Prognosis Of Cardiogenic Shock Research Articles

Relationship between the albumin-corrected anion gap and short-term prognosis among patients with cardiogenic shock: a retrospective analysis of the MIMIC-IV and eICU databases

ObjectivesWe aimed to investigate the association between the albumin-corrected anion gap (ACAG) and the prognosis of cardiogenic shock (CS).DesignA multicentre retrospective cohort study.SettingData were collected from the Medical Information Mart...

Impact of symptom duration and mechanical circulatory support on prognosis in cardiogenic shock complicating acute myocardial infarction.

Mortality rates in patients with cardiogenic shock complicating acute myocardial infarction (AMICS) remain high despite advancements in AMI care. Our study aimed to investigate the impact of prehospital symptom duration on the prognosis of AMICS patients and those receiving mechanical circulatory support (MCS). We conducted aretrospective cohort study with data registered in the Netherlands Heart Registration. Atotal of 1,363 patients with AMICS who underwent percutaneous coronary intervention between 2017 and 2021 were included. Patients presenting after out-of-hospital cardiac arrest were excluded. Most patients were male (68%), with amedian age of 69years (IQR 61-77), predominantly presenting with ST-elevation myocardial infarction (86%). The overall 30-day mortality was 32%. Longer prehospital symptom duration was associated with ahigher 30-day mortality with the following rates: < 3 h, 26%; 3-6 h, 29%; 6-24 h, 36%; ≥ 24 h, 46%; p < 0.001. In asubpopulation of AMICS patients with MCS (n = 332, 24%), symptom duration of > 24 h was associated with significantly higher mortality compared to symptom duration of < 24 h (59% vs 45%, p = 0.029). Multivariate analysis identified > 24 h symptom duration, age and in-hospital cardiac arrest as predictors of 30-day mortality in MCS patients. Prolonged prehospital symptom duration was associated with significantly increased 30-day mortality in patients presenting with AMICS. In AMICS patients treated with MCS, asymptom duration of > 24 h was an independent predictor of poor survival. These results emphasise the critical role of early recognition and intervention in the prognosis of AMICS patients.

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.

Gender differences in cardiogenic shock: characteristics and prognosis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Clinico San Carlos. Background Cardiogenic shock (CS) is a life-threatening condition caused by severe heart dysfunction. While significant advances have been made in the management and treatment of cardiogenic shock, there is growing recognition of the importance of considering gender-specific differences in the presentation and outcomes of this condition. Recent research highlights gender-related variations in how the condition is presented, managed, and its outcomes. Understanding these differences is crucial for tailored and effective treatment. Our goal is to identify potential gender differences in terms of the characteristics and prognosis of CS. Methods From 2013 to 2023, 142 consecutive patients diagnosed with CS in and admitted to an Acute Cardiac Care Unit in a tertiary care hospital were recruited. Demographic, clinical, and analytical variables were retrospectively collected. Patient were followed-up to November-2023 and clinical events were also recorded. For purposes of analysis, patients were classified in woman (N=95) and men (N=47). Success, in terms of IABP use, was defined as patient’s survival to the index event. Failure of IABP was defined as in-hospital death. A multivariate logistic regression analysis was performed to identify potential predictors of success. A descriptive analysis of clinical, analytical, and demographic parameters was performed in both groups, followed by a survival curve analysis to assess differences in prognosis between both sexes. Results Mean age was 67.3±12.2 years and 67.0% were females. There were no significant differences in cardiovascular risk factor and comorbidities between groups: hypertension (61.2% vs 38.8%, p 0.077), diabetes (65.9% vs 34.1%, p 0.866), chronic kidney disease (75% vs 25%, p 0.465), previous stroke (61.5% vs 38.5%, p 0.666) in woman vs men group respectively. STEMI was the most frequent cause of CS requiring an IABP in men (33.7%) but NSTEMI was in women (67.7%). Regarding the CS classification, both groups had a similar distribution of the severity and complexity of the shock (Figure 1). There were also no differences in hemodynamic parameters, analytical results, complete revascularization, and left ventricular ejection fraction (LVEF) between men and women (Figure 1). There were also no differences in hemodynamic parameters, analytical results, complete revascularization, and left ventricular ejection fraction (LVEF) between men and women (Figure 1). The complications, mortality (Figure 2), and long-term mortality were also similar in both groups. Conclusions In our observational study, there were no differences between genders in terms of characteristics, shock complexity, and prognosis.

