Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations: Review of Heart Failure-Related Cardiogenic Shock

The various perioperative issues of structural heart diseases and cardiogenic shock

Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.

The medical treatment of cardiogenic shock

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

Hemodynamic management of cardiogenic shock in the intensive care unit

Hemodynamic derangements are defining features of cardiogenic shock. Randomized clinical trials have examined the efficacy of various therapeutic interventions, from percutaneous coronary intervention to inotropes and mechanical circulatory support (MCS). However, hemodynamic management in cardiogenic shock has not been well-studied. This State-of-the-Art review will provide a framework for hemodynamic management in cardiogenic shock, including a description of the 4 therapeutic phases from initial 'Rescue' to 'Optimization', 'Stabilization' and 'de-Escalation or Exit therapy' (R-O-S-E), phenotyping and phenotype-guided tailoring of pharmacological and MCS support, to achieve hemodynamic and therapeutic goals. Finally, the premises that form the basis for clinical management and the hypotheses for randomized controlled trials will be discussed, with a view to the future direction of cardiogenic shock.

Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock

OBJECTIVE

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS.

METHODS

Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation.

RESULTS

105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = .054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = .027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007-4.774; p = .048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = .015), which, however, could not be confirmed in multivariable Cox regression.

CONCLUSION

The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.

Practical Guidance for Hemodynamic Assessment by Right Heart Catheterization in Management of Heart Failure

Heart failure is a clinical syndrome characterized by the inability of the heart to meet the circulatory demands of the body without requiring an increase in intracardiac pressures at rest or with exertion. Hemodynamic parameters can be measured via right heart catheterization, which has an integral role in the full spectrum of heart failure: from ambulatory patients to those in cardiogenic shock, as well as patients being considered for left ventricular device therapy and heart transplantation. Hemodynamic data are critical for prompt recognition of clinical deterioration, assessment of prognosis, and guidance of treatment decisions. This review is a field guide for hemodynamic assessment, troubleshooting, and interpretation for clinicians treating patients with heart failure.

Inotropic Agents: Are We Still in the Middle of Nowhere?

Inotropes are prescribed to enhance myocardial contractility while vasopressors serve to improve vascular tone. Although these medications remain a life-saving therapy in cardiovascular clinical scenarios with hemodynamic impairment, the paucity of evidence on these drugs makes the choice of the most appropriate vasoactive agent challenging. As such, deep knowledge of their pharmacological and hemodynamic effects becomes crucial to optimizing hemodynamic profile while reducing the potential adverse effects. Given this perspective, it is imperative for cardiologists to possess a comprehensive understanding of the underlying mechanisms governing these agents and to discern optimal strategies for their application across diverse clinical contexts. Thus, we briefly review these agents' pharmacological and hemodynamic properties and their reasonable clinical applications in cardiovascular settings. Critical interpretation of available data and the opportunities for future investigations are also highlighted.

The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.

Mechanical Circulatory Support in Cardiogenic Shock: Uses in the Emergency Setting

Cardiogenic shock is a lethal condition with significant morbidity, characterized by myocardial insults leading to low cardiac output and ensuing systemic hypoperfusion. While mortality rates remain high, we have improved upon our recognition and definition of cardiogenic shock, now with an emphasis on defining stages of shock to help guide effective treatment strategies with either pharmacologic or mechanical circulatory support. In this review, the authors summarize these stages as well as discuss indications, function, selection, and troubleshooting of the various temporary mechanical circulatory support devices.

The Intra-aortic Balloon Pump: A Focused Review of Physiology, Transport Logistics, Mechanics, and Complications

Critical care transport medicine (CCTM) teams are playing an increasing role in the care of patients in cardiogenic shock requiring mechanical circulatory support devices. Hence, it is important that CCTM providers are familiar with the pathophysiology of cardiogenic shock, the role of mechanical circulatory support, and the management of these devices in the transport environment. The intra-aortic balloon pump is a widely used and accessible cardiac support device capable of increasing cardiac output and reducing work on the left ventricle through diastolic augmentation and counterpulsation. This article reviews essential CCTM-based considerations for patients supported by intra-aortic balloon pump, including indications for placement, mechanics and physiology, potential issues during transport, and associated complications.

