Non-shock Groups Research Articles

Improved phenotyping of cardiogenic shock after out-of-hospital cardiac arrest

Abstract Background Cardiogenic shock (CS) is an important cause of mortality after out-of-hospital cardiac arrest (OHCA). The SCAI classification is a simple grading system to reflect the spectrum of CS but fails to reflect phenotypes of CS based on haemodyamic/haemometabolic criteria [1,2]. Purpose We applied the SCAI grade and features of tissue hypoperfusion (i.e., elevated lactate) to develop a phenotypic classification of CS after resuscitated OHCA of cardiac aetiology and evaluate its association with outcome. Methods Patients with resuscitated OHCA of presumed cardiac aetiology were included in the King’s Out-of-hospital Cardiac Arrest Registry (KOCAR), and Uniwersyteckie Centrum Kliniczne w Gdańsku, Poland (UCK) between 1st May 2012 and 31st December 2020. Patients were classified into phenotypes of CS according to a combination of SCAI grade and lactate concentration on arrival at the hospital. Patients were then placed into one of 4 groups - those with SCAI grades A-B, i.e., no CS, were termed non-shocked if lactate <5, hypoperfusion group if lactate ≥5. Amongst those with CS (SCAI grades C-E), those with lactate <5 were considered to be in haemodynamic shock, and those with lactate ≥5 were in haemometabolic shock (Figure 1). The primary endpoint was mortality and cause of death at hospital discharge. Amongst surviving patients, the neurological outcome was defined by the Cerebral Performance Category (CPC) score. Results Of 627 patients (median age 62.9 ± 20.7, and 76.4% male), 218 patients (34.8%) were classified as non-shocked, 116 (18.5%) as hypoperfused, 106 (16.9%) as haemodynamic shock, and 187 (29.8%) as haemometabolic shock. Low flow time increased as the shock classification deteriorated, with the shortest time in the non-shocked group and the longest in the haemometabolic shock group (p <0.001). There were lower rates of initial shockable rhythm in haemometabolic shock followed by hypoperfused patients (p <0.001) and higher rates of adrenaline use in these groups (p< 0.001). Survival with good neurological outcome was most common in the non-shocked, then in haemodynamic shock groups, followed by the hypoperfusion group and with significantly less favourable survival in the haemometabolic shock group CS (Table 1; Figure 1; p<0.001). Modes of death differed significantly by shock classification group. Patients in the non-shock and hypoperfusion groups had low rates of cardiac multiple organ dysfunction syndrome (MODS) death, with the highest rates of neurological death seen amongst the hypoperfused group (35.7%). Patients in the haemodynamic shock group had substantially higher cardiac death rates, and those in the haemometabolic shock group had the highest cardiac and MODS death rates. Conclusion A classification based on SCAI grade and lactate levels identifies distinct phenotypes of CS after OHCA and may identify specific sub-groups for selection of mechanical circulatory support devices.Table 1Figure 1

Elevated endothelial dysfunction-related biomarker levels indicate the severity and predict sepsis incidence

This study was conducted to investigate the relationship between serum endothelial dysfunction-related biomarker levels and organ dysfunction severity in septic patients and the predictive value of these levels during sepsis. In total, 105 patients admitted to the Department of Critical Care Medicine were enrolled between September 2020 and November 2021. Serum syndecan-1 and soluble thrombomodulin(sTM) levels were measured by enzyme-linked immunosorbent assay, and clinical and laboratory data were recorded. Enroll patients were divided into the infection (n = 28), septic nonshock (n = 31), and septic shock (n = 46) groups . Serum syndecan-1 (102.84 ± 16.53 vs. 55.38 ± 12.34 ng/ml), and sTM(6.60 ± 1.44 ng/ml vs. 5.23 ± 1.23 ng/ml, P < 0.01) levels were increased in the septic group compared with those in the infection group. Serum syndecan-1 levels were closely positively correlated with serum sTM (rs = 0.712, r2 = 0.507, P < 0.001). Additionally, serum syndecan-1(rs = 0.687, r2 = 0.472, P < 0.001) and sTM levels (rs = 0.6, r2 = 0.36, P < 0.01) levels were significantly positively correlated with the sequential organ failure assessment scores respectively. Syndecan-1 (AUC 0.95 ± 0.02, P < 0.0001) was more valuable for prediction sepsis than was sTM (AUC 0.87 ± 0.04, P < 0.0001). Compared with sTM (AUC 0.88 ± 0.03, P < 0.001), syndecan-1 (AUC 0.95 ± 0.02, P < 0.001) and SOFA score (AUC 0.95 ± 0.02, P < 0.001) were better predictors of septic shock. Serum syndecan-1 and sTM levels were associated with organ dysfunction severity in septic patients, and both were good predictors for early identification of sepsis, particularly in patients undergoing septic shock.