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.

Impact of chronic total occlusion on prognosis in cardiogenic shock due to unprotected left main coronary artery culprit lesion. Insights from the Polish Registry of Acute Coronary Syndromes.

Notwithstanding readily available revascularization, significant advancements in mechanical circulatory support, and pharmacological progress, cardiogenic shock (CS) secondary to unprotected left main culprit lesion-related acute myocardial infarction (ULMCL-related AMI) is associated with very high mortality. In this population, chronic total occlusion (CTO) is relatively frequent. This study sought to assess the association between the presence of CTO and 12-month mortality in patients with CS due to ULMCL-related AMI. The study included consecutive patients admitted for AMI-related CS with ULMCL who underwent percutaneous coronary intervention (PCI) and were enrolled in the prospective Polish Registry of Acute Coronary Syndromes (PL-ACS) between January 2017 and December 2021. The patients were stratified into two groups based on the presence of at least one CTO. The primary endpoint was all-cause death at 12 months. Of the 250 included patients, 60 (24%) patients had one or more CTOs of a major coronary artery (+CTO), and in 190 (76%) patients, the presence of CTO was not observed (-CTO). The 12-month mortality rates for the +CTO and -CTO patients were 85% and 69.8%, respectively (P log-rank = 0.03). After multivariable adjustment for differences in the baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (hazard ratio, 1.423; 95% CI, 1.027-1.973; P = 0.034). Our analysis showed that in patients with CS due to ULMCL-related AMI treated with PCI, the presence of CTO is associated with worse 12-month prognosis.

Treatment of Acute Myocardial Infarction and Cardiogenic Shock: Outcomes of the RECOVER III Postapproval Study by Society of Cardiovascular Angiography and Interventions Shock Stage.

The Society for Cardiovascular Angiography and Interventions proposed a staging system (A-E) to predict prognosis in cardiogenic shock. Herein, we report clinical outcomes of the RECOVER III study for the first time, according to Society for Cardiovascular Angiography and Interventions shock classification. The RECOVER III study is an observational, prospective, multicenter, single-arm, postapproval study of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support. Patients enrolled in the RECOVER III study were assigned a baseline Society for Cardiovascular Angiography and Interventions shock stage. Staging was then repeated within 24 hours after initiation of Impella. Kaplan-Meier survival curve analyses were conducted to assess survival across Society for Cardiovascular Angiography and Interventions shock stages at both time points. At baseline assessment, 16.5%, 11.4%, and 72.2% were classified as stage C, D, and E, respectively. At ≤24-hour assessment, 26.4%, 33.2%, and 40.0% were classified as stage C, D, and E, respectively. Thirty-day survival among patients with stage C, D, and E shock at baseline was 59.7%, 56.5%, and 42.9%, respectively (P=0.003). Survival among patients with stage C, D, and E shock at ≤24 hours was 65.7%, 52.1%, and 29.5%, respectively (P<0.001). After multivariable analysis of impact of shock stage classifications at baseline and ≤24 hours, only stage E classification at ≤24 hours was a significant predictor of mortality (odds ratio, 4.8; P<0.001). In a real-world cohort of patients with acute myocardial infarction with cardiogenic shock undergoing percutaneous coronary intervention with Impella support, only stage E classification at ≤24 hours was significantly predictive of mortality, suggesting that response to therapy may be more important than clinical severity of shock at presentation.

Circulating dipeptidyl peptidase 3: new hope for a specific treatment to improve prognosis in cardiogenic shock?

Circulating dipeptidyl peptidase 3: new hope for a specific treatment to improve prognosis in cardiogenic shock?

