Mortality In Cardiogenic Shock Patients Research Articles

Abstract 4138252: Association between Pressure-Adjusted Heart Rate and Mortality in Cardiogenic Shock

Introduction: Among patients with cardiogenic shock (CS), high right atrial pressure (RAP) and low mean arterial pressure (MAP) are associated with in-hospital mortality. Pressure-adjusted heart rate (PAHR), defined as heart rate * RAP-to-MAP ratio (HR * [RAP/MAP]), integrates these parameters and has been used to identify cardiovascular dysfunction in critical illness. Higher PAHR values associate with higher surgical ICU mortality, but the prognostic significance of PAHR has not been assessed in cardiac intensive care unit (CICU) patients with CS. Hypothesis: We hypothesized that higher PAHR values are associated with higher risk of in-hospital mortality in patients with CS. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multinational registry of CICUs coordinated by the TIMI Study Group. Among CS admissions (2018-2023) undergoing invasive hemodynamic assessment within 24h of CICU admission, we calculated PAHR (in bpm) and assessed its relationship with in-hospital mortality. Patients on temporary mechanical circulatory support were excluded. Odds ratios were adjusted for age, sex, vasoactive-inotropic score (VIS), SCAI stage, and preceding cardiac arrest. Subgroup analyses stratifying by CS subtype were performed. Results: Among the 1411 CS admissions in the analysis cohort (mean age 61 years, 31% women), 18% had AMI-CS, 75% had HF-CS, and 7% had secondary CS. At the time of assessment (median 1.4h after CICU admission), 75% were on vasoactive support (median VIS 3.8). Median HR was 92 (Q1-Q3 77-109) bpm, RAP 15 (Q1-Q3 10-19) mmHg, MAP 75 (Q1-Q3 67-87) mmHg, and PAHR 17 (Q1-Q3 11-24) bpm. A stepwise gradient of higher in-hospital mortality with increasing PAHR values (p-trend <0.001; Fig ) was observed. In adjusted models, a higher PAHR was associated with higher in-hospital mortality (aOR per 10-bpm, 1.35 [95% CI, 1.15-1.58]), and had stronger prognostic associations with mortality than its individual hemodynamic components (Fig) . Conclusion: Higher PAHR is strongly associated with in-hospital mortality in CS patients. PAHR, a simple parameter which is readily calculable without needing a pulmonary artery catheter, may aid in identifying CS patients at higher risk of death.

Concomitant cardiac arrest on cardiogenic shock patients. Differences in clinical profile and outcomes with non-cardiac arrest patients. The Shock CAT Study

Abstract Background Mortality on cardiogenic shock (CS) remains undesirable, although CS patients with or without concomitant CA may have different prognoses and clinical profile. Purpose The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mid-term mortality in CS patients with and without cardiac arrest on admission in a Mediterranean cohort. Method Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS), in-hospital and 6 months mortality were analysed comparing patients with and without CA at admission. Results A total of 382 CS patients (p) were included: CA 34.8% (n=133 p) and non-CA 65.2% (n=249 p). CA patients were younger than non-CA (61.9 vs 67.4 years, p<0.001) with higher prevalence of men (82% vs 71.8%, p= 0.024). Acute coronary syndrome was the main CS cause (60.7%) and ST elevation myocardial infarction (STEMI) was higher in CA patients than non-CA (55.6% vs 42.6%, p<0.001). In CA group, time to recover of spontaneous circulation was 24 min (IQR: 14-40 min) and hypothermia was performed in 55% of cases. CA patients had less prevalence of cardiovascular risk factors (hypertension, diabetes and dyslipidaemia) and lower pH at admission (7.19 vs 7.31, p<0.001) and higher lactate peak (6.9 vs 5.0, p=0.001) than non-CA patients. MCS was implanted in 35.3% of all CS patients, with lower use in CA patients (23.3% vs 41.8%, p<0.001), mainly due to lower intraaortic balloon pump (19.5% vs 35.5%, p=0.001), without differences in the use of extracorporeal membrane oxygenation (ECMO) (11.4% vs 8.7%, p=0.40) or Impella (10.6% vs 12.8%. p=0.54). Cardshock score was higher in CA patients than non-CA (4.68 vs 4.2, p=0.038), without differences in IABP score (2.31 vs 2.20, p= 0.621) or SCAI D/E (42.1% vs 33.3%, p= 0.090). In-hospital mortality was higher in CA patients (42.9% vs 27.7%, p=0<0.001). Moreover, 6-months mortality remains higher in CA than non-CA patients, although without statistical significance (47.7% vs 38.3%, p=0.079). Conclusions In a Mediterranean CS cohort, concomitant CA patients were younger, with higher prevalence in men with STEMI. MCS had a lower used in CA patients, although without differences in ECMO or Impella. In-hospital mortality was 35% higher in CA patients than non-CA, although 6-months mortality only trend to be higher in CA group.