Timing of Repair in Postinfarction Ventricular Septal Defect

The optimal timing of postinfarction ventricular septal defect (PI-VSD) repair is subject to debate. Patients with ventricular septal defect (VSD) and ST-elevation myocardial infarction (STEMI) were queried using appropriate International Classification of Diseases, Ninth and Tenth Revision Clinical Modification codes from the National Inpatient Sample (2003 to 2018). VSD repair was identified using appropriate International Classification of Diseases, Ninth and Tenth Revision Procedure Coding System codes. Data were stepwise stratified by cardiogenic shock (CS) and time of repair from admission to create 6 clinically relevant groups: shock 1 (CS; 0 to 7 days), shock 2 (CS; 8 to 14 days), and shock 3 (CS; >14 days). Nonshock groups were classified similarly. The primary outcome was in-hospital mortality. Multilevel hierarchical logistic regression was used to adjust for confounders for each group. We identified 10,902 patients with PI-VSD. In shock 1 (n=5,794), VSD repair was associated with lower mortality (OR 0.76; 95% CI 0.68 to 0.86, p <0.001) compared to no VSD repair. In shock 2 (n=1,009) mortality was numerically lower in those who received VSD repair, but not statistically different. In shock 3 (n=483), mortality was numerically higher in those who received VSD repair, but not statistically different. In nonshock 1 (n=5,108), VSD repair was associated with higher mortality (odds ratio [OR] 1.59; 95% confidence interval [CI] 1.33 to 1.90; p <0.001). In nonshock 2 (n=1,265), mortality was numerically higher in patients with VSD repair, although not statistically different. In nonshock 3 (n=472), mortality was numerically lower in patients with VSD repair, although not statistically different. Mechanical circulatory support use increased over the 16 years (relative change+18%, p <0.001), with no significant change in mortality among patients with PI-VSD. In conclusion, in patients with CS, early PI-VSD repair was associated with lower mortality. However, in patients without CS, early PI-VSD repair was associated with higher mortality.

Predictive Value of Procalcitonin and Neutrophil-to-Lymphocyte Ratio Variations for Bloodstream Infection with Septic Shock.

BackgroundLittle is known of neutrophil-to-lymphocyte ratio (NLR) variations in septic shock. Hence, the predictive value of procalcitonin (PCT) and NLR variations for septic shock in bloodstream infection were explored.Material/MethodsWe analyzed 146 patients with bloodstream infection admitted to the Intensive Care Unit (ICU) of the First Affiliated Hospital of Anhui Medical University from October 2016 to May 2020. PCT and NLR were evaluated at 0 and 48 h after admission, and their variations (ΔPCT and ΔNLR) were calculated. The patients were divided into a shock group (n=80) and a non-shock group (n=66) and a gram-positive cocci group (n=69) and a gram-negative bacilli group (n=77). The predictive value of ΔPCT and ΔNLR was compared among groups.ResultsAUROC of NLR0h (0.756) higher than PCT0h (0.743).ΔPCT (0.561 vs 0.301) and ΔNLR (0.609 vs 0.361) were significantly higher in the shock group than in the non-shock group (P<0.05). No significant difference was seen in ΔPCT and ΔNLR in the gram-positive cocci infection group. However, the gram-negative bacilli infection group showed a significant difference in ΔPCT (0.606 vs 0.312) and ΔNLR (0.872 vs 0.508) between the shock and non-shock groups (P<0.05). ΔPCT+ΔNLR showed the best area under the curve (0.937), with a high sensitivity (78.80%) and specificity (90.80%), for predicting septic shock.ConclusionsThe prediction efficiency of initial NLR is higher than that of PCT. ΔPCT+ΔNLR best predicted septic shock in patients with bloodstream infections, with better accuracy for gram-negative infections.

Renal Oxygen Saturation as an Early Indicator of Shock in Children.

BackgroundShock is a life-threatening syndrome in which tissue perfusion and oxygen delivery are inadequate. Near-infrared spectroscopy (NIRS) has been suggested as a noninvasive tool for monitoring and detecting the state of inadequate tissue perfusion. Renal and mesenteric oximetry show decreased cardiac output earlier than systemic or global parameters of tissue oxygenation or cerebral oximetry. However, until now there has been no study on the validity of regional renal oxygen saturation (rRSO2) by NIRS for diagnosing shock in children.PurposeTo analyze the validity of rRSO2 by NIRS to diagnose shock in children.Patients and MethodsThis cross-sectional study was conducted in critically ill children (aged 1 month–18 years) who were admitted to the pediatric intensive care unit (PICU), from September to November 2020, consecutively. Patients were classified into two groups: shock and non-shock. The diagnosis of shock is based on clinical criteria (tachycardia, sign of hypoperfusion and decrease systolic blood pressure <P5 according to age). Measurement of rRSO2 by NIRS was performed by the doctor in charge when the patient came to PICU. The baseline rRSO2 value (%) made a receiver operating characteristic (ROC) curve and was used to find the optimal cut-off value and calculated sensitivity and specificity.ResultsWe enrolled 20 critically ill patients. The baseline rRSO2 in the shock (n=10) and non-shock (n=10) groups were, 44.00±4.95 vs 78.70±4.52 (p 0.003). The optimal cutoff value of the baseline rRSO2 to predict shock is less than 58.5% with area under the curve (AUC) value is 94.4% (95% CI of 84.4–100%), p 0.001, sensitivity 90% and specificity 90% in critically ill children.ConclusionThe rRSO2 value by NIRS can differentiate between shock and non-shock in critically ill patients accurately.