Association between short-term systemic use of glucocorticoids and prognosis of cardiogenic shock: a retrospective analysis

ObjectiveTo investigate the prescription rate of short-term systemic use of glucocorticoids during hospitalization in patients with cardiogenic shock (CS), and outcomes related with glucocorticoid use.MethodsWe extracted patients' information from the Medical Information Mart for Intensive Care IV version 2.0 (MIMIC-IV v2.0) database. The primary endpoint was 90-day all-cause mortality. Secondary safety endpoints were infection identified by bacterial culture and at least one episode of hyperglycemia after ICU admission. Propensity score matching (PSM) was used to balance baseline characteristics. The difference in cumulative mortality rate between these treated with and without glucocorticoids was assessed by Kaplan–Meier curve with log-rank test. Independent risk factors for endpoints were identified by Cox or Logistic regression analysis.ResultsA total of 1528 patients were enrolled, and one-sixth of these patients received short-term systemic therapy of glucocorticoids during hospitalization. These conditions, including rapid heart rate, the presence of rheumatic disease, chronic pulmonary disease and septic shock, high lactate level, the requirements of mechanical ventilation and continuous renal replacement therapy, were associated with an increase in glucocorticoid administration (all P ≤ 0.024). During a follow-up of 90 days, the cumulative mortality rate in patients treated with glucocorticoids was significantly higher than that in these untreated with glucocorticoids (log-rank test, P < 0.001). Multivariable Cox regression analysis showed that glucocorticoid use (hazard ratio 1.48, 95% confidence interval [CI] 1.22–1.81; P < 0.001) was independently associated with an increased risk for 90-day all-cause mortality. This result was consistent irrespective of age, gender, the presence of myocardial infarction, acute decompensated heart failure and septic shock, and inotrope therapy, but was more evident in low-risk patients as assessed by ICU scoring systems. Additionally, multivariable Logistic regression analysis showed that glucocorticoid exposure was an independent predictor of hyperglycemia (odds ratio 2.14, 95% CI 1.48–3.10; P < 0.001), but not infection (odds ratio 1.23, 95% CI 0.88–1.73; P = 0.221). After PSM, glucocorticoid therapy was also significantly related with increased risks of 90-day mortality and hyperglycemia.ConclusionsReal-world data showed that short-term systemic use of glucocorticoids was common in CS patients. Importantly, these prescriptions were associated with increased risks of adverse events.

Impact of pre-existing history of heart failure on patient profile, therapeutic management and prognosis in cardiogenic shock: Insights from the FRENSHOCK registry

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Emergency and Acute Cardiovascular Care Working Group from the French Society of Cardiology Aims There is a large heterogeneity in patients presenting with cardiogenic shock (CS). To better apprehend this heterogeneity is crucial to adapt treatment and improve prognosis in these severe patients. Of note the presence (or absence) of a pre-existing history of chronic heart failure (CHF) at time of CS onset may be entire part of this heterogeneity and data focusing on this aspect are lacking. Methods We aimed to compare CS patients with new-onset HF to those with worsening CHF in the multicenter FRENSHOCK registry. Altogether, 772 CS patients were prospectively included: 433 with a previous history of CHF and 339 without. Worsening CHF patients were older (68 +/- 13.4 vs. 62.7 +/- 16.2, p&amp;lt;0.001) and had a greater burden of extra-cardiac co-morbidities. At admission, acute myocardial infarction was predominantly observed in the new-onset HF group (49.9% vs. 25.6%, p&amp;lt;0.001). When focusing on hemodynamic parameters, worsening CHF patients showed more congestion and higher ventricular filling pressures. Worsening CHF patients experienced higher in-hospital all-cause mortality (31.3% vs. 24.2%, p=0.029). Conclusions Our results emphasize the great heterogeneity of the patients presenting with CS. Worsening CHF patients had higher risk profile and this translated in a 30% increase in in-hospital all-cause mortality. The heterogeneity of this population prompts us to better determine the phenotype of CS patients to adapt their management.

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.

Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry.

The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching. 273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528). AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Effect of Hemoglobin Levels in Patients with Cardiogenic Shock of Any Cause: Insights from a Single-Centre, Prospective Registry.

