Incidence Of Cardiogenic Shock Research Articles

Abstract 11100: Persistent Gender Disparities in STEMI Mortality: Insights From the Midwest STEMI Consortium

Introduction: Over the past two decades, national and regional initiatives have been dedicated to closing the gender gap and resolving disparities in STEMI care and outcomes for females. In this study, we explored how gender disparities have evolved in a well-established regional STEMI system in the US. Methods: Using the Midwest STEMI Consortium database, we examined sex differences in STEMI treatment and outcomes when stratified by decade from 2003 to 2009 versus 2010 to 2020. Results: Among 12,878 consecutive STEMI patients, 30.3% were female. Females were older and more likely to have a history of hypertension and diabetes as compared to males in both time periods (2003-2009 and 2010-2020). Females persistently had longer door-to-balloon times, underwent less revascularization with PCI, and received GDMT less often than males in both time periods. From 2003 to 2009, the incidence of cardiogenic shock was higher in females. Despite improvements in the rate of in-hospital mortality in the last decade, the post-discharge to 1-year mortality risk was significantly higher in females compared to males in both time periods. Conclusions: Over the past two decades, gender disparities in STEMI care and outcomes have persisted. Despite an improvement in the rate of in-hospital mortality, sex differences persist with females having a higher risk of discharge to 1-year mortality. This is in part due to persistent discrepancies in baseline comorbidities and patient care, including longer door-to-balloon times and less GDMT at discharge. These findings underscore the need for both regional and national efforts to close this persistent gap.

Abstract 15873: Trends, Predictors, and Cardiovascular Outcomes Among Primary vs Secondary Takotsubo Syndrome - Nationwide Inpatient Sample Analysis

Introduction: Takotsubo Syndrome (TTS), also known as stress-induced cardiomyopathy can be primary/idiopathic or secondary to physical stressor including acute illness. There is limited data on cardiovascular outcomes among primary TTS (pTTS) and secondary (sTTS). Methods: The National Inpatient Sample from the year 2016 to 2019 was queried to assess outcomes in pTTS and sTTS. The primary outcome was all-cause mortality, and secondary outcomes were acute kidney injury (AKI) heart failure (HF), stroke, cardiogenic shock (CS), and sudden cardiac arrest (SCA).We did trend analysis of outcomes, length of stay (LOS) and inflation adjusted hospital charges. The primary analysis used was pearson chi-Square, linear regression, and multivariate matching using STATA 17MP. Results: A total of 158,715 patients (pTTS n= 57,560 (38%); sTTS n= 101,155 (62%)). The cohorts were female predominant. On univariate and chi-square linear regression, we found higher odds and incidence of all-cause mortality, AKI, heart failure, and stroke in sTTS as compared to pTTS. After matching for confounding variables, all-cause mortality (OR 1.3; CI 1.1 - 1.56; p < 0.001), and AKI (OR 1.10; CI 1.03 - 1.03; p < 0.001) was still high in sTTS, but interestingly HF (OR 0.93; CI 0.88 - 0.99 ; p = 0.023), stroke (aOR 0.50; CI 0.43-0.59; p < 0.001), and MCS (aOR 0.61; CI 0.47-0.79; p < 0.001) were lower in sTTS as compared to pTTS. There was no difference in CS and SCA between pTTS and sTTS. Self-pay and prior CABG were most predictive of mortality for sTTS. Yearly trend analysis showed an uptrend for all non-HF outcomes in both pTTS and sTTS, a stable trend for HF, while trends showed higher incidence of CS in sTTS as compared to pTTS. Mean LOS and inflation adjusted hospital charges were higher in sTTS compared to pTTS. Conclusions: sTTS have worse cardiovascular outcomes as compared to pTTS and associated with higher inflation adjusted hospital charges and length of stay likely due to critical underlying primary illness.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection.

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.

Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy

Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS. To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT). This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021. PPCM complicated by CS. The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT. Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001). These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.

Left Ventricular Support for Unprotected Left Main Coronary Artery Interventions (The Dayton Heart and Vascular Impella Registry).

Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function <40% (17% vs. 2%;P < 0.025). In a selected group of patients with LM disease, unsupported PCI appears to be a feasible and safe procedure. In high-risk patients, the use of Impella 2.5 appears to be superior to IABP in LM PCI resulting in favorable short-term outcomes.