Inotropes and mortality in patients with cardiogenic shock: an instrumental variable analysis from the SWEDEHEART registry.

The use of inotropic agents in treating cardiogenic shock (CS) remains controversial. This study investigates the effect of inotropes on 30-day mortality in CS patients using data from the SWEDEHEART registry (The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies). Data were sourced from the national SWEDEHEART registry for all CS patients in Sweden from 2000 to 2022. The primary endpoint was 30-day all-cause mortality. We employed multilevel Cox proportional-hazards regression with instrumental variable and inverse probability weighting propensity score to adjust for confounders. The treatment-preference instrument was the quintile of preference for inotrope use at the treating hospital. A total of 16 214 patients (60.5% men, 39.5% women) were included; 23.5% had diabetes, 10.2% had a previous myocardial infarction (MI), and 13.8% had previous heart failure (HF). The median age was 70 years (IQR; 19), with 66.4% over 70. Acute coronary syndrome (ACS) caused CS in 82.9%. Inotropes were administered to 43.8% of patients, while 56.2% did not receive them. There were 7 875 (48.1%) deaths. Patients treated with inotropes were, on average, two years younger and more likely to have ACS, while those not treated had more previous MI and were less likely to undergo PCI. The number of CS cases decreased by 12% per year (Ptrend<0.001), and inotrope use increased by 5% per year (Ptrend<0.001). Unadjusted mortality in CS rose by 2% per calendar year (Ptrend<0.001). Inotropes were associated with higher mortality (adjusted HR 1.72; 95% CI 1.26-2.35; P=0.001), with significant interactions between inotrope treatment, age, and diagnosis (Pinteraction<0.001 and Pinteraction=0.018). In this observational study, inotropes were linked to higher mortality in CS patients, particularly those younger than 70. While CS cases decreased, inotrope use and mortality increased in Sweden.

The glycemic gap as a prognostic indicator in cardiogenic shock: a retrospective cohort study

BackgroundStress-induced hyperglycemia (SIH) is associated with poor outcomes in cardiogenic shock (CS), and there have been inconsistent results among patients with or without diabetes mellitus (DM). The glycemic gap (GG) is derived by subtracting A1c-derived average glucose from blood glucose levels; it is a superior indicator of SIH. We aimed to explore the role of GG in the outcomes of patients with CS.MethodsData on patients diagnosed with CS were extracted from the MIMIC-IV v2.0 database to investigate the relationship between GG and 30-day mortality (Number of absolute GG subjects = 359; Number of relative GG subjects = 357). CS patients from the Second Affiliated Hospital of Wenzhou Medical University were enrolled to explore the correlation between GG and lactic acid (Number of absolute GG subjects = 252; Number of relative GG subjects = 251). Multivariate analysis, propensity score-matched (PSM) analysis, inverse probability treatment weighting (IPTW), and Pearson correlation analysis were applied.ResultsAbsolute GG was associated with 30-day all-cause mortality in CS patients (HRadjusted: 1.779 95% CI: 1.137–2.783; HRPSM: 1.954 95% CI: 1.186–3.220; HRIPTW: 1.634 95% CI: 1.213–2.202). The higher the absolute GG level, the higher the lactic acid level (βadjusted: 1.448 95% CI: 0.474–2.423). A similar trend existed in relative GG (HRadjusted: 1.562 95% CI: 1.003–2.432; HRPSM: 1.790 95% CI: 1.127–2.845; HRIPTW: 1.740 95% CI: 1.287–2.352; βadjusted:1.294 95% CI: 0.369–2.219). Subgroup analysis showed that the relationship existed irrespective of DM. The area under the curve of GG combined with the Glasgow Coma Scale (GCS) for 30-day all-cause mortality was higher than that of GCS (absolute GG: 0.689 vs. 0.637; relative GG: 0.688 vs. 0.633). GG was positively related to the triglyceride-glucose index. Kaplan–Meier curves revealed that groups of higher GG with DM had the worst outcomes. The outcomes differed among races and GG levels (all P < 0.05).ConclusionsAmong patients with CS, absolute and relative GGs were associated with increased 30-day all-cause mortality, regardless of DM. The relationship was stable after multivariate Cox regression analysis, PSM, and IPTW analysis. Furthermore, they reflect the severity of CS to some extent. Hyperlactatemia and insulin resistance may underlie the relationship between stress-induced hyperglycemia and poor outcomes in CS patients. They both improve the predictive efficacy of the GCS.