Data regarding the short-term prognostic impact of hemoglobin levels in cardiogenic shock (CS) patients is limited. The study examines the prognostic impact of hemoglobin levels in patients with CS. Consecutive patients with CS of any etiology from 2019 to 2021 were included at one institution. Hemoglobin levels were retrieved from the day of admission (i.e., day 1), and on days 2, 3, 4, and 8 of intensive care unit (ICU) treatment thereafter. The primary endpoint was 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman´s correlations, C-statistics, Kaplan-Meier analyses as well as multivariable logistic and Cox regression analyses. From a total of 250 consecutive patients admitted with CS, 54% died within 30 days. Hemoglobin levels on day 4 and on day 8 were associated with moderate discrimination for 30-day all-cause mortality (area under the curve (AUC) 0.598 - 0.666), whereas hemoglobin level on day 1 was not predictive for 30-day all-cause mortality (AUC = 0.504). There was no association with 30-day all-cause mortality when stratified by the presence of anemia (defined as hemoglobin level < 12 g/dL) on day 1 (54% vs. 55%; log rank p = 0.906; HR = 0.981; 95% CI 0.698 - 1.378; p = 0.910). However, a decrease of hemoglobin by > 2 g/dL from day 1 to day 3 of ICU treatment was associated with an increased risk of 30-day all-cause mortality (56% vs. 41%; log rank p = 0.014; HR = 1.831; 95% CI 1.108 - 3.026; p = 0.018). Hemoglobin levels on day 1 were not associated with prognosis in CS. However, an early decrease of hemoglobin levels from day 1 to day 3 indicated impaired short-term prognosis in CS patients.

Impact of Pre-Existing History of Heart Failure on Patient Profile, Therapeutic Management, and Prognosis in Cardiogenic Shock: Insights from the FRENSHOCK Registry.

There is a large heterogeneity among patients presenting with cardiogenic shock (CS). It is crucial to better apprehend this heterogeneity in order to adapt treatments and improve prognoses in these severe patients. Notably, the presence (or absence) of a pre-existing history of chronic heart failure (CHF) at time of CS onset may be a significant part of this heterogeneity, and data focusing on this aspect are lacking. We aimed to compare CS patients with new-onset HF to those with worsening CHF in the multicenter FRENSHOCK registry. Altogether, 772 CS patients were prospectively included: 433 with a previous history of CHF and 339 without. Worsening CHF patients were older (68 +/- 13.4 vs. 62.7 +/- 16.2, p &lt; 0.001) and had a greater burden of extra-cardiac comorbidities. At admission, acute myocardial infarction was predominantly observed in the new-onset HF group (49.9% vs. 25.6%, p &lt; 0.001). When focusing on hemodynamic parameters, worsening CHF patients showed more congestion and higher ventricular filling pressures. Worsening CHF patients experienced higher in-hospital all-cause mortality (31.3% vs. 24.2%, p = 0.029). Our results emphasize the great heterogeneity of the patients presenting with CS. Worsening CHF patients had higher risk profiles, and this translated to a 30% increase in in-hospital all-cause mortality. The heterogeneity of this population prompts us to better determine the phenotype of CS patients to adapt their management.

Abstract 14685: Predictors of Prognosis in Cardiogenic Shock Complicating Initially Acute Myocardial Infarction

