were intubated in the prehospital setting, of which three quarters presented with OHCA. Median PaO2 and PCO2 were both within normal ranges among 30-day survivors and non-survivors. However, non-survivors required 10-25% higher median fraction of inspired oxygen (p&amp;lt;0.001; FiO2), positive-end-expiratory pressure (p=0.002; PEEP), and minute ventilation (p&amp;lt;0.001; MV). Differences in IMV settings were mainly driven by non-survivors without OHCA (see table). Conclusion In a contemporary cohort of patients with AMICS, use of IMV increased during the observation period from 2010 to 2017. Observations did not reveal any association between 30-day mortality and IMV parameters in OHCA-patients, whereas FiO2, PEEP, and MV were significantly elevated in 30-day non-survivors without OHCA.

Using Machine Learning for Early Prediction of Cardiogenic Shock in Patients With Acute Heart Failure

<h2>Abstract</h2><h3>Background</h3> Despite technological and treatment advancements over the past 2 ​decades, cardiogenic shock (CS) mortality has remained between 40% and 60%. Our objective was to develop an algorithm that can continuously monitor heart failure patients and partition them into cohorts of high and low risk for CS. <h3>Methods</h3> We retrospectively studied 24,461 patients hospitalized with acute decompensated heart failure, 265 of whom developed CS, in the Johns Hopkins Health System. Our cohort identification approach is based on logistic regression and makes use of vital signs, lab values, and medication administrations recorded during the normal course of care. <h3>Results</h3> Our algorithm identified patients at high risk of CS. Patients in the high-risk cohort had 10.2 times (95% confidence interval, 6.1-17.2) higher prevalence of CS than those in the low-risk cohort. Patients who experienced CS while in the high-risk cohort were first deemed high risk a median of 1.7 ​days (interquartile range, 0.8-4.6) before CS diagnosis was made by their clinical team. To evaluate <i>actionability</i>, we randomly selected 50 patients designated as high risk who did develop CS and 50 who did not. On review of true positive cases, from the time of model identification as high risk to the eventual diagnosis of CS, 12% of patients had possible inappropriate therapy, and for 50% of patients, more tailored therapy options existed. On review of the false positive cases, 44% of cases were considered at high risk of CS or end-stage cardiomyopathy by their clinical teams or went onto develop other types of shock. <h3>Conclusions</h3> This risk model was able to predict patients at higher risk of CS in a time frame that allowed a change in clinical care. The actionability evaluation demonstrates a possible opportunity to intervene as part of a CS algorithm for escalation of care.

Impella support as a bridge to heart surgery in patients with cardiogenic shock.

OBJECTIVESIn patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known to yield better outcomes than emergency surgery. We aimed to investigate the effectiveness of Impella (Abiomed, Danvers, MA, USA) as a bridge to cardiac surgery in patients with cardiogenic shock.METHODSWe reviewed 7 patients with cardiogenic shock who underwent Impella support as a bridge to cardiac surgery using cardiopulmonary bypass at our institution between April 2018 and August 2021.RESULTSCardiogenic shock was caused by ventricular septal rupture in 3 patients, papillary muscle rupture in 1 and acute myocardial infarction in 3. Cardiac surgery was delayed by 1–7 (3.9 ± 2.5) days with Impella support after the diagnosis of cardiogenic shock, during which the hepatic and renal function of the patients improved significantly. Device-related or operation-related adverse events included re-exploration for bleeding in 3 patients, acute limb ischaemia due to thromboembolism in 1 and intraoperative aortic dissection in 1. Thirty-day mortality was 14.3%, and the cumulative survival was 71.4% at 1 year. The survival tended to be better than that in historical control group in which extracorporeal membrane oxygenation was used as a bridge to surgery (P = 0.0992).CONCLUSIONSImpella is an effective tool for bridging patients with cardiogenic shock to surgery. This strategy may improve surgical outcomes in patients with cardiogenic shock. However, prolonged Impella support may increase significant adverse events, and further investigation is required to determine the optimal duration of support before surgery.