Association between Albumin-Corrected Anion Gap and Mortality in Patients with Cardiogenic Shock.

Cardiogenic shock (CS) is a critical illness with a high mortality rate in clinical practice. Although some biomarkers have been found to be associated with mortality in patients suffering from CS in previous studies. The albumin-corrected anion gap (ACAG) has not been studied in depth. Our study aimed to explore the relationship between ACAG and mortality in patients with CS. All baseline data was extracted from Medical Information Mart for Intensive Care-IV version: 2.0 (MIMIC-IV). According to the prognosis at 30 days of follow-up, they were divided into survivors and non-survivors groups. The survival curves between the two groups were drawn using the Kaplan-Meier method and the log-rank test. Valid factors were selected using the least absolute shrinkage and selection operator (LASSO) logistic analysis model. Analysis was performed to investigate the relationship between mortality and all enrolled patients using restricted cubic spline (RCS) and Cox proportional hazards models. Receiver operating characteristic (ROC) curves were used to assess the predictive ability of ACAG. Evaluation of final result stability using sensitivity analysis. 839 cases were selected to meet the inclusion criteria and categorized into survivors and non-survivors groups in the final analysis. The ACAG value measured for the first time at the time of admission was selected as the research object. Kaplan-Meier (K-M) survival curves showed that cumulative 30- and 90-day survival decreased progressively with elevated ACAG (p 0.001), and multifactorial Cox regression analyses showed ACAG to be an independent risk factor for increased 30- and 90-day mortality in patients suffering from CS (p 0.05). RCS curves revealed that all-cause mortality in this group of patients increased with increasing ACAG ( 2 = 5.830, p = 0.120). The ROC curve showed that the best cutoff value for ACAG for predicting 30-day mortality in patients with CS was 22.625, with a sensitivity of 44.0% and a specificity of 74.7%. The relationship between ACAG and CS short-term mortality remained stable in all sensitivity analyses (All p 0.05). The ACAG is an independent risk factor for 30- and 90-day mortality in CS patients and predicts poor clinical outcomes in CS patients. According to our study, elevated ACAG at admission, especially when ACAG 20 mmol/L, was an independent predictor of all-cause mortality in CS.

Decoding cardiogenic shock: assessing shock index and its variants as prognostic indicators for in-hospital mortality.