Introduction: Despite modern treatment methods, cardiogenic shock mortality complicates acute myocardial infarction (CS-AMI) remains high. Hypothesis: The study of factors affecting CS-AMI outcomes is essential. Methods: Data from the all-comers' National Registry of Coronary Interventions from 2016 to 2020 were evaluated. Of 50,745 patients with AMI (STEMI/NSTEMI) 2,822 patients (5.6%) had initially CS (72.6% men, mean age 67.6 (12) yrs). The study analyzed the predictive value of such traditional cardiovascular risk factors related to the MI (sex, age, previous PCI or CABG, renal failure, localization of MI, time delay to reperfusion), comorbidities (expressed by the Deyo modification of Charlson comorbidity index), the severity of the condition on admission (mechanical ventilation, resuscitation), the extent of coronary artery disease and procedural success (the number of affected vessels, TIMI flow before and after PCI, LM disease), and such untraditional factors as season, weekday and day time. Multivariable analysis was used to identify independent predictors of prognosis in patients with CS-AMI. Results: The 30days mortality was 50.7%. As independent predictors of prognosis were identified age (older 80yrs, OR 4.97;95% CI 3.73-6.61), resuscitation (1.34; 1.07-1.67), mechanical ventilation (1.39;1.10-1.75), 3-vessel disease 1.39;1.12-1.72), left main disease (1.26; 1.01-1.57), and post-procedural TIMI flow lower 3 (1.14; 0.79-1.66). The independent predictive value of the comorbidity index was not confirmed (1.062;0.796-1.417). The numerically higher mortality rate was shown during a) autumn time (54.2%) and winter (51.8%), b) weekend (51.45%) (vs. working week (50.03%)), c) working hours (49.3%) (vs. the after-working hours (47.6%)). The multivariate analysis did not confirm the independent predictive value of these variables. Conclusions: Mortality of CS-AMI patients is significantly and independently influenced by factors confounding their circulatory instability, such as resuscitation and respiratory failure, the extent of coronary disease, and the success of reperfusion therapy. The independent impact of comorbidity and non-traditional factors on the prognosis of these patients has not been confirmed.

Emerging biomarkers for risk stratification in cardiogenic shock: steps closer to precision?

The prognosis of cardiogenic shock (CS) remains poor despite advances in cardiovascular and critical care therapies, with in-hospital mortality remaining 30–50%.1,2 Heterogeneity among patients with CS—including on the basis of shock aetiology and contributing mechanisms, as well as clinical trajectory—may complicate early risk stratification and treatment selection.3–6 Subphenotyping patients with CS using blood-based biomarkers have accordingly been increasingly pursued.7 Biomarkers may provide important clinical information supporting individualized prognosis and treatment decision-making and may provide insight into mechanisms of disease. While markers of peripheral tissue metabolism and organ function are widely used clinical predictors, their use is limited by the fact that (i) they may lag behind clinical state, (ii) they reflect both acute and chronic influences, (iii) they represent final common pathway markers and are not aetiology-specific, and (iv) they may be abnormal due to aetiologies beyond the adequacy of perfusion (e.g. lactate may rise in response to exogenous epinephrine administration). While biomarkers of myocardial injury (troponin) and ventricular overload (brain natriuretic peptide) have significant prognostic ability in other cardiac conditions, their performance in CS is suboptimal.8 Given that inflammation plays key roles in the pathophysiology of CS,9 a number of studies have evaluated the performance of inflammatory and immune biomarkers such as C-reactive protein,10 neutrophil-to-lymphocyte ratio,11 growth-differentiating factor 15,12 and angiopoietin 2.13 The extent of systemic inflammation may vary from patient-to-patient with CS: recent work suggests that a subset of patients with myocardial infarction experience more significant transcriptional upregulation of acute inflammatory pathways,14 potentially contributing to the presence of superimposed inflammatory shock in some patients with CS—a clinically important group given their worse prognosis and differing haemodynamic profile.15 The availability of biomarkers to identify and possibly predict clinical trajectory on the basis of shock mechanism may possibly support early therapeutic decision-making.

Gender Differences in Cardiogenic Shock Patients: Clinical Features, Risk Prediction, and Outcomes in a Hub Center.