STS INTERMACS Database: The Key to Conduct Single-Arm Trials in Advanced Heart Failure Patients

BackgroundSafe introduction of novel mechanical circulatory support (MCS) devices into clinical practice is a challenging process. Single-arm trials using a control arm from existing database is an effective alternative that could be applied for regulatory approval. This study analyzes the capability of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to establish objective performance criteria and select patient population that could be used for future single-arm MCS trials. MethodsPatients with INTERMACS profiles IM1-2 and IM3-5, who underwent implantation of isolated left ventricular assist devices between 2014 and 2017, were included. Both cohorts were further stratified into shock and nonshock groups using surrogate markers of shock (extracorporeal membrane oxygenation, temporary ventricular assist device, vasopressor infusions). Survival, transplantation rates, adverse events, 6-minute walk test, and quality-of-life measures were obtained for all 4 groups at 6 and 12 months. ResultsTotal of 7907 patients were divided into IM1-2 (n = 3909), IM3-5 (n = 3998), shock (n = 3469), and nonshock (n = 3040) groups. Recategorization occurred in 11% of patients from the IM3-5 group into the shock group. Overall, patients in the shock group had similar outcomes to the IM1-2 group (1-year survival: 86% vs 85%; P = .74). Patients in the nonshock group also had similar outcomes to the IM3-5 (1-year survival: 90% vs 90%; P = .43). ConclusionsThe INTERMACS database can successfully establish objective performance criteria and concurrent control group for single-arm trials that could be used to support regulatory approval of new, less invasive MCS. INTERMACS data allow reliable comparisons of outcomes and adverse events.

Swine hemorrhagic shock model and pathophysiological changes in a desert dry-heat environment.

BackgroundThis study aimed to establish a traumatic hemorrhagic shock (THS) model in swine and examine pathophysiological characteristics in a dry-heat environment.MethodsForty domestic Landrace piglets were randomly assigned to four study groups: normal temperature non-shock (NS), normal temperature THS (NTHS), desert dry-heat non-shock (DS), and desert dry-hot THS (DTHS) groups. The groups were exposed to either normal temperature (25°C) or dry heat (40.5°C) for 3 h. To induce THS, anesthetized piglets in the NTHS and DTHS groups were subjected to liver trauma and hypovolemic shock until death, and piglets in the NS and DS groups were euthanized at 11 h and 4 h, respectively. Body temperature, blood gas, cytokine production, and organ function were assessed before and after environmental exposure at 0 h and at every 30 min after shock to death. Hemodynamics was measured post exposure and post-shock at 0 h and at every 30 min after shock to death.ResultsSurvival, body temperature, oxygen delivery, oxygen consumption, and cardiac output were significantly different for traumatic hemorrhagic shock in the dry-heat groups compared to those in the normal temperature groups. Lactic acid and IL-6 had a marked increase at 0.5 h, followed by a progressive and rapid increase in the DTHS group.ConclusionsOur findings suggest that the combined action of a dry-heat environment and THS leads to higher oxygen metabolism, poorer hemodynamic stability, and earlier and more severe inflammatory response with higher mortality.

The correlation of clinical and subclinical presentations with dengue serotypes and plasma viral load: the case of children with dengue hemorrhagic fever in Vietnam

Numerous studies have been carried out on patients afflicted with dengue hemorrhagic fever (DHF), but various issues related to the disease, including the characteristics of the dengue virus (DENV), remain unclear. To address this deficiency, the current research was conducted to determine the correlation of clinical and subclinical presentations with dengue serotypes and plasma viral load. This prospective cohort study, which was performed at Tien Giang General Hospital from 2009 to 2014, involved 481 children who were under 15 years of age and had DHF for less than 72 hours. Results showed that among the patients, the highest proportion were composed of those suffering from DENV-1 infection (44.7%). The progression of the disease to dengue shock syndrome (DSS) owing to infection with DENV-2 and DENV-1 was significantly higher than that caused by infection with DENV-3 and DENV-4. No statistically significant differences in DENV viremia were found between the non-shock DHF and DSS groups. Finally, no correlation was found between dengue plasma viral load and clinical and subclinical presentations. The findings led to the conclusion that dengue serotypes can be used as a basis in ascertaining the prognosis of DSS and DHF.