Cardiogenic Shock

Abstract: Cardiogenic shock (CS) is the most common cause of death in hospitalized patients with acute myocardial infarction (AMI). The incidence and mortality of CS in hospitals is also high, although advanced therapy is widely used in CS patients. CS is a condition characterized by inadequate cardiac output due to primary cardiovascular diseases, leading to clinical and biochemical manifestations of insufficient tissue perfusion. CS complicates 5–10% of AMI. STEMI increases the risk of CS approximately twice as much as NSTEMI. In the last 10 years, in-hospital mortality due to CS that occurs in AMI has not changed, that is at 40-50%. The pathophysiology of CS shows several overlaps and can occur simultaneously, that is starting with a cardiac insult that reduces cardiac output, central hemodynamic changes, microcirculatory dysfunction, systemic inflammatory response syndrome, and multi-organ dysfunction. CS classification based on SCAI, divided into 5, that’s A(at risk), B(beginning CS), C(classic CS), D(deteriorating), and E(extremis). The key to managing CS is treating the patient as soon as possible, as each higher SCAI shock stage was associated with increased hospital mortality. All patients with suspected ACS-associated CS should have an early invasive strategy with appropriate revascularization. Vasoactive medicines have the potential to improve hemodynamics but at the expense of increased myocardial oxygen consumption and arrhythmogenic risk. Mechanical circulatory support (MCS) has insufficient data as the first-line device solution for CS patients. However, the use of durable MCS devices in a bridge-to-bridge strategy is becoming more prevalent and is supported by clinical recommendations. APACHE-III and SAPS-II, had the best mortality discrimination values to assess the outcome in CS patients.&#x0D; Keywords: cardiogenic shock, classification, heart failure, myocardial infarction, SCAI

Sex-related differences in cardiogenic shock: Can we do better in women?

Key PointsThe overall incidence of cardiogenic shock (CS) increased over time in both men and women, although women had lower incidence of acute myocardial infarction (AMI)‐CS and non‐AMI‐CS across all age groups.A favorable trend of reduction in in‐hospital mortality was seen among all age groups regardless of sex in CS patients, except in young AMI‐CS patients (20–44 years) in whom a notable uptrend was observed.After adjustment using propensity score matching, middle‐aged women (45–64 years) with AMI‐CS had higher in‐hospital mortality compared to their male counterparts, while women with non‐AMI‐CS experienced a higher mortality across all age categories (except among elderly patients ≥85 years).

Age stratified sex-related differences in incidence, management, andoutcomes of cardiogenic shock.

There is a lack of data on age-stratified sex differences in the incidence, treatment, and outcomes of cardiogenic shock (CS). We sought to study these differences from a contemporary database. Patients admitted with CS (2004-2018) were identified from the United States National Inpatient Sample. We compared CS (acute myocardial infarction-related cardiogenic shock [AMI-CS] and non-acute myocardial infarction-related cardiogenic shock [Non-AMI-CS]) incidence, management, and outcomes in males and females, stratified into four age groups (20-44, 45-64, 65-84, and ≥85 years of age). Propensity score matching (PSM) was used for adjustment. A total of 1,506,281 weighted hospitalizations for CS were included (AMI-CS, 39%; Non-AMI-CS, 61%). Across all age groups, females had a lower incidence of CS compared with males. After PSM and among the AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 45-64(28.5% vs. 26.3%) and 65-84 years(39.3% vs. 37.9%) (p < 0.01, for all). Among the Non-AMI-CS cohort, higher mortality among females compared with males was observed in the age groups20-44 (33.5% vs. 30.5%), 45-64(35.1% vs. 31.9%), and 65-84 years(41.7% vs. 40.3%) (p < 0.01, for all). Similar age-dependent differences in the management of CS were also observed between females and males. Females have a lower incidence of CS regardless of age. Significant disparities in the management and outcomes of CS were observed based on sex. However, these disparities varied by age and etiology of CS (AMI-CS vs. Non-AMI-CS) with pronounced disparity among females in the age range of 45-84 years.