Cardiogenic shock (CS) is associated with high in-hospital mortality. Objective assessment of its severity and prognosis is paramount for timely therapeutic interventions. This study aimed to evaluate the efficacy of the shock index (SI) and its variants as prognostic indicators for in-hospital mortality. A retrospective study involving 1282 CS patients were evaluated. Baseline patient characteristics, clinical trajectory, hospital outcomes, and shock indices were collected and analysed. Receiver operating characteristic (ROC) curves were employed to determine the predictive accuracy of shock indices in predicting in-hospital mortality. Of those evaluated, 866 (67.6%) survived until discharge. Non-survivors were older (66.0±13.7 vs. 57.4±16.2, P<0.001), had a higher incidence of cardiac risk factors, and were more likely to present with acute coronary syndrome (33.4% vs. 16.1%, P<0.001) and out-of-hospital cardiac arrest (11.3% vs. 5.3%, P<0.001). All mean shock indices were significantly higher in non-survivors compared with survivors. ROC curves demonstrated that adjusted shock index (ASI), age-modified shock index (AMSI), and shock index-C (SIC) had the highest predictive accuracy for in-hospital mortality, with AUC values of 0.654, 0.667, and 0.659, respectively. Subgroup analysis revealed that SIC had good predictive ability in patients with STEMI (AUC: 0.714) and ACS (AUC: 0.696) while AMSI and ASI were notably predictive in the OHCA group (AUC: 0.707 and 0.701, respectively). Shock index and its variants, especially ASI, AMSI, and SIC, may be helpful in predicting in-hospital mortality in CS patients. Their application could guide clinicians in upfront risk stratification. SIC, ASI, and AMSI show potential in predicting in-hospital mortality in specific CS subsets (STEMI and OHCA). This is the first study to evaluate SI and its variants in CS patients.

Lactate as a Predictor of 30-Day Mortality in Cardiogenic Shock.

Background/Objectives: This study sought to evaluate the efficacy of various lactate measurements within the first 24 h post-intensive care unit (ICU) admission for predicting 30-day mortality in cardiogenic shock patients. It compared initial lactate levels, 24 h levels, peak levels, and 24 h clearance, alongside the Simplified Acute Physiology Score 3 (SAPS3) score, to enhance early treatment decision-making. Methods: A retrospective analysis of 64 patients assessed the prognostic performance of lactate levels and SAPS3 scores using logistic regression and AUROC calculations. Results: Of the baseline parameters, only the SAPS3 score predicted survival independently. The lactate level after 24 h (LL) was the most accurate predictor of mortality, outperforming initial levels, peak levels, and 24 h-clearance, and showing a significant AUROC. LL greater than 3.1 mmol/L accurately predicted mortality with high specificity and moderate sensitivity. Conclusions: Among lactate measurements for predicting 30-day mortality in cardiogenic shock, the 24 h lactate level was the most effective one, suggesting its superiority for early prognostication over initial or peak levels and lactate clearance.

Vasopressors and inotropes in cardiogenic shock patients: an analysis of the MIMIC-IV database

IntroductionPharmacological support has become the mainstay therapy in patients with cardiogenic shock (CS). Unfortunately, the clinical benefits of such potent drugs remain unclear, therefore, the present study aims to elucidate the safety and efficacy of vasoactive agents in CS patients.MethodsMedical Information Mart for Intensive Care (MIMIC) IV databases were used for this retrospective study. The primary outcome of this study was 30-day all-cause mortality. The subgroup analysis of was the relationship between the combined use of vasopressors and inotropes and 30-day all-cause mortality.ResultsA total of 2,216 patients diagnosed with CS were enrolled in this study. The non-survivors group was more likely to be older, presented with chronic kidney disease, have a lower systolic blood pressure, lower heart rate, and higher respiratory rate (all p &amp;lt; 0.05). In the multivariate Cox regression analysis, only dopamine [HR (95%CI): 1.219 (1.003–1.482)], norepinephrine [HR (95%CI): 2.528 (1.829–3.493)], and milrinone [HR (95%CI): 0.664 (0.512–0.861)] remained an independent predictor for 30-day all-cause mortality. Furthermore, a subgroup analysis was performed and found that no statistically significant difference between no vasopressor/inotrope use and 1 vasopressor/inotrope use (p = 0.107). Meanwhile, a substantial deterioration of cumulative survival was observed when a combination of 2 or more vasopressors/inotropes was used in CS patients in comparison with no vasopressor/inotrope or only 1 vasopressor/inotrope use (all p &amp;lt; 0.05).ConclusionsUsing vasopressors/inotropes agents was associated with a higher risk of 30-day all-cause mortality in CS patients. In addition, only milrinone was associated with a better prognosis among the available vasoactive agents.

