Mortality In Cardiogenic Shock Research Articles

Predictive models for mortality in cardiogenic shock: a systematic review and meta-analysis

Abstract Background Cardiogenic shock (CS) is a time-critical emergency with high mortality and morbidity, yet prognostication remains challenging with neither guidelines nor consensus on the comparative applicability of existing risk scores used in CS. We aimed to evaluate discrimination and calibration of existing risk scores in predicting mortality in CS. Methods We searched MEDLINE, Embase, and Scopus databases up to 1 January 2024 for articles developing, redeveloping or validating a multivariable model predicting short-term mortality in adults with CS. Area under curve (AUC) statistics and observed versus expected (O:E) ratios were used to assess discrimination and calibration respectively. We conducted random-effects inverse-variance weighted meta-analyses on 6 prevalent, well-validated prediction models (IABP-SHOCK II, CardShock, SAPS II, SOFA, APACHE II and SAVE) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity. Results We included 92 studies (115 study cohorts, 75,228 patients) in our analysis, with 43 unique prediction models identified. Our meta-analysis revealed that the CS-specific CardShock score had the overall best discrimination (AUC 0.73; 95% CI 0.70-0.76) and calibration (O:E 1.06; 95% CI 0.79-1.41). SOFA performed second best in discrimination (AUC: 0.72, 95%-CI: 0.68 to 0.75) but tended to underpredict mortality (AUC: 0.85, 95%-CI: 0.65-1.12). IABP and APACHE had comparable discrimination (AUC 0.71), IABP tended to overpredict (O:E 1.24; 95% CI 0.995-1.55) while APACHE (O:E 0.93; 95% CI 0.57-1.53) tended to underpredict mortality. In subgroup analysis, CardShock performed best based on mechanical circulatory support type (AUC 0.74-0.76, O:E 0.82-0.99), location (AUC 0.67-0.87, O:E 1.00-1.25) and study type (AUC 0.73-0.97, O:E 0.91-1.99). Conclusion Among well-validated risk scores, the CardShock score performed best in discriminating and calibrating mortality. Its variable performance across subgroups underscores the need for more research to identify an ideal risk prediction model that considers emerging therapies and use in multiple scenarios.

A practical nomogram and risk stratification system for predicting in-hospital mortality of patients with non-acute myocardial infarction related cardiogenic shock

Abstract Background The morbidity and mortality of Cardiogenic Shock(CS) remain high despite the advance in management these years1.As acute myocardial infarction (AMI) is considered to be the most common reason for cardiogenic shock,Non-AMI related CS is excluded from the majority of CS studies and remains largely understudied2. Considering its inherent complexity and hemodynamically multiplicity, it is needed to focusing on these patients to identify specific risk factors, which may be conducive to the promotion of critically CS patients with early decision and timely intervention. Purpose In this study,we sought to investigate the variables which are predictive of in hospital mortality in non AMI related CS patients, developed and validated a practical nomogram for risk quantification. Methods 1298 patients and 548 patients with cardiogenic shock from the MIMIC-IV (version 1.0) and MIMIC-III(version1.4) databaes were included in the study after excluding acute myocardial infarction. We used in-hospital death and 30 day survival as the end points. Lasson and logistic regression analysis were used to identify statistically significant predictors which were finally involved in the nomogram. The predictive performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration after comparing with commonly used ICU scores for in-hospital death.Lastly, we plotted Kaplan-Meier curves of three subgroup classified by the identified cutoff values of the nomogram to further assess the discriminative ability of the prognosis. Results The in-hospital mortality of patients with non-AMI related CS is about 36.6%.After the analysis of regression, age, heart rate, wbc, albumin, lactic acid, GCS score, urine volume, using vasopressor were identified as the most critical factors for the in-hospital death. Based on the these results, a nomogram for predicting in-hospital death was established.The calibration plot also shows good consistency between nomogram prediction and actual in-hospital mortality.In addition, compared with other scores, the AUC value of nomogram was 0.806 (95% CI = 0.799-0.831) in the training queue, 0.814 (95% CI = 0.771-0.852) in the internal validation queue and 0.730 (95% CI = 0.690-0.767) in the external validation set, which was significantly higher than other commonly used ICU scoring systems(SAPSII, APSIII and SOFA).Also, three risk subgroups were created using two boundary points (303 and 339) of the nomogram score and the survival curve shows that there were significant differences in the 30 day survival of each subgroup. Conclusion A prognostic nomogram and risk stratification system of non-AMI related CS were established and verified, which can provide a practical tool for individualized clinical management of patients.Workflow of the study.Nomogram for non-AMI related CS patients