The prognostic value of Th1/Th2 cytokines on septic children with or without neutropenia

Objective To explore the characteristics and value for predicting prognosis of cytokines in septic children with or without neutropenia. Methods Totally 138 septic children were divided into the neutropenia and non-neutropenia groups according to absolute neutropenic count. Septic children were divided into the shock and non-shock groups according to circulation function and organ perfusion. The levels of C-reactive protein, procalcitonin, cytokines, PRISM-Ⅲ and clinical outcomes were analyzed between the relative groups. Results (1) Totally 138 septic children were recruited, 64 with neutropenia and 74 without neutropenia. The level of PRISM-Ⅲ of the neutropenia group was significantly higher than that of the non-neutropenia group (P=0.048).Mortality showed no significant difference between the two groups, but hospital stay in the neutropenia group was longer than that in the non-neutropenia group. The levels of C-reactive protein, IL-6, and IL-10 ihe neutropenia group were significantly higher than those of the non-neutropenia group (P=0.001; P=0.001; P=0.032). The level of TNF-α in the neutropenia group was significantly lower than that of the non-neutropenia group (P=0.032). (2)Among the 64 septic children with neutropenia, 23 were combined with shock. The PRISM-Ⅲ level of the shock group was significantly higher than that of the non-shock group (P=0.001). The mortality of the shock group (43.5%, 10/23) was significantly higher than the non-shock group (2.4%, 1/41) (P=0.001). C-reactive protein, procalcitonin, IL-6, IL-10 and TNF-α in the shock group elevated obviously than those in the non-shock group (P=0.001; P=0.001; P=0.001; P=0.005; P=0.019). The area under receiver operating characteristic curve was 0.8 for IL-6 (cut-off value 315.38 pg/mL), 0.8 for IL-10 (cut-off value 45.18 pg/mL), and 0.85 for TNF-α (cut-off value 1.95 pg/mL). (3) Among the 74 septic children without neutropenia, 19 were combined with shock. The PRISM-Ⅲ level of the shock group was significantly higher than that of the non-shock group (P=0.022).There was no significant difference of mortality between the two groups (P=0.3). IL-10 level in the shock group elevated obviously than that in the non-shock group (P=0.015).(4) Among the 42 children with sepsis shock, 23 were combined with neutropenia. The PRISM-Ⅲ level of the neutropenia group was significantly higher than that of the non-neutropenia group (P=0.005). There was no significant difference of mortality between the two groups (P=0.29). The levels of C-reactive protein, procalcitonin, IL-6 and IL-10 in the neutropenia group were significantly higher than those in the non-neutropenia group (P=0.001; P=0.001; P=0.001; P=0.035). There was no difference of TNF-α level between the two groups.(5) Among the 96 children without sepsis shock, 41 were combined with neutropenia. No difference of PRISM-Ⅲ level was observed between the neutropenia and non-neutropenia groups. The mortality of the neutropenia group was significantly lower than that in the non-neutropenia group (2.4% vs 20%, P=0.02). The levels of C-reactive protein and IL-6 in the neutropenia group were significantly higher than those in the non-neutropenia group (P=0.005; P=0.033). The TNF-α level was significantly lower than that in the non-neutropenia group (P=0.007). Conclusions Compared to children without neutropenia, septic children combined with neutropenia have longer hospital stay, and septic shock children combined with neutropenia have higher mortality, and levels of IL-6, IL-10 and TNF-α were also significantly increased. The levels of IL-6, IL-10 and TNF-α can help to predict prognosis of children with sepsis. Key words: Sepsis; Shock; Septic shock; Neutropenia; Non- neutropenia; Cytokine; Children; Prognosis

Differential protein expression in patients with urosepsis

PurposeUrosepsis in adults comprises approximately 25% of all sepsis cases, and is due to complicated urinary tract infections in most cases. However, its mechanism is not fully clarified. Urosepsis is a very complicated disease with no effective strategy for early diagnosis and treatment. This study aimed to identify possible target-related proteins involved in urosepsis using proteomics and establish possible networks using bioinformatics. MethodsFifty patients admitted to the Urology Unit of Lanzhou General PLA (Lanzhou, China), from October 2012 to October 2015, were enrolled in this study. The patients were further divided into shock and matched-pair non-shock groups. 2-DE technique, mass spectrometry and database search were used to detect differentially expressed proteins in serum from the two groups. ResultsSix proteins were found at higher levels in the shock group compared with non-shock individuals, including serum amyloid A-1 protein (SAA1), apolipoprotein L1 (APOL1), ceruloplasmin (CP), haptoglobin (HP), antithrombin-III (SERPINC1) and prothrombin (F2), while three proteins showed lower levels, including serotransferrin (TF), transthyretin (TTR) and alpha-2-macroglobulin (A2M). ConclusionNine proteins were differentially expressed between uroseptic patients (non-shock groups) and severe uroseptic patients (shock groups), compared with non-shock groups, serum SAA1, APOL1,CP, HP, SERPINC1and F2 at higher levels, while TF, TTR and A2M at lower levels in shock groups.these proteins were mainly involved in platelet activation, signaling and aggregation, acute phase protein pathway, lipid homeostasis, and iron ion transport, deserve further research as potential candidates for early diagnosis and treatment. (The conclusion seems too simple and vague, please re-write it. You may focus at what proteins have been expressed and introduce more detail about its significance.)