The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. This was a retrospective and observational study. The study was conducted at a University hospital. This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.

Characteristics, management, and mid-term prognosis of older adults with cardiogenic shock admitted to intensive care units: Insights from the FRENSHOCK registry

BackgroundThe incidence of heart failure and cardiogenic shock (CS) in older adults is continually increasing due to population aging. To date, prospective data detailing the specific characteristics, management and outcomes of CS in this population are scarce. MethodsFRENSHOCK is a prospective registry including 772 CS patients from 49 centers. We studied 1-month and 1-year mortality among patients over 75-year-old, adjusted for independent predictors of 1-month and 1-year mortalities. ResultsOut of 772 patients included, 236 (30.6%) were 75 years old or more (mean age 81.9 ± 4.7 years, 63.6% male). Compared to patients <75 years old, older adults had a higher prevalence of comorbidities including hypertension, dyslipidemia, chronic kidney disease, and history of heart disease. Older adults were characterized by a lower blood pressure, as well as higher creatinine and lower haemoglobin levels at presentation. Yet, they were less likely to be treated with norepinephrine, epinephrine, invasive ventilation, and renal replacement therapy. They showed a higher 1-month (aHR: 2.5 [1.86–3.35], p < 0.01) and 1-year mortality (aHR: 2.01 [1.58–2.56], p < 0.01). Analysis of both 1-month and 1-year mortality stratified by age quartiles showed a gradual relationship between aging and mortality in CS patients. ConclusionA third of patient with CS in critical care unit are older than 75 years and their risk of death at one month and one year is more than double compared to the younger ones. Further research is essential to identify best therapeutic strategy in this population.NCT02703038

Novel risk score of mortality prediction for critical cardiogenic shock patients

Abstract Background Patients with critical cardiogenic shock have a high mortality rate. However, evidence for a specific scoring system for mortality prediction is obscure. Purpose This study aimed to identify independent predictors to build a reliable scoring system for survival prediction and risk identification in patients with cardiogenic shock. Methods This study enrolled critically ill patients with cardiogenic shock in the intensive care unit (ICU) between January 1, 2010, and December 31, 2021. A total of 1,607 patients were enrolled in this study. A novel scoring system for cardiogenic shock mortality prediction, the Kaohsiung Veterans General Hospital Cardiogenic Shock (KVHCS) score,was developed based on independent predictors. Further validation was performed using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Results The mean age of the patients was 67.6 ± 14 years, with male predominance (76%). Patients in the death subgroup were older (72.4 ± 12.8 vs. 66 ± 14 years, P &amp;lt; 0.001), had higher APACHE II (24.1 ± 9.9 vs. 14.6 ± 8.6, P &amp;lt; 0.001) scores, and had more comorbidities. A five-strata KVHCS score was constructed. Compared to the predictive ability of the APACHE II score (AUC = 0.75, P &amp;lt; 0.001) on ICU mortality, the KVHCS score (AUC = 0.87, P &amp;lt; 0.001) had a more powerful performance. It was also more reliable at predicting 30-day mortality (AUC = 0.81 vs. 0.73). Coronary artery disease (CAD) had the greatest contribution to mortality, whereas diabetes mellitus (DM) was a positive predictor of ICU discharge survival but had a negative impact on long-term outcomes. Conclusions For critical cardiogenic shock patients in the ICU, CAD was the most important factor negatively affecting ICU survival, whereas DM patients had better survival at ICU discharge but worse long-term outcome. The novel KVHCS score had better risk level prediction for mortality in cardiogenic shock patients than the traditional APACHE II score.Figure 3

Platelet Count During Course of Cardiogenic Shock.

The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.

D-Dimer Levels and the Risk of 30-Day All-Cause Mortality in Cardiogenic Shock Stratified by Etiology.