Incidence and predictors of weaning failure from veno-arterial extracorporeal membrane oxygenation therapy in patients with cardiogenic shock

Abstract Background Mortality in cardiogenic shock (CS) remains high even when mechanical circulatory support (MCS) restores adequate circulation. Despite extensive research efforts in recent years, evidence on MCS in this setting is so far neutral. Especially, weaning from MCS is a challenging aspect of daily MCS management and standardized guidance is not yet available. Purpose This study aims to investigate incidence and predictors of weaning failure from venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with CS. Methods Patients with CS treated with VA-ECMO at 23 tertiary-care centres in 7 countries were analysed. Weaning failure was defined as death during VA-ECMO support and death within two days after VA-ECMO explantation. To evaluate whether patient or treatment specific characteristics could serve as predictors for weaning success or failure multivariable logistic regressions models were fitted. Results A total of 685 patients with CS treated with VA-ECMO were included in this study. Median age was 57 (49-66) years and 542 (77.1%) were male. More than half of the patients presented with CS due to acute myocardial infarction (AMI) (n=438, 63.9%) and prior cardiac arrest (n=431, 62.9%). Median lactate upon admission was 7.6 mmol/l (4.1-12.7). Of these, 410 patients (59.9%) were successfully weaned from VA-ECMO, whereas in 275 patients (40.1%) weaning failed. Of the successfully weaned patients 162 (39.5%) died before hospital discharge. The mortality of the overall cohort was 63.8%. AMI was slightly less common in patients with failed weaning. Age (Odds ratio (OR) 1.04, 95% confidence interval (CI): 1.02, 1.06; p<0.001) and cardiac arrest before VA-ECMO implantation (OR 1.68, 95%-CI: 1.09, 2.6; p=0.019) where the only baseline parameters associated with weaning failure. Lactate clearance within 24h after VA-ECMO initiation was associated with successful weaning (OR 0.13, 95%-CI: 0.07, 0.26; p<0.001, Figure 1). Conclusion VA-ECMO weaning is common and fails in 40% of patients in whom it is attempted. 60% of patients are discharged alive after a successful VA-ECMO weaning attempt. Older age, cardiac arrest, and slow clearing of lactate are predictors of failed ECMO weaning. These data illustrate the complex factors contributing to successful mechanical circulatory support.Figure 1

Sex-specific prediction of cardiogenic shock complicating acute coronary syndromes: the SEX-SHOCK score

Abstract Background Mortality of cardiogenic shock (CS) complicating acute coronary syndromes (ACS) remained nearly unchanged over the last two decades. Female CS patients are less likely to receive guideline recommended care, while having worse in-hospital outcomes as compared to males.1 Presently available tools to assess the risk of developing CS in the setting of ACS, such as the ORBI risk score, were developed in predominantly male patient populations, while not considering inflammatory mediators or proxies of cardiorenal function. Purpose The present study aimed (i) to test the sex-specific performance of the ORBI model to predict in-hospital CS in patients presenting with ACS, and (ii) to develop and externally validate a better performing risk prediction model for both, women and men. Methods Among 44’220 ACS patients recruited in the Swiss AMIS-Plus study, the sex-specific performance of the ORBI risk score to estimate the probability for the development of CS was tested. By harnessing regression- and machine-learning based modelling approaches (ie, random forest [RF], multiple layer perceptron [MLR], and logistic regression [LR]), independent predictors of in-hospital CS were identified in sex-disaggregated data. Best performing models and variables were then used to develop SEX-SHOCK, a novel risk prediction model that accounts for sex-specific disease characteristics. External validation was done in 4’787 ACS patients recruited in the SPUM-ACS study. Results The ORBI risk prediction model demonstrated lower discriminatory performance in female patients relative to males (AUC [95%CI]: 0.76 (0.74-0.78) vs. 0.81(0.80-0.83); p<0.001). RF, MLR, and LR identified C-reactive protein, creatinine, left-ventricular function, and ST-segment elevation as most potent predictors of in-hospital CS beyond the parameters included in ORBI, with the performance of LR-based models superseding those of RF and MLR. By combining most important predictors with best performing models, the SEX-SHOCK score was developed, showing superior performance as compared to ORBI in both females (AUC 0.80, 95%CI 0.78-0.82; p<0.01) and males ACS patients (AUC 0.83, 0.82-0.85; p<0.001), which prevailed upon 10-fold cross validation. Following external validation in SPUM-ACS, SEX-SHOCK showed improved discriminatory performance over ORBI in both females (0.84, 95% CI 0.78-0.89; p<0.05) and males (0.81, 95% CI 0.78-0.85; p<0.01), with the most pronounced improvement observed in female patients (△C-statistics%=6.23 vs. 2.79%; p <0.001). Conclusion Our study highlights important sex differences in the performance of available tools for risk prediction of developing in-hospital CS among patients presenting with ACS. By harnessing regression- and machine-learning-based approaches, the SEX-SHOCK risk score was developed, outperforming existing risk prediction models in internal and external validation cohorts.