Association of day 4 cumulative fluid balance with mortality in critically ill patients with influenza: A multicenter retrospective cohort study in Taiwan.

BackgroundFluid balance is a fundamental management of patients with sepsis, and this study aimed to investigate the impact of cumulative fluid balance on critically ill patients with influenza admitted to an intensive care unit (ICU).MethodsThis multicenter retrospective cohort study was conducted by the Taiwan Severe Influenza Research Consortium (TSIRC) which includes eight medical centers. Patients with virology-proven influenza infection admitted to ICUs between October 2015 and March 2016 were included for analysis.ResultsA total of 296 patients were enrolled (mean age: 61.4±15.6 years; 62.8% men), and 92.2% (273/296) of them required mechanical ventilation. In the survivors, the daily fluid balance was positive from day 1 to day 3, and then gradually became negative from day 4 to day 7, whereas daily fluid balance was continuously positive in the non-survivors. Using the cumulative fluid balance from day 1–4 as a cut-off point, we found that a negative cumulative day 1–4 fluid balance was associated with a lower 30-day mortality rate (log-rank test, P = 0.003). To evaluate the impact of shock on this association, we divided the patients into shock and non-shock groups. The positive correlation between negative day 1–4 fluid balance and mortality was significant in the non-shock group (log-rank test, P = 0.008), but not in the shock group (log-rank test, P = 0.396). In a multivariate Cox proportional hazard regression model adjusted for age, sex, cerebrovascular disease, and PaO2/FiO2, day 1–4 fluid balance was independently associated with a higher 30-day mortality rate (aHR 1.088, 95% CI: 1.007–1.174).ConclusionsA negative day 1–4 cumulative fluid balance was associated with a lower mortality rate in critically ill patients with influenza. Our findings indicate the critical role of conservative fluid strategy in the management of patients with complicated influenza.

CLINICAL FACTORS FOR DEVELOPING SHOCK IN RADIOCONTRAST MEDIA INDUCED ANAPHYLAXIS.

The aim of this study was to investigate the time interval between radiocontrast media (RCM) administration and the development of anaphylactic shock, and risk factors associated with RCM-induced anaphylactic shock. We reviewed the medical records of 154 patients with RCM-induced anaphylaxis presenting to the emergency department of a tertiary care hospital between January 2005 and December 2014. Clinical features of RCM-induced anaphylaxis were analyzed, and patients were categorized into shock and non-shock groups to identify associated factors in affected patients. Of the 154 cases of RCM-induced anaphylaxis, 101 (65.9%) patients experienced shock. The median time between RCM exposure and the onset of shock was 11 min (interquartile range, 7.0-18.8). In patients with RCM-induced anaphylaxis accompanying shock, the median time from RCM to the first symptom onset was 6 min (interquartile range, 5.0-10.0). In the multivariate analysis, age, neurological manifestations, and allergy history except RCM were associated with the development of shock. RCM-induced anaphylaxis was commonly accompanied with shock, and the time interval between RCM exposure and the onset of shock was short. Physicians should pay attention to the development of potential cardiovascular collapse in anaphylaxis patients of old age and with neurologic manifestations.

ShockOmics: multiscale approach to the identification of molecular biomarkers in acute heart failure induced by shock.

BackgroundThe ShockOmics study (ClinicalTrials.gov identifier NCT02141607) is a multicenter prospective observational trial aimed at identifying new biomarkers of acute heart failure in circulatory shock, by means of a multiscale analysis of blood samples and hemodynamic data from subjects with circulatory shock.Methods and DesignNinety septic shock and cardiogenic shock patients will be recruited in three intensive care units (ICU) (Hôpital Erasme, Université Libre de Bruxelles, Belgium; Hospital Universitari Mutua Terrassa, Spain; Hôpitaux Universitaires de Genève, Switzerland). Hemodynamic signals will be recorded every day for up to seven days from shock diagnosis (time T0). Clinical data and blood samples will be collected for analysis at: i) T1 < 16 h from T0; ii) T2 = 48 h after T0; iii) T3 = day 7 or before discharge or before discontinuation of therapy in case of fatal outcome; iv) T4 = day 100.The inclusion criteria are: shock, Sequential Organ Failure Assessment (SOFA) score > 5 and lactate levels ≥ 2 mmol/L. The exclusion criteria are: expected death within 24 h since ICU admission; > 4 units of red blood cells or >1 fresh frozen plasma transfused; active hematological malignancy; metastatic cancer; chronic immunodepression; pre-existing end stage renal disease requiring renal replacement therapy; recent cardiac surgery; Child-Pugh C cirrhosis; terminal illness. Enrollment will be preceded by the signature of the Informed Consent by the patient or his/her relatives and by the physician in charge.Three non-shock control groups will be included in the study: a) healthy blood donors (n = 5); b) septic patients (n = 10); c) acute myocardial infarction or patients with prolonged acute arrhythmia (n = 10).The hemodynamic data will be downloaded from the ICU monitors by means of dedicated software. The blood samples will be utilized for transcriptomics, proteomics and metabolomics (“-omics”) analyses.DiscussionShockOmics will provide new insights into the pathophysiological mechanisms underlying shock as well as new biomarkers for the timely diagnosis of cardiac dysfunction in shock and quantitative indices for assisting the therapeutic management of shock patients.