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

INTRODUCTION AND OBJECTIVES

Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV).

METHODS

Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis.

RESULTS

Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage.

CONCLUSIONS

NIV seems to be relatively effective and safe in the treatment of early-stage CS.

Acute Heart Failure: From The Emergency Department to the Intensive Care Unit

Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.

A new nomogram to predict in-hospital mortality in patients with acute decompensated chronic heart failure and diabetes after 48 Hours of Intensive Care Unit

BACKGROUND

The study set out to develop an accurate and clinically valuable prognostic nomogram to assess the risk of in-hospital death in patients with acute decompensated chronic heart failure (ADCHF) and diabetes.

METHODS

We extracted clinical data of patients diagnosed with ADCHF and diabetes from the Medical Information Mart for Intensive Care III database. Risk variables were selected utilizing least absolute shrinkage and selection operator regression analysis, and were included in multivariate logistic regression and presented in nomogram. bootstrap was used for internal validation. The discriminative power and predictive accuracy of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC), calibration curve and decision curve analysis (DCA).

RESULTS

Among 867 patients with ADCHF and diabetes, In-hospital death occurred in 81 (9.3%) patients. Age, heart rate, systolic blood pressure, red blood cell distribution width, shock, β-blockers, angiotensin converting enzyme inhibitors or angiotensin receptor blockers, assisted ventilation, and blood urea nitrogen were brought into the nomogram model. The calibration curves suggested that the nomogram was well calibrated. The AUC of the nomogram was 0.873 (95% CI: 0.834-0.911), which was higher that of the Simplified Acute Physiology Score II [0.761 (95% CI: 0.711-0.810)] and sequential organ failure assessment score [0.699 (95% CI: 0.642-0.756)], and Guidelines-Heart Failure score [0.782 (95% CI: 0.731-0.835)], indicating that the nomogram had better ability to predict in-hospital mortality. In addition, the internally validated C-index was 0.857 (95% CI: 0.825-0.891), which again verified the validity of this model.

CONCLUSIONS

This study constructed a simple and accurate nomogram for predicting in-hospital mortality in patients with ADCHF and diabetes, especially in those who admitted to the intensive care unit for more than 48 hours, which contributed clinicians to assess the risk and individualize the treatment of patients, thereby reducing in-hospital mortality.

Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis

BACKGROUND

Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of "spoke" centers to tertiary/"hub" centers with higher capabilities. However, outcomes associated with such transfers are largely unknown beyond those reported in individual health networks.

OBJECTIVES

To analyze a contemporary, multicenter CS cohort with the aim of comparing characteristics and outcomes of patients between transfer (between spoke and hub centers) and nontransfer cohorts (those primarily admitted to a hub center) for both acute myocardial infarction (AMI-CS) and heart failure-related HF-CS. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality.

METHODS

The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high-volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020.

RESULTS

Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these patients, 528 (58.1%) had heart failure-related CS (HF-CS), and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stages C and D, when compared to nontransfer patients. Transfer patients had higher mortality rates (37% vs 29%, < 0.001) than nontransfer patients; the differences were driven primarily by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer or within 24 hours of arrival was associated with decreased mortality rates. Among transfer AMI-CS patients, BMI > 28 kg/m2, worsening renal failure, lactate > 3 mg/dL, and increasing numbers of vasoactive drugs were associated with increased mortality rates.

CONCLUSION

More than half of patients with CS managed at high-volume CS centers were transferred from another hospital. Although transfer patients had higher mortality rates than those who were admitted primarily to hub centers, the outcomes and their predictors varied significantly when classified by HF-CS vs AMI-CS.

Racial disparities among patients with cardiac sarcoidosis and arrhythmias in the United States: A propensity matched-analysis from the national inpatient sample database 2016-2020

BACKGROUND

Cardiac sarcoidosis (CS) is frequently associated with conduction abnormalities and arrhythmias. In this study, we aim to evaluate racial disparities in the frequency of arrhythmias, and associated co-morbidities, among patients with CS.