Prognostic Factors Associated with Mortality in Cardiogenic Shock - A Systematic Review and Meta-Analysis.

Cardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock. We performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock. We identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality. This analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Predictors of short-term mortality in cardiogenic shock: insights from an Egyptian multicenter registry

BackgroundCardiogenic shock (CS) remains a major cause of morbidity and mortality, particularly in developing countries where there are limited resources and a lack of data on CS outcomes. This study aimed to investigate 30-day all-cause mortality in Egyptian patients with CS at tertiary referral centers.ResultsThis prospective, observational multicenter registry analyzed 16,681 patients from six cardiac centers, to evaluate the incidence, causes and predictors of CS-related mortality. Among the 529 diagnosed CS patients, 68.2% had an ischemic etiology. No discernable variations were observed in clinical or laboratory features, as well as mortality rates, between ischemic and non-ischemic CS patients. Within 30 days, 210 deaths (39.7%) occurred. Non-survivors with ischemic CS had a higher prevalence of diabetes, worsening renal function, and were more likely to receive multiple inotropes. Mortality did not significantly differ between acute coronary syndrome patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (42.7% vs. 43.7%, p < 0.887). However, anterior STEMI patients had significantly higher mortality than those with inferior STEMI (49.5% vs. 21.6%, p < 0.003). Multivariate regression analysis identified predictors of mortality in CS, including the median hospital stay duration, leucocyte count, alanine transaminase levels, highest creatinine levels, resuscitated cardiac arrest, and use of norepinephrine, epinephrine, and dopamine.ConclusionIn an Egyptian cohort, CS incidence was 3.17%, with no mortality difference based on the underlying etiology. Independent predictors of 30-day all-cause mortality included worsening renal function, leucocyte count, resuscitated cardiac arrest, and use of multiple inotropes/vasopressors.Graphical abstract

Venoarterial extracorporeal membrane oxygenation: from evidence to clinical practice

Mortality for cardiogenic shock is still high despite optimal pharmacological therapy. Therefore, active mechanical circulatory support devices are increasingly used; venoarterial extracorporeal membrane oxygenation (VA-ECMO) enables full circulatory and respiratory support. However, recent data show that in patients with infarct-related shock unselected early use of VA-ECMO does not improve survival and is associated with major bleeding and peripheral ischemic complications. Nowadays, waiting for the results of definitive randomized controlled trials, the main indication for ECMO utilization is in selected patients with cardiac arrest, in those with shock for advanced heart failure refractory to conventional therapy, in those with fulminant myocarditis, in patients candidate for heart transplant or ventricular assistance, especially in presence of respiratory insufficiency and severe biventricular dysfunction. An important recommendation is its utilization in specialized, high-volume centers in the setting of hub and spoke hospitals.