If the shoe fits: Antitachycardia pacing in children and patients with congenital heart disease

It is now more than 10 years since the publication of groundbreaking major clinic studies such as AVID and MADIT that created the foundation for clinical indications for implantable cardioverter-defibrillator (ICD) use in adults at risk for sudden death. Since that time, the technology that enables the ICD has progressed, with reductions in device size, advances in software and lead technology, and innovations in system design, making them more reliable and easier to implant. However, as increasing long-term experience with ICDs has accumulated, we have become distressingly aware that the risk reduction in cardiac sudden death-associated ICD implantation cannot be considered to be a free ride. Complications associated with long-term ICD patients are often heralded by unnecessary or frankly inappropriate shocks owing to misinterpretation of nonlethal rhythms, missensed rhythms, and lead faults. 1 van Rees J.B. Borleffs J.W. de Bie M.K. et al. Inappropriate cardioverter-defibrillator shocks. J Am Coll Cardiol. 2011; 57: 556-562 Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar , 2 Berul C.I. Van Hare G.F. Kertesz N.J. et al. Results of a multicenter retrospective implantable cardioverter-defibrillator registry of pediatric and congenital heart patients. J Am Coll Cardiol. 2008; 51: 1685-1691 Abstract Full Text Full Text PDF PubMed Scopus (301) Google Scholar Proarrhythmic effects of inappropriate shock may rarely lead to ICD storm, and increasing data suggest that such shocks may contribute to deterioration of myocardial function and overall survival. 1 van Rees J.B. Borleffs J.W. de Bie M.K. et al. Inappropriate cardioverter-defibrillator shocks. J Am Coll Cardiol. 2011; 57: 556-562 Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar , 3 Poole J.E. Johnson G.W. Hellkamp A.S. et al. Prognostic importance of defibrillator shocks in patients with heart failure. New Engl J Med. 2008; 359: 1009-1017 Crossref PubMed Scopus (1139) Google Scholar Perhaps equally important (although less dramatic) is the pervasive effect of both appropriate and inappropriate shocks, resulting in increased anxiety and deterioration of quality of life in both adults and children. 4 Koopman H.M. Vrijmoet-Wiersma C.M. Langius J.N. et al. Psychological functioning and disease-related quality of life in pediatric patients with an implantable cardioverter defibrillator. Pediatr Cardiol. 2012; 33: 569-575 Crossref PubMed Scopus (47) Google Scholar , 5 Jacq F. Foulldrin G. Savouré A. et al. A comparison of anxiety, depression and quality of life between device shock and nonshock groups in implantable cardioverter defibrillator recipients. Gen Hosp Psychiatry. 2009; 31: 266-273 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar Antitachycardia pacing reduces appropriate and inappropriate shocks in children and congenital heart disease patientsHeart RhythmVol. 9Issue 11PreviewAntitachycardia pacing (ATP) can reduce implantable cardioverter-defibrillator shocks, but its use in children and patients with congenital heart disease (CHD) is not well described. Full-Text PDF

056 Leucocyte telomere/telomerase dynamics in patients with implantable cardioverter defibrillator; potential biomarker for ventricular arrhythmias

IntroductionImplantable cardioverter defibrillators (ICDs) have been shown to reduce mortality in patients with ischaemic cardiomyopathy at a high risk of ventricular arrhythmias (VA), which are the commonest cause of sudden...

Factors associated with shock in anaphylaxis

BackgroundThe aim of this study was to investigate the clinical characteristics of anaphylactic shock and the factors associated with anaphylactic shock in anaphylaxis. MethodsData were retrospectively collected from patients with anaphylaxis for 10 years. Study subjects were searched with broad disease codes including anaphyla-, adverse, angioedema, allergy, insect bite, bee, and hypersensitivity to prevent omission. All the 294 study subjects were divided into shock and nonshock groups. ResultsThe mean age of the subjects was 43 years old, and males comprised 162 patients (55%). There were 119 patients (41%) in the shock group and 175 patients in the nonshock group. Age was older in the shock group than in the nonshock group; however, there was no difference in sex between 2 groups. Frequent causes of anaphylaxis were drugs in the shock group and food in the nonshock group. Nonsteroidal anti-inflammatory drugs and radiocontrast media were the most common cause of drug-induced anaphylaxis in the nonshock group and shock group, respectively. Cardiovascular symptoms were the most frequent symptoms in the shock group. Factors associated with the shock in cases with anaphylaxis were old age, emergency department (ED) arrival by emergency medical services use, radiocontrast material, symptoms with cyanosis, syncope, and dizziness. ConclusionElderly anaphylactic patients with symptoms of cyanosis, syncope, and dizziness were at increased risk for the development of shock. Physicians in the ED have to be alert to the possibility of progression to shock in patients with anaphylaxis, and early recognition of anaphylactic shock is critical for adequate treatment.

