Management Of Cardiogenic Shock Research Articles

Science Pulse: Management of cardiogenic shock and trial design - time for a paradigm shift! Insights from the 3CT Meeting.

Science Pulse: Management of cardiogenic shock and trial design - time for a paradigm shift! Insights from the 3CT Meeting.

Management of cardiogenic shock in older adults: A commentary on the 2024 American Heart Association Scientific Statement

Management of cardiogenic shock in older adults: A commentary on the 2024 American Heart Association Scientific Statement

ICU management of cardiogenic shock before mechanical support.

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS). Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock. Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

Understanding the complexity of cardiogenic shock management: the added value of advanced computational modeling.

The purpose of this review is to explain the value of computational physiological modeling for in-depth understanding of the complex derangements of cardiopulmonary pathophysiology during cardiogenic shock, particularly when treated with temporary mechanical circulatory support (tMCS) devices. Computational physiological models have evolved in recent years and can provide a high degree of clinical realism in the simulation of cardiogenic shock and related conservative and interventional therapies. These models feature a large spectrum of practically relevant hemodynamic and respiratory parameters tunable to patient-specific disease states as well as adjustable to medical therapies and support device settings. Current applications work in real-time and can operate on an ordinary computer, laptop or mobile device. The use of computational physiological models is increasingly appreciated for educational purposes as they help to understand the complexity of cardiogenic shock, especially when sophisticated management of tMCS is involved in addition to multimodal critical care support. Practical implementation of computational models as clinical decision support tools at the bedside is at the horizon but awaits rigorous clinical validation.

Impella vs Veno-arterial extracorporeal membrane oxygenation in cardiogenic shock: a systematic review and meta-analysis of propensity score matched studies

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abiomed Singapore PTE. Ltd. Background/Introduction Cardiogenic shock is a life-threatening condition associated with multi-organ failure and death. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is well-established in the management of cardiogenic shock; however, mortality rates have remained relatively consistent over the past two decades. Impella is a transluminal microaxial ventricular assist device that improves haemodynamics by unloading the left ventricle and represents an alternative to VA-ECMO. No randomised controlled trials exist to date comparing Impella versus VA-ECMO given difficulties in recruiting patients due to the acute nature of the condition. Whilst a plethora of non-randomised, comparative studies have been published, many are confounded by underlying differences in baseline disease characteristics. Propensity score matched / adjusted studies may mitigate confounding by accounting for differences in important covariates that impact outcomes. Purpose The objective of this study was to conduct a systematic review and meta-analysis of propensity score matched / adjusted studies to assess the clinical outcomes of Impella versus VA-ECMO in cardiogenic shock patients. Methods A systematic review was undertaken to identify all comparative studies of Impella and VA-ECMO in cardiogenic shock which performed propensity score matching / adjustment of outcomes to account for important covariates. The study limitations were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. In-hospital/30-day survival and bleedings requiring transfusion were meta-analysed using the random effects method. Results Six propensity score matched / adjusted studies comparing Impella versus VA-ECMO in cardiogenic shock were included in the meta-analysis. A statistically significant difference in in-hospital/30-day mortality was detected between patients treated with Impella (39.6%) versus VA-ECMO (53.8%) (odds ratio [OR] 95% confidence interval [95% CI]: 0.57 [0.44, 0.74]; p<0.0001). Similarly, Impella (19.9%) was associated with statistically significantly fewer bleeding events requiring transfusion compared with VA-ECMO (28.8%) (OR=0.61 [0.46, 0.80]; p=0.0004). Conclusion(s) This systematic review identified no randomised controlled trials of Impella versus VA-ECMO. The meta-analysis of propensity matched observational trials, represents the highest level of evidence available to date, and suggests that Impella may be associated with increased survival rates and decreased bleeding. Randomised controlled trials are urgently needed to assess cardiac support modalities in cardiogenic shock.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational multicentric prospective study

Abstract Funding Acknowledgements None. Background Although temporary mechanical circulatory support devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process from VA-ECMO although there are no standardized protocols. Purpose We sought to evaluate the accuracy of echocardiographic indices in predicting successful weaning from VA-ECMO in CS patients. We tested total isovolumic time (tIVT), an index of ventricular performance(1,2), and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; E/e’ at mitral valve; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Multicentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Waning trials were performed daily starting from 48 hours after VA-ECMO institution. A stepwise decrease of VA-ECMO blood flow was applied, until reaching 1 or 1.5 L/min. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died in hospital for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (Figure 1-A): stroke volume (SV) >13.2 ml (HR 4.12 [1.71-9.95], p 0.002), tIVT >23.6 min/sec (HR 0.14 [0.02-1.03], p 0.053), LV VTI >6.6 cm (HR 4.99 [1.94-12.87], p<0.001), MAPSE >6.15 mm (HR 4.42 [1.90-10.24], p 0.001), TAPSE >11 mm (HR 10.13 [1.37-7.02], p 0.023), RV S’ >7 cm (HR 5.40 [1.45-20.12], p 0.012). LVEF, E/e’ and S’ at mitral valve did not reach the statistical significance. Figure 1-B shows Kaplan-Meier analysis on echocardiographic indices collected during the last weaning trial; figure 2 details HR of all these parameters. Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Parameters reflecting ventricular activation and systo-diastolic interaction already demonstrated superiority in defining ventricular performance. Considering the known limitations of LVEF (HR, loading and LV dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation in the acute setting.