Gender-based differences in clinical profile, management and mortality in cardiogenic shock. Prognostic accuracy of CardShock vs IABP Score, the Shock-CAT study

Abstract Funding Acknowledgements None. Background Mortality in cardiogenic shock (CS) remains very high. Gender could influence in aetiology, management, outcomes and risk stratification predictors. Purpose The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mortality risk in CS patients depending on sex and compare the prognostic accuracy of CardShock and IABP scores between sexes 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 Spain, including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS) were analysed comparing women and men. Cardshock and IABP score have been compared to assess 90-days mortality risk between sexes. Results A total of 382 CS patients (p) were included: women 24.9% (n=95 p) and men 75.1% (n=287p). Women were older than men (68.9 vs 64.1 years, P=0.004). CS due to acute coronary syndrome (ACS) was more frequent in men (66.6% vs 43.2%), and myocarditis (1.7 vs 6.3%), stress cardiomyopathy (0.3% vs 8.4%) and severe aortic stenosis (2.4% vs 6.3%) were more prevalent in women, all p&amp;lt;0.001. Cardiac arrest was more prevalent in men than women (38.4% vs 25.3%, p=0.020). MCS was implanted in 35.3% of patients, without gender differences (men 36.6%, women 31.6%, p=0.376). Even though there was a non-significant trend to lower use in women of IABP (31.1% vs 26.5%), Impella (13.5% vs 7.4%) or ECMO (10.4% vs 7.4%). Risk scores were similar between sexes: Cardshock (men:4.32 vs 4.40 women, p=0.674) and IABP score (men: 2.31 vs 2.04 women, p=0.190). There were no differences between men and women in in-hospital mortality (32.4% vs 34.7%, p=0.675) or 6-months mortality (41.5% vs 40%, p=0.989). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score in men (area under the curve -AUC- 0.72 vs 0.64) respectively, p=0.009, although both scores were similar in women (AUC 0.70 vs 0.72, p=0.635), Figures 1-2. Conclusions Women with CS were older than men and had less ACS and cardiac arrest at admission. There is a non-significant lower use of mechanical assistance devices in women, although in-hospital or 6-months mortality were similar in both sexes. IABP score provided better 90-days mortality risk prediction than CardShock score in men, but both scores were similar in women with cardiogenic shock.Men ROC Curves 90-days MortalityWomen ROC Curves 90-days Mortality

An association between early rescue left heart unloading during VA-ECMO treatment and prognosis of cardiogenic shock; the post-hoc study of the EARLY-UNLOAD trial

Abstract Funding Acknowledgements None. Background/introduction Recently published studies showed prophylactic left heart unloading does not improve mortality in cardiogenic shock (CS) treated with venoatrial extracorporeal membrane oxygenation (VA-ECMO). However, significant proportion of patients on VA-ECMO treatment for CS require early rescue left heart unloading. Purpose To compare characteristics and prognosis according to rescue-unloading timing in patients with CS treated with VA-ECMO. Methods This study is a post-hoc analysis of the EARLY-UNLOAD trial (NCT04775472), the trial evaluated an impact of an early prophylactic unloading strategy using left atrial cannulation (LAC) within 12 hours from the initiation of VA-ECMO treatment. This analysis was performed per-protocol basis for patients without violation (N = 108). Patients were classified into four groups according to timing of left heart unloading: prophylactic (&amp;lt;12h, N = 53), early rescue (&amp;lt;30h, N = 16), late rescue (&amp;gt;30h, N= 10), and no unloading (N = 29). The primary endpoint was in-hospital mortality, and secondary endpoint was 30-day all-cause death. Logistic regression was used to search factors related to the primary endpoint. Results Among patients in the conservative strategy arm, rescue unloading was performed in 47% of patients, and 29% of patients received left heart unloading within 30 hours. Median time from ECMO pump on to rescue unloading was 23 hours. Compared to other groups, the early rescue group had the highest initial arterial lactate level (6.2 vs 11.4 vs 4.3 vs 6.3 mmol/L, prophylactic, early rescue, late rescue, and no unloading, respectively, P = 0.011) and SAPS2 score at baseline (52.7 vs 68.2 vs 50.6 vs 55.7, P = 0.017). Inotropes requirement on day 1 was also highest in the group (vasoactive-inotropic score, 12.4 vs 31.2 vs 7.5 vs 13.8, P = 0.014). The early rescue unloading group showed the highest in-hospital mortality (Figure 1, 87.5%, P = 0.004) and 30-day mortality (75%, P = 0.029). Survival analysis using Kaplan-Meier analysis and log-rank test showed significant difference of probability of all cause death at 30 days among these 4 groups (Figure 2, P by log-rank test = 0.049). In the logistic regression models for in-hospital mortality, rescue unloading within 30 hours was associated with increased odds ratio (OR) for in-hospital mortality (OR = 6.87, 95% confidence interval [CI] = 1.31-35.92.15, P = 0.022). Conclusions In this post-hoc analysis of the EARLY-UNLOAD trial, early-rescue unloading within 30 hours was associated with increased in-hospital mortality in patient treated with VA-ECMO for CS.