A comparison of anxiety, depression and quality of life between device shock and nonshock groups in implantable cardioverter defibrillator recipients

Background Using standardized scales, we assessed the point prevalence, the severity of anxiety and depressive disorders, and the quality of life (QOL) in implantable cardioverter defibrillator (ICD) recipients who received a device shock. Methods Forty research subjects with device shocks (Group 1) and 25 without shocks (Group 2) were interviewed after ICD implantation using the Mini International Neuropsychiatric Interview (MINI), the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Results The point prevalence of anxiety disorders was higher in Group 1 (37.5%) than in Group 2 (8%) ( P=.009). Depressive symptoms scores were higher in Group 1 (4.75) than in Group 2 (2.24) ( P=.04)), but the prevalence of depressive disorders or the anxiety scores were not significantly different. A positive correlation was found between the number of shocks and the depressive symptoms scores ( P=.05, r=0.24); there was a negative correlation between the mental health subscore of the SF-36 and the number of shocks ( r=−0.36, P=.003). The point prevalence of depressive disorders was higher in the group with congenital cardiac diseases (50%) than in the valvular (8%) and ischemic groups (23%) ( P=.04), and the mental health composite summary score of the SF-36 was lower in this group (46.34) than in those with valvular and ischemic disease (56.09 and 52.61, respectively) ( P=.03). Conclusion Exposure to shocks may lead to an increased risk of anxiety and depressive symptoms. Research subjects receiving a high number of shocks and research subjects with congenital cardiovascular diseases were at higher risk of depressive symptoms or at higher risk of poorer psychological aspects of QOL.

Baseline comorbidities and treatment strategy in elderly patients are associated with outcome of cardiogenic shock in a community-based population

Background Cardiogenic shock (CGS) historically results in high inhospital mortality, particularly in elderly patients. Factors that contribute to increased mortality and treatment strategies that improve short- and long-term outcomes in patients with CGS remain to be established. Methods The study consisted of 1263 consecutive patients with acute myocardial infarction admitted from Olmsted County, Minn, during the period 1988 to 2000; of these, 73 (6%) developed cardiogenic shock. Short- and long-term mortality was compared between the elderly and younger populations in both shock and nonshock groups. Results In patients with acute myocardial infarction, age of ≥65 years was associated with increased long-term mortality for nonshock patients (unadjusted relative risk [RR] 5.23, 95% CI 4.10–6.67, P < .001) and to a lesser degree in patients with cardiogenic shock (unadjusted RR 2.02, 95% CI 1.12–3.65, P = .02). Among cardiogenic shock patients, estimated survival at 1 and 5 years for elderly patients was 38% and 24%, respectively, and in younger patients, 57% and 52%, respectively. When adjusted for confounding variables, elderly noncardiogenic shock patients had significantly increased long-term mortality (adjusted RR 4.38, 95% CI 3.42–5.61, P < .001) compared to younger nonshock patients. In contrast, elderly patients with cardiogenic shock demonstrated a weaker trend toward worse outcomes (adjusted RR 1.80, 95% CI 1.00–3.27, P = .051) compared to younger patients with shock. Conclusions The relationship between age and long-term mortality is stronger among patients who do not develop cardiogenic shock. Advanced age was not found to be as strong a risk factor for survival in patients with cardiogenic shock; comorbidities and less aggressive treatment appear to be the major factors resulting in poor outcomes in the elderly patient with cardiogenic shock.

Efficacy and safety of monoclonal antibody to human tumor necrosis factor alpha in patients with sepsis syndrome. A randomized, controlled, double-blind, multicenter clinical trial. TNF-alpha MAb Sepsis Study Group