Respiratory support modalities in cardiogenic shock: insights from a prospective multicenter registry

Abstract Funding Acknowledgements None. Background Respiratory support is a vital component of the comprehensive management of cardiogenic shock (CS). However, there is a lack of data comparing the application of different respiratory support modalities in CS patients. Purpose Aim of this study was to examine the use of low-flow oxygen (LFO), non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV) in a cohort of CS patients and assess their effects on 60-day mortality. Methods We analyzed a cohort of CS patients enrolled in a multicenter prospective registry from twelve cardiac intensive care units from March 2020 to August 2022. Patients were categorized according to the maximum intensity of respiratory support during intensive care unit stay into three groups: LFO, NIV, and IMV. Clinical characteristics and mortality were compared between groups. Results A total of 375 patients were included in our analysis. The median age of the population was 65 years, with 77% being males. During their ICU stay, 139 patients (37%) received LFO, 61 (16%) were treated with NIV, and 175 (47%) underwent IMV. Patients treated with IMV presented more frequently with cardiac arrest (41% vs 8% in the LFO group and 5% in the NIV group, p = 0.00). Patients treated with LFO and NIV had a higher prevalence of CS related to acute decompensated heart failure (40% and 57% vs 21% in the IMV group, p = 0.00); moreover, they presented with less severe respiratory distress, milder tissue hypoperfusion, and better SCAI class upon admission. At sixty days follow-up 128 patients (34%) died: 41% in the IMV group, 28% in the LFO group and 26% in the NIV group (p = 0.02). Multivariate analysis revealed that NIV was independently associated with improved survival (OR 0.47, 95% CI 0.22-0.99, p = 0.05), while age, lactate levels, and glomerular filtration rate were predictors of mortality. A tendency towards improved survival with NIV was observed even after excluding patients with cardiac arrest. Conclusions Compared to previous registries, our study highlights a significant shift in the management of CS, marked by a growing preference for NIV. Notably, this approach, when employed in well-selected patients in the early stages of CS, correlates with lower mortality rates. These findings underscore the significance of personalized treatment strategies for CS patients, considering their clinical presentation, the degree of respiratory distress, and tissue perfusion.60-day survival curvesMultivariate regression analysis

Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock.

Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center.

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Frailty and In-Hospital Outcomes for Management of Cardiogenic Shock without Acute Myocardial Infarction.

(1) Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Frailty and cardiovascular diseases are intertwined, commonly sharing risk factors and exhibiting bidirectional relationships. The relationship of frailty and non-acute myocardial infarction with cardiogenic shock (non-AMI-CS) is poorly described. (2) Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for non-AMI-CS. We classified them into frail and non-frail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. (3) Results: A total of 503,780 hospitalizations for non-AMI-CS were identified. Most hospitalizations involved frail adults (80.0%). Those with frailty had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 2.03-2.20, p < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, such as acute kidney injury, delirium, and longer length of stay. Importantly, non-AMI-CS hospitalizations in the frail group had lower use of mechanical circulatory support but not rates of cardiac transplantation. (4) Conclusions: Frailty is highly prevalent among non-AMI-CS hospitalizations. Those accompanied by frailty are often associated with increased rates of morbidity and mortality compared to those without frailty.

Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association.

Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.

Optimal Heart Failure Medical Therapy and Mortality in Survivors of Cardiogenic Shock: Insights From the FRENSHOCK Registry.

The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline-directed heart failure (HF) medical therapy (GDMT) and one-year survival rate in patients who are post-CS. FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in-hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one-year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one-year all-cause mortality compared with non-triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19-0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one-year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001). In survivors of CS, the one-year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors.

Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity. Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock, although its contribution has declined over the past two decades, compared with other causes. Despite some advances in cardiogenic shock management, this clinical syndrome is still burdened by an extremely high mortality. Its management is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished. With these aims, medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role. The purpose of this article is to review current evidence on the use of these medications in patients with cardiogenic shock and discuss specific clinical settings with indications to their use.

Modelling and Simulation of the Combined Use of IABP and Impella as a Rescue Procedure in Cardiogenic Shock: An Alternative for Non-Transplant Centres?