Incidence of Cardiogenic Shock Among Acute STEMI Cardiac Patients

Coronary Artery disease is a serious health issue affecting both men and women thus becoming the leading cause of death globally. Aims: To determine the frequency of cardiogenic shock in patients with acute ST elevation myocardial infarction. Study Design: Cross-sectional comparative study. Methodology: All newly diagnosed acute ST elevation MI patients were included. Detailed history followed by detailed clinical examination was done. ECG and urinary output were measured to detect ICS. All this information was recorded on Performa. Statistical analysis: Data was analyzed using SPSS version 25. Cardiogenic shock was stratified among age and gender by applying chi square test. Results: Age as mean ± SD was 60 ± 1.26 years. Males were 68% while females were 32% enrolled in present study. Results showed that only 10% patients had cardiogenic shock while 90% were without it. Conclusion: It was concluded that the frequency of cardiogenic shock was low (10%) in patients with acute ST elevation myocardial infarction. Keywords: Cardiogenic Shock, Myocardial Infarction and Mortality.

Surgical management and outcomes in patients with acute type A aortic dissection and cerebral malperfusion

ObjectiveThe study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion. MethodsFrom 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses. ResultsMedian age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (P = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 (P = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 (P = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 (P = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor. ConclusionsPatients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.

Incidence and clinical predictors of the development of cardiogenic shock after primary angioplasty in patients with ST elevation myocardial infarction

There is a rich literature on ST elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). However, little is known about patients who are initially hemodynamically stable and develop CS after percutaneous coronary intervention (PCI). To determine incidence and evaluate clinical characteristics as well as in-hospital outcomes of patients with STEMI who develop cardiogenic shock after PCI. A total of 352 consecutive patients were retrospectively enrolled in the PAMI registry of the cardiology B department of Fattouma Bourguiba university hospital between January 2000 and March 2017. Patients with hemodynamic instability at presentation prior to PCI were excluded. Out of 352 patients with STEMI, 35 patients (9.9%) develop cardiogenic shock after PCI. These patients were older (age > 65 years; P = 0.021), more often diabetic (68.3% vs. 37.2%; P = 0.002), and had prior stroke/transient ischemic attack (22.2% vs. 10.5%; P = 0.027). Cardiogenic shock after PCI occured more frequently in patients with anterior STEMI ( P = 0.012), door to balloon time > 120 minutes ( P = 0.02), and systolic blood pressure at admission < 120 mmHg ( P < 0.001). On the electrocardiogram, wide QRS at presentation ( P = 0.033), presence of bundle branch block ( P = 0.021) and persistence of ST segment elevation after PCI ( P < 0.001) were associated with higher incidence of CS after PCI. The overall in-hospital mortality of patients with post procedural CS was 64.3% vs. 3.5%, P < 0.001. At multivariate analysis, significant predictors of an increased risk of CS after PCI were: age > 65 years (odd ratio = 1.05;95% CI:0.49-2.33; P = 0.02), systolic blood pressure < 120 mmHg (odd ratio = 3.9,95% CI: 1.95–7.78, P < 0.001) and door to balloon time > 120 minutes (odd ratio =1.07, 95% CI 0.49–2.33; P = 0.02). Cardiogenic shock after PCI in STEMI carries an extremely high mortality. These patients had unfavourable premorbid conditions and poor outcomes.

Abstract 14371: Incidence of Cardiogenic Shock in In-Hospital vs Out of Hospital ST-elevation Myocardial Infarction

Background: Cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction. We aimed to study if the incidence of CS is different in patients who develop in-hospital STEMI compared to patients admitted with out-of-hospital STEMI (Direct STEMI). Methods: All STEMI patients who underwent Percutaneous Coronary Intervention (PCI) at the Cleveland Clinic main campus between January 1, 2011, to July 15, 2019, were included in our study. Patients were classified depending on the location of STEMI into in-hospital or out of hospital (direct STEMI) and the incidence of cardiogenic shock was compared between both the groups. Results: There were a total of 1715 patients who were admitted to our hospital with STEMI from outside (direct STEMI) compared to 132 patients who developed in-hospital STEMI. Baseline characteristics were quite similar except for a higher prevalence of smoking in the direct STEMI group and a higher prevalence of prior PCI and prior heart failure in the in-hospital STEMI group. We found that 25.8% of patients with In-hospital STEMI developed cardiogenic shock whereas only 7.9% of patients with direct STEMI developed cardiogenic shock. Conclusion: Patients with in-hospital STEMI are three times more likely than direct STEMI patients to develop cardiogenic shock. Integration of therapeutic strategies around cardiogenic shock may be important in improving outcomes of this high-risk group of patients with STEMI.