The study investigates the prognostic impact of D-dimer levels in patients with cardiogenic shock (CS). Although D-dimer levels were found to be associated with prognosis in various clinical settings such as heart failure or acute myocardial infarction (AMI), the prognostic role of D-dimer levels in CS patients has not yet been clarified. Consecutive CS patients with and without concomitant AMI were prospectively included from 2019 to 2021. The prognostic impact of D-dimer levels was tested for 30-day all-cause mortality within the entire study cohort and stratified by the presence or absence of AMI. Statistical analyses included C-statistics, Kaplan-Meier, and multivariate Cox regression analyses. One hundred and twenty-three consecutive CS patients were included with an overall all-cause mortality at 30 days of 55%. The median D-dimer level on admission was 8.44 mg/L, whereas D-dimer levels were higher in 30-day non-survivors compared to survivors (median 13.0 vs. 5.2 mg/L; p = 0.011). D-dimer levels above the median were associated with an increased risk of 30-day all-cause mortality compared to patients with lower D-dimer levels (66% vs. 54%, log rank p = 0.050; HR = 1.594; 95% CI 0.979 - 2.594; p = 0.061), especially in patients with non-AMI-related CS (65% vs. 30%, log rank p = 0.010). The prognostic value of D-dimer levels was still demonstrated after multivariate adjustment (HR = 1.024; 95% CI 1.004 - 1.045; p = 0.020). D-dimer measurement may be a reliable biomarker to predict the risk of 30-day mortality in CS patients, especially in patients with non-AMI related CS.

Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock.

This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.

Prognostic Value of the AST/ALT Ratio versus Bilirubin in Patients with Cardiogenic Shock.

This study investigates the prognostic value of the aspartate-to-alanine aminotransferase ratio (i.e., AST/ALT ratio) and bilirubin in patients with cardiogenic shock (CS). Despite ongoing improvements regarding the treatment of CS patients, invasive care unit (ICU) mortality in CS patients remains unacceptably high. Limited data regarding the prognostic value of the AST/ALT ratio and bilirubin in patients suffering from CS is available. The authors hypothesize the measurement of liver enzymes during the course of CS may be an easy and feasible method to assess right-heart dysfunction and prognosis in patients with CS. Consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from the day of disease onset (day 1), days 2, 3, 4 and 8. The prognostic value of the AST/ALT ratio and bilirubin was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses. A total of 157 CS patients were included, with an overall rate of all-cause mortality at 30 days of 51%. The median AST/ALT ratio on day 1 was 1.4, and the median bilirubin was 0.63 mg/dL. No association of the baseline AST/ALT ratio (HR = 1.005; 95% CI 0.649-1.558; p = 0.981) and bilirubin (HR = 1.320; 95% CI 0.834-2.090; p = 0.236) with the risk of 30-day all-cause mortality was found. In contrast, the AST/ALT ratio on day 4 was associated with the risk of 30-day all-cause mortality (HR = 2.826; 95% CI 1.227-6.510; p = 0.015), which was still evident after the multivariable adjustment (HR = 2.830; 95% CI 1.054-7.690; p = 0.039). The AST/ALT ratio during the course of ICU hospitalization from day 4-but not the baseline AST/ALT ratio and bilirubin-was associated with an increased risk of 30-day all-cause mortality in CS patients.

Machine Learning Analysis of Association of Capillary Refill Time With In-Hospital Mortality in Cardiogenic Shock Patients

Machine Learning Analysis of Association of Capillary Refill Time With In-Hospital Mortality in Cardiogenic Shock Patients

Incidence of hypoxic hepatitis in patients with cardiogenic shock and association with mortality.

Shock of any cause leads to end-organ damage due to ischaemia, especially in perfusion-sensitive organs such as the liver. In septic shock, hypoxic hepatitis (S-HH) is defined as the 20-fold increase of the upper normal limit of aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) and is associated with a mortality of up to 60%. However, as pathophysiology, dynamics, and treatment differ between septic and cardiogenic shock (CS), the S-HH definition may not be suitable for CS. Therefore, we aim to evaluate if the S-HH definition is applicable in CS patients. This analysis was based on a registry of all-comer CS patients treated between 2009 and 2019 at a tertiary care centre with exclusion of minors and patients without all necessary ASAT and ALAT values. N = 698. During in-hospital follow-up, 386 (55.3%) patients died. The S-HH was not significantly associated with in-hospital mortality in CS patients. To define HH among patients with CS (C-HH), optimal cut-off values were found to be ≥1.34-fold increase for ASAT and ≥1.51-fold increase for ALAT in serial measurements. The incidence of C-HH was 254/698 patients (36%) and C-HH showed a strong association with in-hospital mortality (odds ratio 2.36, 95% confidence interval: 1.61, 3.49). The C-HH is a frequent and relevant comorbidity in patients with CS, although its definition varies from the established definition of HH in patients with septic shock. As C-HH contributed to excess mortality risk, these findings emphasize the need for further investigation of therapies reducing the occurrence of C-HH and also improving the associated outcome.