The treatment of critically ill patients remains an evolving and controversial issue. Mechanical circulatory support through a percutaneous approach for the management of cardiogenic shock has taken place in recent years. The combined use of IABP and the Impella 2.5 device may have a role to play for this group of patients. A simulation approach may help with a quantitative assessment of the achievable degree of assistance. In this paper, we analyse the interaction between the Impella 2.5 pump applied as the LVAD and IABP using the numerical simulator of the cardiovascular system developed in our laboratory. Starting with pathological conditions reproduced using research data, the simulations were performed by setting different rotational speeds for the LVAD and driving the IABP in full mode (1:1) or partial mode (1:2, 1:3 and 1:4). The effects induced by drug administration during the assistance were also simulated. The haemodynamic parameters under investigation were aa follows: mean aortic pressure, systolic and diastolic aortic pressure, mean pulmonary arterial pressure, mean left and right atrial pressure, cardiac output, cardiac index, left and right ventricular end-systolic volume, left ventricular end-diastolic volume and mean coronary blood flow. The energetic variables considered in this study were as follows: left and right ventricular external work and left and right atrial pressure-volume area. The outcome of our simulations shows that the combined use of IABP and Impella 2.5 achieves adequate support in the acute phase of cardiogenic shock compared to each standalone device. This would allow further stabilisation and transfer to a transplant centre should the escalation of treatment be required.

Vasoactive medication requirements in the first 24 hours of cardiogenic shock: association with mortality and mechanical circulatory support

Abstract Background Vasoactive medications and Mechanical Circulatory Support (MCS) are both central to the contemporary management of cardiogenic shock (CS). There are limited data on the interaction between vasoactive medication dosing and MCS in patients with CS. Purpose We investigated the association between in-hospital mortality and vasoactive medication dosing among patients with CS who did and did not receive MCS during hospitalization. Methods We included patients with CS admitted to our cardiac intensive care unit (CICU) between 2007 and 2015. The peak combined vasoactive medication dose during the first 24 hours of CICU admission was recorded and converted to norepinephrine equivalents (NEE)(references 1 &amp; 2). The primary outcome was in-hospital mortality. Multivariable logistic regression was used to adjust for relevant variables and calculate adjusted odds ratios (OR). Results Of 1078 patients with CS (median age 69.0 years [Interquartile Range 59.1-77.3], 36.8% female, 59% with acute myocardial infarction), 721 (66.9%) received vasoactive medications in the first 24 hours and 510 (47.3%) received MCS (87% intra-aortic balloon pump). Among those receiving vasoactive medications during the first 24 hours, the median NEE was 0.16 (Interquartile Range 0.06-0.40) mcg/kg/min. In hospital mortality was 34.4% overall, and was lower among those who received MCS (26.1% versus 41.9%, p&amp;lt;0.001; adjusted OR 0.71 95% CI 0.50-0.99) and higher among those who received vasoactive medications (38.1% versus 26.9%, p&amp;lt;0.001). A gradient of mortality was observed according to the use of vasoactive medications and MCS (Fig. 1). We found a strong incremental association between in-hospital mortality and NEE (adjusted OR 1.11 per 0.1 mcg/kg/min, 95% CI 1.06–1.16, P&amp;lt;0.001; Fig. 2). Mortality was lower across the spectrum of NEE for patients who received MCS (Fig. 2). There was no statistically significant difference in the slope of the relationship between in-hospital mortality and NEE in patients who did and did not receive MCS (p = 0.86). Conclusion Increasing vasoactive medication requirement during the first 24 hours of CICU admission is incrementally associated with in-hospital mortality in CS, representing a simplified marker of shock severity. Patients who received MCS were at lower risk of mortality across the spectrum of vasopressor requirements, emphasizing the potential synergy between these two complementary approaches to hemodynamic support.Figure 1Figure 2

Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock

Introduction and objectivesCardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV). MethodsRetrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis. ResultsThree hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09–2.63) and 1 year mortality (OR 1.61, 95% CI 1.04–2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage. ConclusionsNIV seems to be relatively effective and safe in the treatment of early-stage CS.