Abstract 11513: Impact of Family History of Coronary Artery Disease on Clinical Outcomes in Takotsubo Cardiomyopathy

Introduction: Family history of coronary artery disease (CAD) is a critical risk factor for CAD, underscoring the contribution of genetic factors to disease pathogenesis and susceptibility. Takotsubo cardiomyopathy (TCM) simulates the clinical features of and frequently coexists with CAD. However, the association between family history of CAD (FHxCAD) and TCM is unclear. Aim: We examined the impact of FHxCAD on in-hospital clinical outcomes of TCM patients. Methods: This retrospective cohort study was conducted using the National Inpatient Sample database [2016-2018]. We identified 4,733 patients admitted to hospital with a primary diagnosis of TCM (ICD-10 coding system); 648 (13.7%) had a FHxCAD. We performed propensity score matching at 1:1 ratio (n=646, matched TCM with FHxCAD; n=646, matched TCM without FHxCAD), and we compared in-hospital outcomes and complications between TCM patients with or without a FHxCAD. Results: In the unmatched cohort, the TCM with FHxCAD group had a reduced incidence of cardiogenic shock, acute kidney injury (AKI) and acute respiratory failure (ARF); lower mortality rates; shorter length of stay (LOS); and decreased total charge compared to the TCM without FHxCAD group (p&lt;0.05). After propensity score matching, the TCM with FHxCAD group, when compared with the TCM without FHxCAD group, also had a lower incidence of cardiogenic shock (2.2% vs. 6.3%, p&lt;0.001; odds ratio [OR] 0.33, 95% confidence interval [CI], 0.18-0.61), AKI (5.1% vs. 8.7%, p=0.016; OR 0.57, 95% CI, 0.36-0.88), and ARF (5.7% vs. 12.7%, p&lt;0.001; OR 0.42, 95% CI, 0.28-0.63); decreased in-hospital mortality (&lt;11 vs. 3.1%, p=0.002; OR 0.2, 95% CI, 0.07-0.57); shorter LOS (2.66 ± 1.96 days vs. 3.40 ± 3.05 days, p&lt;0.001); and a reduced total charge (p=0.001), respectively. The incidence of cardiac arrest and ventricular arrhythmias did not differ significantly based on FHxCAD in the unmatched or matched cohorts. Conclusions: Family history of CAD was associated with favorable clinical outcomes in both unmatched and propensity-matched cohorts of in-hospital TCM patients. Further studies are necessary to identify mechanisms contributing to the association between in-hospital TCM outcomes and FHxCAD.

Abstract 13635: Isolated Right Ventricular Stress Cardiomyopathy: A Systematic Review of Literature

Background: Takotsubo Cardiomyopathy (TTC), also known as stress cardiomyopathy, is characterized by transient systolic and diastolic dysfunction without evidence of significant coronary artery stenosis. In 2012, TTC attributed to about 0.02% of hospitalizations in the United states, largely seen in the elderly female population. Although it primarily affects the left ventricle, there are different variant patterns documented mostly affecting younger individuals. Here we present a systematic review of right ventricle TTC. Methods: On January 7th, 20221, a systematic search without limitation in the time frame was conducted using Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases and a total of 9 cases were identified (1 case was excluded due to duplicity). Results: The mean age of the patients listed was 65.2 ± 23.35 with majority (8/9) 88% of patients being women. Commonest presentation was dyspnea (67%), followed by chest pain (22%), nonspecific discomfort in 11%, and acute heart failure in 11%. Cardiogenic shock was reported in 56% of the cases. Management and treatment included inotropic or vasopressor support in 67% of the cases and 11% requiring venoarterial extracorporeal membrane oxygenation (V-A ECMO). Improvement of right ventricular function was reported in all but 1 patient who died. Conclusion: Isolated right ventricular stress cardiomyopathy is rare but possibly underreported. Though associated with a higher incidence of cardiogenic shock on presentation than traditional stress cardiomyopathy, they do seem to spontaneously recover once out of the acute phase of the syndrome as noted in our study. While the pathogenesis of stress cardiomyopathy is still not fully understood, genetic predispositions may be involved. Current recommendations for management include conventional heart failure medications including beta blockers, ACE inhibitors and diuretics despite limited evidence.