METHODS

White and African American (AA) patients diagnosed with CS were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models.

RESULTS

A total of 7,935 patients with CS were included in the study. The propensity-matched sample comprised of 5,570 patients, of whom 2,785 were White and 2,785 were AA. AA patients had a longer mean length of hospital stay (LOS) (7.84 vs. 6.94, p<0.01), a higher mean Charlson Comorbidity Index (CCI) score (3.10 vs. 2.84, p<0.01), and significantly higher incidences of cardiogenic shock [(9.2% vs 6.3%, p<0.01), aOR 1.45 (95% CI 1.17-1.78), p<0.01] and acute kidney injury (AKI) [(34.3% vs. 26.9%, p<0.01), aOR 1.41 (95% CI 1.24-1.61), p<0.01]. From an arrhythmia perspective, AA CS patients were shown to have a lower frequency of: (1) ventricular tachycardia (32.5% vs. 37.9%, p<0.01), (2) ventricular fibrillation (5.4% vs.7.2%, p<0.01), (3) first-degree AV block (1.8% vs. 4.1%, p<0.01), (4) complete AV block (6.3% vs. 14.2%, p<0.01), and (5) atrial fibrillation (31.8% vs. 34.8%, p=0.016) when compared to Whites with CS. Mortality remained higher for AAs (3.8% vs. 2.7%, p=0.024).

CONCLUSION

Our study demonstrates a higher incidence of cardiac arrhythmias among White patients but a higher incidence of cardiogenic shock, AKI, mean LOS, and mortality among AA patients with cardiac sarcoidosis.

Management of cardiogenic shock: a narrative review

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

Contemporary approach to cardiogenic shock care: a state-of-the-art review

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Dynamic load modulation predicts right heart tolerance of left ventricular cardiovascular assist in a porcine model of cardiogenic shock

Ventricular assist devices (VADs) offer mechanical support for patients with cardiogenic shock by unloading the impaired ventricle and increasing cardiac outflow and subsequent tissue perfusion. Their ability to adjust ventricular assistance allows for rapid and safe dynamic changes in cardiac load, which can be used with direct measures of chamber pressures to quantify cardiac pathophysiologic state, predict response to interventions, and unmask vulnerabilities such as limitations of left-sided support efficacy due to intolerance of the right heart. We defined hemodynamic metrics in five pigs with dynamic peripheral transvalvular VAD (pVAD) support to the left ventricle. Metrics were obtained across a spectrum of disease states, including left ventricular ischemia induced by titrated microembolization of a coronary artery and right ventricular strain induced by titrated microembolization of the pulmonary arteries. A sweep of different pVAD speeds confirmed mechanisms of right heart decompensation after left-sided support and revealed intolerance. In contrast to the systemic circulation, pulmonary vascular compliance dominated in the right heart and defined the ability of the right heart to adapt to left-sided pVAD unloading. We developed a clinically accessible metric to measure pulmonary vascular compliance at different pVAD speeds that could predict right heart efficiency and tolerance to left-sided pVAD support. Findings in swine were validated with retrospective hemodynamic data from eight patients on pVAD support. This methodology and metric could be used to track right heart tolerance, predict decompensation before right heart failure, and guide titration of device speed and the need for biventricular support.

Cardiogenic Shock: Pathogenesis, Classification, and Management

Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.

Impact of Female Sex on Cardiogenic Shock Outcomes: A Cardiogenic Shock Working Group Report

BACKGROUND

Studies reporting cardiogenic shock (CS) outcomes in women are scarce.

OBJECTIVES

The authors compared survival at discharge among women vs men with CS complicating acute myocardial infarction (AMI-CS) and heart failure (HF-CS).

METHODS

The authors analyzed 5,083 CS patients in the Cardiogenic Shock Working Group. Propensity score matching (PSM) was performed with the use of baseline characteristics. Logistic regression was performed for log odds of survival.