Out of hospital sudden cardiac arrest as a prognostic factor for in-hospital mortality in patients admitted with cardiogenic shock

Abstract Funding Acknowledgements None. Background The mortality in cardiogenic shock (CS) is still high despite new comprehensive therapies. Cardiac arrest (CA) frequently complicates CS which can have an unfavourable effect on the course after admission. Purpose The study aimed to analyse the clinical characteristics and prognosis of patients admitted with CS after out-of-hospital cardiac arrest (OHCA) compared to the group without OHCA. Methods The studied group consisted of a total of 80 patients with an average age of 62 ± 13 years (81 % male) admitted to tertiary hospital with CS in the period 2021-2022. The severity of the shock according to the Society for Cardiac Angiography and Interventions (SCAI) SHOCK classification among the whole population was from C to E: 7 (9%), 38 (48%), and 35 (43%), respectively. The cohort was divided into 2 subgroups: the OHCA group consisted of 23 individuals (29%) and the without OHCA (non-OHCA group) consisted of 57 individuals. Results The groups did not differ in terms of demographic parameters and comorbidities. There were no differences in baseline heart rate 95 [50;114] vs. 91 [77;105] beats per minute and mean artery pressure 75 [70;97] vs. 82 [70;97] mmHg for OHCA vs. non-OHCA, respectively, all p&amp;gt; 0.05. Patients from OHCA group had higher baseline creatinine level 1.65 [1.35;1.88] vs. 1.37 [1.08; 1.65] mg/dL, p=0.019, white blood cell count 12 [9;16] vs. 17 [12;23] × 109/L, p=0.015 and lower pH from blood gas analysis 7.0 [6.9;7.2] vs. 7.3 [7.2;7.4], p&amp;lt;0.001). In the OHCA group, 90% of cases of CS were caused by acute coronary syndrome (ACS), while in the group without OHCA, 76% were due to ACS and 20 % due to the progression of chronic heart failure, p=0.032. Mechanical Circulatory Support (MCS) was used in almost every patient (98% non-OHCA vs. 95% OHCA), however, the OHCA group was more often treated with V-A ECMO 14 (64%) vs. 16 (28%) in the non-OHCA, p=0.004. The overall number of in-hospital deaths was 57 (71%). The OHCA group had significantly higher in-hospital mortality 22 (96%) compared to the non-OHCA patients 35 (61%), p=0.002. Conclusion Patients experiencing CS complicated by OHCA have more often ischaemic ethology of shock, have a greater degree of organ damage and a lower pH in blood gas analysis at admission, and have extremely high in-hospital mortality rates when compared with patients facing CS but without prior OHCA, which underscores the urgent need for improved prevention methods, interventions, and public awareness.

Clinical characteristics and outcome of non-acute myocardial syndrome cardiogenic shock in comparison to its ischaemic aetiology