Abstract 11501: Morbid Obesity Eliminates the Obesity Paradox in Patients Hospitalized for Heart Failure

Introduction: For reasons unclear, obesity has been paradoxically associated with reduced mortality in patients hospitalized for heart failure. In this study, we analyze if this paradox extends to patients with morbid obesity. Methods: This was a retrospective cohort study using the 2018 Nationwide Inpatient Sample that included adult patients hospitalized with a primary diagnosis of heart failure. Patients with morbid obesity and non-morbid obesity were compared to those without obesity as a comorbidity. The primary outcome was mortality. Secondary outcomes included length of stay, total charges, and cardiogenic shock. Multivariate regression analysis was used to adjust for age, race, Charlson Comorbidity Index, and other relevant comorbidities with a p-value &lt;0.2 in univariate screen. Statistical analysis was performed using Stata 17.0. Results: A total of 1,248,490 (weighted) heart failure hospitalizations were included. Multivariate regression analysis revealed a trend for increased mortality in the morbidly obese with an odds ratio (OR) 1.10 (p=0.056). It also revealed paradoxically decreased mortality in patients with non-morbid obesity with an OR 0.73 (p=0.000), confirming the presence of the obesity paradox in this population. In the subgroup with reduced ejection fraction, morbid obesity was associated with increased mortality, with an OR 1.68 (p=0.029). Morbid obesity was also associated with increased length of stay and total hospitalization charges, but decreased incidence of cardiogenic shock. Conclusions: Morbid obesity eliminates, and in some cases reverses the obesity paradox in patients hospitalized for heart failure. More research is required to clarify the mechanisms behind this counterintuitive phenomenon.

IMPLEMENTATION OF STANDARDIZED SCREENING OF CARDIOGENIC SHOCK (CS) FOR ALL PATIENTS ADMITTED TO THE CCU AT THE NEW BRUNSWICK HEART CENTRE