IntroductionThere is scarce knowledge about gender differences in clinical presentation, management, use of risk stratification tools and prognosis in cardiogenic shock (CS) patients.PurposeThe primary endpoint was to investigate the differences in characteristics, management, and in-hospital mortality according to gender in a cohort of CS patients admitted to a tertiary hub center. The secondary endpoint was to evaluate the prognostic performance of the Society of Cardiovascular Angiography and Interventions (SCAI) classification in predicting in-hospital mortality according to sex.MethodsThis is a retrospective single-Center cohort study of CS patients treated by a multidisciplinary shock team between September 2014 and December 2020. Baseline characteristics and clinical outcomes according to gender were registered. Discrimination of SCAI classification was assessed using the area under the receiver operating characteristic curve (AUC).ResultsOverall, 163 patients were included, 39 of them female (24%). Mean age of the overall cohort was 55 years (44–62), similar between groups. Compared with men, women were less likely to be smokers and the prevalence of COPD and diabetes mellitus was significantly lower in this group (p < 0.05). Postcardiotomy (44 vs. 31%) and fulminant myocarditis (13 vs. 2%) were more frequent etiologies in females than in males (p = 0.01), whereas acute myocardial infarction was less common among females (13 vs. 33%). Regarding management, the use of temporary mechanical circulatory support, mechanical ventilation, or renal replacement therapy was frequent and no different between the groups (88, 87, and 49%, respectively, in females vs. 42, 91, and 41% in males, p > 0.05). In-hospital survival in the overall cohort was 53%, without differences between groups (52% in females vs. 55% in males, p = 0.76). Most of the patients (60.7%) were in SCAIE at presentation without differences between sexes. The SCAI classification showed a moderate ability for predicting in-hospital mortality (overall, AUC: 0.653, 95% CI 0.582–0.725). The AUC was 0.636 for women (95% CI 0.491–0.780) and 0.658 for men (95% CI 0.575–0.740).ConclusionsOnly one in four of patients treated at a dedicated CS team were female. This may reflect differences in prevalence of severe heart disease at young (<65) ages, although a patient-selection bias cannot be ruled out. In this very high-risk CS population of multiple etiologies, overall, in-hospital survival was slightly above 50% and showed no differences between sexes. Treatment approaches, procedures, and SCAI risk stratification performance did not show gender disparities among treated patients.

Laboratory Predictors of Prognosis in Cardiogenic Shock Complicating Acute Myocardial Infarction.

Cardiogenic shock is a state of reduced cardiac output leading to hypotension, pulmonary congestion, and hypoperfusion of tissues and vital organs. Despite the advances in intensive care over the last years, the morbidity and mortality of patients remain high. The available studies of patients with cardiogenic shock suggest a connection between clinical variables, the level of biomarkers, the results of imaging investigations, strategies of management and the outcome of this group of patients. The management of patients with cardiogenic shock initially complicating acute myocardial infarction is challenging, and the number of studies in this area is growing fast. The purpose of this review is to summarize the currently available evidence on cardiogenic shock initially complicating acute myocardial infarction with particular attention to predictors of prognosis, focusing on laboratory variables (established and new), and to discuss the practical implementation. Currently available scoring systems developed during the past few decades predict the clinical outcome of this group of patients using some of the established biomarkers among other variables. With the new laboratory biomarkers that have shown their predictive value in cardiogenic shock outcomes, a new design of scoring systems would be of interest. Identifying high-risk patients offers the opportunity for early decision-making.

Sex Differences In All-Cause Mortality Following Institution Of Veno-Arterial ECMO As A Bridge To Definitive Management

Sex Differences In All-Cause Mortality Following Institution Of Veno-Arterial ECMO As A Bridge To Definitive Management

Clinical Characteristics and Predictors of In-Hospital Mortality in Patients With Cardiogenic Shock: Results From the RESCUE Registry.

In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean patients with CS. The RESCUE study (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With CS) is a multicenter, retrospective, and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality. In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and nonischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intraaortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multivariable analysis, age ≥70years (odds ratio [OR], 2.73 [95% CI, 1.89-3.94], P<0.001), body mass index <25 kg/m2 (OR, 1.52 [95% CI, 1.08-2.16], P=0.017), cardiac arrest at presentation (OR, 2.16 [95% CI, 1.44-3.23], P<0.001), vasoactive-inotrope score >80 (OR, 3.55 [95% CI, 2.54-4.95], P<0.001), requiring continuous renal replacement therapy (OR, 4.14 [95% CI, 2.88-5.95], P<0.001), mechanical ventilator (OR, 3.17 [95% CI, 2.16-4.63], P<0.001), intraaortic balloon pump (OR, 1.55 [95% CI, 1.07-2.24], P=0.020), and extracorporeal membrane oxygenator (OR, 1.85 [95% CI, 1.25-2.76], P=0.002) were independent predictors for in-hospital mortality. The in-hospital mortality of patients with CS remains high despite the high utilization of mechanical circulatory support. Age, low body mass index, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure requiring various support devices were poor prognostic factors for in-hospital mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.