Abstract Funding Acknowledgements None. Background The mortality in cardiogenic shock (CS) remains high but the report mostly concerns CS in the course of acute myocardial syndrome (ACS). There is limited data about non- ischaemic CS. Purpose The aim of this study was to analyse the clinical characteristics, treatments and outcomes in patients with non-ACS CS in comparison to ischemic aetiology CS. Methods 80 patients with an average age of 62 ± 13 years (81 % male) with CS admitted in 2021 and 2022 to tertiary hospital were divided into 2 subgroups: non-acute myocardial infarction cardiogenic shock (non-ACS-CS) consisted of 16 individuals (20%) and CS in the course of ACS (ACS-CS) consisted of 64 (80%) individuals. The main cause of CS in non-ACS group was worsening of previously diagnosed heart failure 11 (14%). Results Patients from non-ACS group were younger 52±16 vs. 65±11 years old, p=0.005. There were no differences in baseline heart rate 90 [72;100] vs. 95 [80;107] beats per minute and mean artery pressure 89 [73;97] vs. 80 [70;97] mmHg for non-ACS-CS vs. ACS-CS, respectively all p&amp;gt;0.05. Patients from non-ACS-CS group had lower baseline troponin level 0.29 [0.04;0.96] vs. 7.05 [0.69;57.4] ng/mL, p=0.003, white blood cell count 11 [9;13] vs. 15 [10;19] × 109/L; p=0.035, procalcitonin 0.06 [0.05;0.28] vs. 0.69 [0.10;2,48] ng/mL, p=0.001 and higher pH 7.4 [7.3;7.5] vs. 7.2 [7.0;7.4], p=0.012 in blood gas analysis when compared with ACS-CS. There were no significant differences in the severity of the shock according to Society for Cardiovascular Angiography and Interventions (SCAI) SHOCK classification among the groups: from C: 1 (6%) vs. 6 (10%), D: 11 (69%) vs. 27 (42%), E: 4 (25%) vs. 31 (48%), respectively for non-ACS vs. ACS-shock. The non-ACS-CS was more often treated with V-A ECMO 10 (63%) vs. 20 (32%) in ACS-CS, p=0.024. The overall number of in-hospital deaths was 57 (71%). The non-ACS-CS group had significantly lower in-hospital mortality 8 (50%) compared to the ACS-CS patients 49 (77%), p=0.034. Conclusion Patients experiencing non-ACS-CS were younger, have lower levels of inflammatory markers and a higher pH in blood gas analysis at admission. Despite more favourable biomarker profile non-ACS-CS group was treated more aggressively and had significantly lower in-hospital mortality rates when compared with patients facing ACS-CS, which indicates the need to look at CS differently depending on its aetiology.

Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry.

Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.

(239) - Relationship of Systemic Vascular Resistance with Mortality in Cardiogenic Shock

(239) - Relationship of Systemic Vascular Resistance with Mortality in Cardiogenic Shock

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.

Body Mass Index and Mortality in Cardiogenic Shock.

We explored the association of body mass index (BMI) with mortality in cardiogenic shock (CS). Using the Cardiogenic Shock Working Group registry, we assessed the impact of BMI on mortality using restricted cubic splines in a multivariable logistic regression model adjusting for age, gender, and race. We also assessed mortality, device use, and complications in BMI categories, defined as underweight (<18.5 kg/m 2 ), normal (18.5-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obese (30-39.9 kg/m 2 ), and severely obese (>40 kg/m 2 ) using univariable logistic regression models. Our cohort had 3,492 patients with CS (mean age = 62.1 ± 14 years, 69% male), 58.0% HF-related CS (HF-CS), and 27.8% acute myocardial infarction (AMI) related CS. Body mass index was a significant predictor of mortality in multivariable regression using restricted cubic splines ( p < 0.0001, p = 0.194 for nonlinearity). When stratified by categories, patients with healthy weight had lower mortality (29.0%) than obese (35.1%, p = 0.003) or severely obese (36.7%, p = 0.01). In HF-CS cohort, the healthy weight patients had the lowest mortality (21.7%), whereas it was higher in the underweight (37.5%, p = 0.012), obese (29.2%, p = 0.003), and severely obese (29.9%, p = 0.019). There was no difference in mortality among BMI categories in AMI-CS.