Urine output for predicting in-hospital mortality of intensive care patients with cardiogenic shock

BackgroundThe role of urine output (UO) in the first 24 h of admission in the clinical management of cardiogenic shock (CS) patients has not been elucidated. MethodsThis study retrospectively analyzed intensive care CS patients in the MIMIC-IV database. Binomial logistic regression analysis was conducted to evaluate whether UO was an independent risk factor for in-hospital mortality in CS patients. The performance of UO in predicting mortality was evaluated by the receiver operating characteristic (ROC) curve and compared with the Oxford Acute Severity of Illness Score (OASIS). The clinical net benefit of UO in predicting mortality was determined using the decision curve analysis (DCA). Survival analysis was performed with Kaplan-Meier curves. ResultsAfter adjusting for confounding factors including diuretic use and acute kidney injury (AKI), UO remained an independent risk factor for in-hospital mortality in CS patients. The areas under the ROC curves (AUCs) of UO for predicting in-hospital mortality were 0.712 (UO, ml/day) and 0.701 (UO, ml/kg/h), which were comparable to OASIS (AUC = 0.695). In terms of clinical net benefit, UO was comparable to OASIS, with different degrees of benefit at different threshold probabilities. Survival analysis showed that the risk of in-hospital death in the low-UO (≤857 ml/day) group was 3.0143 times that of the high-UO (>857 ml/day) group. ConclusionsUO in the first 24 h of admission is an independent risk factor for in-hospital mortality in intensive care CS patients and has moderate predictive value in predicting in-hospital mortality.

Machine learning prediction of in-hospital mortality and external validation in patients with cardiogenic shock: the RESCUE score

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Despite the introduction of mechanical circulatory support (MCS), short-term mortality rates in cardiogenic shock (CS) remain high. Prior CS risk scores have limited reliability because of selected derivation cohorts or inadequate validation. Purpose The aim of this study is to develop and validate externally the risk prediction model for in-hospital mortality in CS patients using machine learning (ML) algorithms. Methods 1247 patients of all-cause CS from the RESCUE registry (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients with CS) between January 2014 and December 2018 were analyzed. Patients were randomly divided into two groups for training and testing at a ratio of 7 to 3. Risk prediction models were estimated with the logistic regression analysis and four ML algorithms: Least absolute shrinkage and selection operator analysis (LASSO), Support vector machine (SVM), Extreme Gradient Boosting (XGB), and Random Forest classifier. Internal validation with the RESCUE registry and external validation with the single center CS registry including 678 patients were performed. Results All four ML models made an agreement with the seven important variables associated with mortality as follows; age, vasoactive inotropic score, left ventricular ejection fraction, lactic acid, cardiac arrest at presentation, requiring continuous renal replacement therapy, and mechanical ventilator. The logistic regression analysis was performed with the risk factors which were derived by ML models. The logistic regression model named RESCUE score showed the predictive performance with an area under the curve (AUC) of 0.86 [95% CI 0.83-0.88] for in-hospital mortality. External validation showed excellent discrimination with an AUC of 0.80 [95% CI 0.76-0.84]. Decision curve analysis indicated that the nomogram conferred high clinical net benefit. Conclusion The RESCUE score using advanced machine learning techniques has excellent predictive performance for the in-hospital mortality of CS regardless of the underlying cause. This model may be useful as a tool to estimate the risk stratification of CS patients.

The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock.

The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock. Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available. All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses. Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P = 0.019). Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.