RESULTS

Among 5,083 patients, 1,522 were women (30%), whose mean age was 61.8 ± 15.8 years. There were 30% women and 29.1% men with AMI-CS (P = 0.03). More women presented with de novo HF-CS compared with men (26.2% vs 19.3%; P < 0.001). Before PSM, differences in baseline characteristics and sex-specific outcomes were seen in the HF-CS cohort, with worse survival at discharge (69.9% vs 74.4%; P = 0.009) and a higher rate of maximum Society for Cardiac Angiography and Interventions stage E (26% vs 21%; P = 0.04) in women than in men. Women were less likely to receive pulmonary artery catheterization (52.9% vs 54.6%; P < 0.001), heart transplantation (6.5% vs 10.3%; P < 0.001), or left ventricular assist device implantation (7.8% vs 10%; P = 0.01). Regardless of CS etiology, women had more vascular complications (8.8% vs 5.7%; P < 0.001), bleeding (7.1% vs 5.2%; P = 0.01), and limb ischemia (6.8% vs 4.5%; P = 0.001). More vascular complications persisted in women after PSM (10.4% women vs 7.4% men; P = 0.06).

CONCLUSIONS

Women with HF-CS had worse outcomes and more vascular complications than men with HF-CS. More studies are needed to identify barriers to advanced therapies, decrease complications, and improve outcomes of women with CS.

Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock

BACKGROUND

Pulmonary artery catheters (PACs) are increasingly used to guide management decisions in cardiogenic shock (CS). The goal of this study was to determine if PAC use was associated with a lower risk of in-hospital mortality in CS owing to acute heart failure (HF-CS).

METHODS AND RESULTS

This multicenter, retrospective, observational study included patients with CS hospitalized between 2019 and 2021 at 15 US hospitals participating in the Cardiogenic Shock Working Group registry. The primary end point was in-hospital mortality. Inverse probability of treatment-weighted logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CI), accounting for multiple variables at admission. The association between the timing of PAC placement and in-hospital death was also analyzed. A total of 1055 patients with HF-CS were included, of whom 834 (79%) received a PAC during their hospitalization. In-hospital mortality risk for the cohort was 24.7% (n = 261). PAC use was associated with lower adjusted in-hospital mortality risk (22.2% vs 29.8%, OR 0.68, 95% CI 0.50-0.94). Similar associations were found across SCAI stages of shock, both at admission and at maximum SCAI stage during hospitalization. Early PAC use (≤6 hours of admission) was observed in 220 PAC recipients (26%) and associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, OR 0.54, 95% CI 0.37-0.81).

CONCLUSIONS

This observational study supports PAC use, because it was associated with decreased in-hospital mortality in HF-CS, especially if performed within 6 hours of hospital admission.

CONDENSED ABSTRACT

An observational study from the Cardiogenic Shock Working Group registry of 1055 patients with HF-CS showed that pulmonary artery catheter (PAC) use was associated with a lower adjusted in-hospital mortality risk (22.2% vs 29.8%, odds ratio 0.68, 95% confidence interval 0.50-0.94) compared with outcomes in patients managed without PAC. Early PAC use (≤6 hours of admission) was associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, odds ratio 0.54, 95% confidence interval 0.37-0.81).

Advances in the Management of Cardiogenic Shock

OBJECTIVES

To review a contemporary approach to the management of patients with cardiogenic shock (CS).

DATA SOURCES

We reviewed salient medical literature regarding CS.

STUDY SELECTION

We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials.

DATA EXTRACTION

We extracted salient study results and scientific statement recommendations regarding the management of CS.

DATA SYNTHESIS

Professional society recommendations were integrated with evaluated studies.

CONCLUSIONS

CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.