The 6-hour lactate clearance rate in predicting 30-day mortality in cardiogenic shock

BackgroundEarly evaluation of prognosis in cardiogenic shock (CS) is crucial for tailored treatment selection. Both lactate clearance and lactate levels are considered useful prognostic biomarkers in patients with CS. However, there is yet no literature comparing the 6-hour lactate clearance rate (Δ6Lac) with lactate levels measured at admission (L1) and after 6 h (L2) to predict 30-day mortality in CS. MethodsIn this observational cohort study, 95 patients with CS were treated at Department of Intensive Care Unit, Yiwu Central Hospital between January 2020 and December 2022. Of these, 88 patients met the eligibility criteria. The lactate levels were measured after admission (L1) as the baseline lactate value, and were measured after 6 h (L2) following admission. The primary endpoint of the study was survival rate at 30 days. A receiver operating characteristic curve was used for data analysis. Univariate and multivariate Cox regression analyses were performed based on Δ6Lac. Kaplan–Meier (KM) survival curves were generated to compare the 30-day survival rates among L1, L2, and Δ6Lac. ResultsThe Δ6Lac model showed the highest area under the curve value (0.839), followed by the L2 (0.805) and L1 (0.668) models. The Δ6Lac model showed a sensitivity of 84.2% and specificity of 75.4%. The L1 and L2 models had sensitivities of 57.9% each and specificities of 89.9% and 98.6%, respectively. The cut-off values for Δ6Lac, L1, and L2 were 18.2%, 6.7 mmol/L, and 6.1 mmol/L, respectively. Univariate Cox regression analysis revealed a significant association between Δ6Lac and 30-day mortality. After adjusting for five models in multivariate Cox regression, Δ6Lac remained a significant risk factor for 30-day mortality in patients with CS. In our fifth multivariate Cox regression model, Δ6Lac remained a risk factor associated with 30-day mortality (hazard ratio [HR]=5.14, 95% confidence interval [CI]: 1.48 to 17.89, P=0.010) as well as L2 (HR=8.42, 95% CI: 1.26 to 56.22, P=0.028). The KM survival curve analysis revealed that L1 >6.7 mmol/L (HR=8.08, 95% CI: 3.23 to 20.20, P <0.001), L2 >6.1 mmol/L (HR=25.97, 95% CI: 9.76 to 69.15, P <0.001), and Δ6Lac ≤18.2% (HR=8.92, 95% CI: 2.95 to 26.95, P <0.001) were associated with a higher risk of 30-day mortality. ConclusionsΔ6Lac is a better predictor for 30-day mortality in CS than lactate levels at admission. It has a predictive value equivalent to that of lactate level at 6 h after admission, making it an important surrogate indicator for evaluating the suitability as well as poor prognosis after CS treatment. We found that a cut-off value of 18.2% for Δ6Lac provided the most accurate assessment of early prognosis in CS.

Blood glucose and lactate levels as early predictive markers in patients presenting with cardiogenic shock: A retrospective cohort study.

Lactate and glucose are widely used biochemical parameters in current predictive risk scores for cardiogenic shock. Data regarding the relationship between lactate and glucose levels in cardiogenic shock are limited. Thus, we aimed to analyze glucose and lactate as early markers for in-hospital mortality in cardiogenic shock. In this retrospective cohort study, 312 patients presenting with cardiogenic shock to a tertiary-care hospital between 2016 and 2018 were included. Apparent cardiogenic shock was defined as hypoperfusion with hemodynamic compromise and biochemical marker increase due to diminished tissue perfusion, corresponding to SCAI shock stages. In-hospital mortality was assessed as the primary endpoint. The median age of the study population was 71 (60-79) years and the etiology of cardiogenic shock was acute myocardial infarction in 45.8%. Overall in-hospital mortality was 67.6%. In the receiver operating curve analysis, the area under the receiver-operating curve (AUC) for prediction of in-hospital mortality was higher for lactate (AUC: 0.757) than for glucose (AUC: 0.652). Both values were significantly associated with outcome (groups created with best cutoff values obtained from the Youden index). Correlation analysis showed a significant non-linear association of both values. In a multivariable stepwise Cox regression analysis, lactate remained an independent predictor for in-hospital mortality, whilst glucose, despite being implicated in energy metabolism, was not independently predictive for mortality. Together, these data suggest that lactate at admission is superior for mortality prediction in patients with apparent cardiogenic shock. Glucose was not independently predictive for mortality.

Relationship Of SCAI Stage Via New Cardiogenic Shock Working Group Criteria On In-hospital Mortality In Cardiogenic Shock

Relationship Of SCAI Stage Via New Cardiogenic Shock Working Group Criteria On In-hospital Mortality In Cardiogenic Shock

PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study.

The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model. A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve. We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001. Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.

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