BACKGROUND The management of cardiogenic shock (CS) remains challenging and is often associated with a high mortality. In an effort to better manage CS, we implemented a multidisciplinary “Shock Team” approach. As part of this effort, all patients admitted to the coronary care unit (CCU) were screened for CS using the Society for Cardiovascular Angiography and Interventions (SCAI) classification. The aim of the study was to 1) determine the feasibility of CS screening, and, 2) characterize the incidence and severity of CS in our CCU. METHODS AND RESULTS All patients admitted to the CCU at our centre over an 11-month period were included. The SCAI classification was used to categorize patients into “at- risk” (stages A-B) and “CS” groups (stages C- E). Screening for CS was to be performed on every patient every 12hr while in CCU by the patient's nurse. Activation of the Shock Team was made at the discretion of the CCU attending, and consisted of immediate communication between the CCU attending, interventional cardiologist and cardiac surgeon on call. During the initial 11-month period, 85% (1202/1419) of patients admitted to CCU were screened according to the SCAI classifications. Screening failures were not uniform throughout the study period, with a few months showing more screening failures (Figure 1). The majority of patients screened were in the at- risk group (91.8%; A-B), while 8.2% were in the CS group (C = 84 (7%), D = 7 (0.58%) and E = 11 (0.92%)). Patients in the CS group were younger (66 ± 13 vs. 68 ± 12 years; p=0.047), experienced higher in-hospital mortality (24% vs. 3.7%, p< 0.0001), and were more likely to be discharged to another facility rather than home (65% vs 25%; p < 0.001), compared to at risk patients. CONCLUSION Our study demonstrates that standardized screening for CS by nursing is feasible, though ongoing education is required to minimize screening failures. Cardiogenic shock is frequently diagnosed in patients admitted to our CCU and is associated with a high mortality. Further study is required to determine if systematic SCAI classification screening can facilitate early diagnosis of cardiogenic shock, shock team activation, and improve outcomes in this patient population. The management of cardiogenic shock (CS) remains challenging and is often associated with a high mortality. In an effort to better manage CS, we implemented a multidisciplinary “Shock Team” approach. As part of this effort, all patients admitted to the coronary care unit (CCU) were screened for CS using the Society for Cardiovascular Angiography and Interventions (SCAI) classification. The aim of the study was to 1) determine the feasibility of CS screening, and, 2) characterize the incidence and severity of CS in our CCU. All patients admitted to the CCU at our centre over an 11-month period were included. The SCAI classification was used to categorize patients into “at- risk” (stages A-B) and “CS” groups (stages C- E). Screening for CS was to be performed on every patient every 12hr while in CCU by the patient's nurse. Activation of the Shock Team was made at the discretion of the CCU attending, and consisted of immediate communication between the CCU attending, interventional cardiologist and cardiac surgeon on call. During the initial 11-month period, 85% (1202/1419) of patients admitted to CCU were screened according to the SCAI classifications. Screening failures were not uniform throughout the study period, with a few months showing more screening failures (Figure 1). The majority of patients screened were in the at- risk group (91.8%; A-B), while 8.2% were in the CS group (C = 84 (7%), D = 7 (0.58%) and E = 11 (0.92%)). Patients in the CS group were younger (66 ± 13 vs. 68 ± 12 years; p=0.047), experienced higher in-hospital mortality (24% vs. 3.7%, p< 0.0001), and were more likely to be discharged to another facility rather than home (65% vs 25%; p < 0.001), compared to at risk patients. Our study demonstrates that standardized screening for CS by nursing is feasible, though ongoing education is required to minimize screening failures. Cardiogenic shock is frequently diagnosed in patients admitted to our CCU and is associated with a high mortality. Further study is required to determine if systematic SCAI classification screening can facilitate early diagnosis of cardiogenic shock, shock team activation, and improve outcomes in this patient population.

Trends, Predictors and Outcomes of Ischemic Stroke Among Patients Hospitalized with Takotsubo Cardiomyopathy

ObjectivesThis study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic). Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT), cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed. BackgroundIschemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. Limited data are available on the incidence of thrombotic ischemic stroke in TCM. Materials and MethodsWe identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes. ResultsFrom 2008 – 2017, the incidence of thrombotic stroke (4.7%–9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%–0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017. ConclusionAmong patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.

Epidemiology and causes of cardiogenic shock.

Cardiogenic shock is a complex clinical syndrome of end-organ hypoperfusion due to impaired cardiac performance. Although cardiogenic shock has traditionally been viewed as a monolithic disorder predominantly caused by severe left ventricular dysfunction complicating acute myocardial infarction (AMI), there is increasing recognition of the diverse causes of cardiogenic shock and wide spectrum of clinical severity. The purpose of this review is to describe the contemporary epidemiology of cardiogenic shock, including trends in clinical outcomes and recent efforts to refine risk assessment. The incidence of cardiogenic shock among patients with AMI has remained remarkably stable at 3-10%; however, the proportion of cardiogenic shock cases related to AMI has decreased over time to ∼30%, while the proportion of cardiogenic shock cases due to acute decompensated heart failure has steadily increased. Estimated in-hospital mortality from cardiogenic shock in contemporary registries is approximately 30-40%, suggesting modest improvement in cardiogenic shock outcomes over the last decade. There is a wide spectrum of clinical severity among patients presenting with cardiogenic shock, which is described by the Society for Cardiovascular Angiography and Interventions clinical staging criteria. Improved clinical characterization and risk assessment of patients with cardiogenic shock may facilitate more effective clinical investigations of this morbid clinical syndrome.

Outcome and Predictors for Mortality in Patients with Cardiogenic Shock: A Dutch Nationwide Registry-Based Study of 75,407 Patients with Acute Coronary Syndrome Treated by PCI.

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.

Outcome and predictors for mortality in cardiogenic shock: a Dutch nationwide registry-based study of 75,407 patients with acute coronary syndrome treated by PCI

Abstract 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