Abstract 16479: The Effects of Pulmonary Artery Catheter Usage and Treatment Intensity on Mortality in Patients With Cardiogenic Shock by Etiology

Background: The routine usage of pulmonary artery catheter (PAC) in the management of cardiogenic shock (CS) by etiology remains controversial. Objectives: We sought to study the prognostic effects of PAC usage and the escalation of care in a large CS cohort. Methods: Multicenter, retrospective, observational study from the Cardiogenic Shock Working Group registry (CSWG) registry. The baseline characteristics, hospital course, and outcome of patients (pts) with acute decompensated heart failure-CS (ADHF) and acute myocardial infarction-CS (AMI) who had PAC during hospitalization were obtained. Different types of interventions were analyzed and compared between survival and non-survival by etiology. Results: The registry had 3524 pts (58% ADHF, 28% AMI). The overall mortality rate was significantly higher in the AMI group (41 vs 29%, p &lt;0.0001). There was no difference in PAC usage (68 vs 62%). In ADHF, the mortality was significantly lower when PAC was used (22 vs 35%, P&lt;0.0001). However, in AMI, there was no significant mortality difference with PAC usage (40 vs 46%, P=0.052).Pts who had PAC (n=2260, 71% male, 2/3 ADHF) were then analyzed. ADHF had longer duration of PAC (6.3 vs 4.7 days). ADHF pts had more comorbidities (CKD, DM, AF) and better admission and max SCAI stage. However, AMI pts were older (60±14 vs 66±12 year p&lt;0001), more HTN and higher transfer rate. During hospitalization, the effect of treatment intensity with mechanical circulatory support (MCS) and drugs usage on mortality is summarized in fig.1 (a,b). Conclusions: In a large CS registry, we identified that ADHF is more common with much better prognosis than AMI despite similar PAC and drugs usage, and less MCS usage. This can be explained by the difference in baseline characteristic and the shock severity. PAC usage did correlate with better survival only in ADHF group. Multiple MCS and multiple drugs usage were associated with higher mortality in both groups. IABP, when used alone, had better survival.

Abstract 11954: Predictors of Adverse Outcome in STEMI Patients Post-PCI With Cardiogenic Shock Requiring Intra-Aortic Balloon Pump Support

Introduction: Cardiogenic shock is a serious complication of ST-segment elevation myocardial infarction (STEMI), however clinical and demographic factors may further impact outcomes. This study investigated how age, gender, income, comorbidities, and arrhythmias affect mortality of STEMI patients receiving intra-aortic balloon pumps (IABP) for management of cardiogenic shock. Methods: This retrospective study used the National Inpatient Sample (NIS) database from 2016 to 2020. We identified STEMI admissions as the principal diagnosis and cardiogenic shock as the secondary diagnosis. Patients who received IABP support were included using the ICD-10 Procedure Coding System (PCS) code 5A02210. Logistic linear regression was used to analyze the data while adjusting for confounding variables such as age, sex, and comorbidities. Results: Of the 24,915 admissions with STEMI requiring IABP post PCI, the average age was 65, 29.5% were female, 28.8% died and 51.7% patients had congestive heart failure. The highest mortality rate was associated with liver disease, followed by left bundle branch block, age over 65, ventricular fibrillation, renal failure, female gender, peripheral vascular disease (PVD), and ventricular tachycardia (table 1). Income in the bottom 25 th percentile also had increased mortality. Conclusion: This study identified several predictors of adverse outcomes in post-PCI STEMI patients with cardiogenic shock requiring IABP support, including ventricular fibrillation, ventricular tachycardia, left bundle branch block, peripheral vascular disease, renal failure, liver disease, age 65 or older, female, and low income. These findings may aid in the management of STEMI patients with cardiogenic shock by allowing healthcare providers to identify patients at high risk for adverse outcomes and tailor their treatment accordingly.

Defining levels of care in cardiogenic shock.

Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.

Impact of day of admission on in-hospital outcomes of cardiogenic shock

BackgroundThe management of cardiogenic shock (CS) requires attentiveness to details and in some cases, invasive interventions. In the past, studies have shown relationships between the day of admission and cardiovascular outcomes. We aim to analyze the trends and in-hospital outcomes of patients admitted with CS over the weekends compared to weekdays. MethodWe identified all patients with CS from the National Inpatient Sample (NIS) database between 2016 and 2020. Using multivariate logistic regression analysis, baseline demographics and in-hospital outcomes were obtained and compared by weekend or weekday admission. ResultsOut of 854,684 CS admissions, 199,255 (23.6%) occurred on weekends. Patients admitted over the weekend had worse outcomes, including higher rates of mortality (aOR 1.09 CI 1.05 – 1.11, p<0.001), cardiac arrest (aOR 1.09 CI 1.04 -1.14, p<0.001), and respiratory failure. We also noted higher percutaneous coronary intervention (PCI) rates (aOR 1.2 CI 1.16 – 1.25, p<0.001) but lower rates of pulmonary artery catheterization (PAC) and post-procedure pneumothorax. Weekend admissions had shorter hospital lengths of stay, and they incurred lower charges ($223,222 vs. $247,908).Between 2016 and 2020, we observed a consistent downward trend in the mortality rates of the weekend and weekday CS admissions, with consistently higher weekend than weekday admissions. ConclusionWeekend admissions for CS are associated with worse outcomes, which have persisted for years. This now begs the question of whether physician dissatisfaction, understaffing, or burn-out are responsible for this finding.