To evaluate the efficacy and safety of anti-tumor necrosis factor alpha monoclonal antibody (TNF-alpha MAb) in the treatment of patients with sepsis syndrome. Randomized, prospective, multicenter, double-blind, placebo-controlled clinical trial. A total of 31 hospitals in the United States and Canada. There were 994 patients with sepsis syndrome enrolled in this clinical trial, and 971 patients were infused with the study drug. Patients were prospectively stratified into shock or nonshock groups and then randomized to receive a single infusion of 15 mg/kg of TNF-alpha MAb, 7.5 mg/kg of TNF-alpha MAb, or placebo. Patients received standard aggressive medical and surgical care during the 28-day postinfusion period. Twenty-eight-day all-cause mortality. The distribution of variables describing demographics, organ system dysfunction or failure, preinfusion Acute Physiology and Chronic Health Evaluation II score, number of organs failing at baseline, initial sites of infection, infecting microorganisms, antimicrobials used, and initial invasive procedures was similar among patients in the TNF-alpha MAb and placebo treatment arms. Among all infused patients, there was no difference in all-cause mortality in patients who received placebo as compared with those who received TNF-alpha MAb. In septic patients with shock (n = 478), there was a trend toward a reduction in all-cause mortality, which was most evident 3 days after infusion: 25 of 162 patients treated with 15 mg/kg of TNF-alpha MAb died, 22 of 156 patients treated with 7.5 mg/kg of TNF-alpha MAb died, and 44 of 160 patients in the placebo group died (15 mg/kg: 44% reduction vs placebo, P = .01; 7.5 mg/kg: 48.7% reduction vs placebo, P = .004). At day 28, the reduction in mortality for shock patients was not significant for either dose of TNF-alpha MAb relative to placebo (15 mg/kg, 61 deaths among 162 patients [37.7% mortality]; 7.5 mg/kg, 59 deaths among 156 patients [37.8% mortality]; placebo, 73 deaths among 160 patients [45.6% mortality]; P = .20 for 7.5 mg/kg and P = .15 for 15 mg/kg). Serious adverse events were reported in 4.6% of all infused patients. No immediate hypersensitivity allergic reactions due to TNF-alpha MAb were reported. Serum sickness-like reactions were seen in 2.5% of patients receiving TNF-alpha MAb. There was no decrease in mortality between placebo and TNF-alpha MAb in all infused patients. In septic shock patients who received TNF-alpha MAb, a significant reduction in mortality was present 3 days after infusion. Although a trend toward reduced mortality continued at 28 days following treatment with TNF-alpha MAb, the difference in mortality among shock patients treated with placebo or TNF-alpha MAb was not significant.

Efficacy and Safety of Monoclonal Antibody to Human Tumor Necrosis Factor α in Patients With Sepsis Syndrome

<h3>Objective.</h3> —To evaluate the efficacy and safety of anti—tumor necrosis factor α monoclonal antibody (TNF-α MAb) in the treatment of patients with sepsis syndrome. <h3>Design.</h3> —Randomized, prospective, multicenter, double-blind, placebo-controlled clinical trial. <h3>Setting.</h3> —A total of 31 hospitals in the United States and Canada. <h3>Patients.</h3> —There were 994 patients with sepsis syndrome enrolled in this clinical trial, and 971 patients were infused with the study drug. <h3>Intervention.</h3> —Patients were prospectively stratified into shock or nonshock groups and then randomized to receive a single infusion of 15 mg/kg of TNF-α MAb, 7.5 mg/kg of TNF-α MAb, or placebo. Patients received standard aggressive medical and surgical care during the 28-day postinfusion period. <h3>Outcome Measure.</h3> —Twenty-eight-day all-cause mortality. <h3>Results.</h3> —The distribution of variables describing demographics, organ system dysfunction or failure, preinfusion Acute Physiology and Chronic Health Evaluation II score, number of organs failing at baseline, initial sites of infection, infecting microorganisms, antimicrobials used, and initial invasive procedures was similar among patients in the TNF-α MAb and placebo treatment arms. Among all infused patients, there was no difference in all-cause mortality in patients who received placebo as compared with those who received TNF-α MAb. In septic patients with shock (n=478), there was a trend toward a reduction in all-cause mortality, which was most evident 3 days after infusion: 25 of 162 patients treated with 15 mg/kg of TNF-α MAb died, 22 of 156 patients treated with 7.5 mg/kg of TNF-α MAb died, and 44 of 160 patients in the placebo group died (15 mg/kg: 44% reduction vs placebo,<i>P</i>=.01; 7.5 mg/kg: 48.7% reduction vs placebo,<i>P</i>=.004). At day 28, the reduction in mortality for shock patients was not significant for either dose of TNF-α MAb relative to placebo (15 mg/kg, 61 deaths among 162 patients [37.7% mortality]; 7.5 mg/kg, 59 deaths among 156 patients [37.8% mortality]; placebo, 73 deaths among 160 patients [45.6% mortality];<i>P</i>=.20 for 7.5 mg/kg and<i>P</i>=.15 for 15 mg/kg). Serious adverse events were reported in 4.6% of all infused patients. No immediate hypersensitivity allergic reactions due to TNF-α MAb were reported. Serum sickness—like reactions were seen in 2.5% of patients receiving TNF-α MAb. <h3>Conclusions.</h3> —There was no decrease in mortality between placebo and TNF-α MAb in all infused patients. In septic shock patients who received TNF-α MAb, a significant reduction in mortality was present 3 days after infusion. Although a trend toward reduced mortality continued at 28 days following treatment with TNF-α MAb, the difference in mortality among shock patients treated with placebo or TNF-α MAb was not significant. (<i>JAMA</i>. 1995;273:934-941)