Age‑adjusted Charlson comorbidity index and in‑hospital mortality in critically ill patients with cardiogenic shock: A retrospective cohort study

Evidence regarding the relationship between age-adjusted Charlson comorbidity index (ACCI) and in-hospital mortality is limited. Therefore, the present study investigated whether there was an independent association between ACCI and in-hospital mortality in critically ill patients with cardiogenic shock (CS) after adjusting for other covariates (age, sex, history of disease, scoring system, in-hospital management, vital signs at presentation, laboratory findings and vasopressors). ACCI, calculated retrospectively after hospitalization between 2008 and 2019, was derived from intensive care unit (ICU) admissions at the Beth Israel Deaconess Medical Center (Boston, MA, USA). Patients with CS were classified into two categories based on predefined ACCI scores (low, <8; high, ≥8). Based on baseline ACCI, the risk of in-hospital mortality in patients with CS was calculated using a multivariate Cox proportional risk model, and the threshold effect was calculated using a two-piece linear regression model. The in-hospital mortality rate was ~1.5 times greater in the ACCI high group compared with that in the ACCI low group [hazard ratio (HR)=1.45; 95% confidence interval (CI), 1.14-1.86]. Additional analysis showed that ACCI had a curvilinear association with in-hospital mortality risk in patients with CS, with a saturation effect predicted at 4.5. When ACCI was >4.5, the risk of in-hospital CS death increased significantly with increasing ACCI (HR=1.122; 95% CI, 1.054-1.194). Overall, ACCI was an independent predictor of in-hospital mortality in ICU patients with CS. A non-linear relationship was revealed between ACCI and in-hospital mortality, where in-hospital mortality increased significantly when ACCI was >4.5.

Acute heart failure: differential diagnosis and treatment

Acute heart failure is a heterogeneous clinical syndrome and is the first cause of unplanned hospitalization in people >65 years. Patients with heart failure may have different clinical presentations according to clinical history, pre-existing heart disease, and pattern of intravascular congestion. A comprehensive assessment of clinical, echocardiographic, and laboratory data should aid in clinical decision-making and treatment. In some cases, a more accurate evaluation of patient haemodynamics via a pulmonary artery catheter may be necessary to undertake and guide escalation and de-escalation of therapy, especially when clinical, echo, and laboratory data are inconclusive or in the presence of right ventricular dysfunction. Similarly, a pulmonary artery catheter may be useful in patients with cardiogenic shock undergoing mechanical circulatory support. With the subsequent de-escalation of therapy and haemodynamic stabilization, the implementation of guideline-directed medical therapy should be pursued to reduce the risk of subsequent heart failure hospitalization and death, paying particular attention to the recognition and treatment of residual congestion.

Temporary mechanical circulatory support devices: practical considerations for all stakeholders

Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.

Update on cardiogenic shock: from detection to team management

PURPOSE OF REVIEW

The following review is intended to provide a summary of contemporary cardiogenic shock (CS) profiling and diagnostic strategies, including biomarker and hemodynamic-based (invasive and noninvasive) monitoring, discuss clinical differences in presentation and trajectory between acute myocardial infarction (AMI)-CS and heart failure (HF)-CS, describe transitions to native heart recovery and heart replacement therapies with a focus on tailored management and emerging real-world data, and emphasize trends in team-based initiatives and interventions for cardiogenic shock including the integration of protocol-driven care.

RECENT FINDINGS

This document provides a broad overview of contemporary scientific consensus statements as well as data derived from randomized controlled clinical trials and observational registry working groups focused on cardiogenic shock management.

SUMMARY

This review highlights the increasingly important role of pulmonary artery catheterization in AMI-CS and HF-CS cardiogenic shock and advocates for routine application of algorithmic approaches with interdisciplinary care pathways. Cardiogenic shock algorithms facilitate the integration of clinical, hemodynamic, and imaging data to determine the most appropriate patient hemodynamic support platform to achieve adequate organ perfusion and decongestion.

Use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock

AIMS

Despite its high incidence and mortality risk, there is no evidence-based treatment for non-ischaemic cardiogenic shock (CS). The aim of this study was to evaluate the use of mechanical circulatory support (MCS) for non-ischaemic CS treatment.

METHODS AND RESULTS

In this multicentre, international, retrospective study, data from 890 patients with non-ischaemic CS, defined as CS due to severe de-novo or acute-on-chronic heart failure with no need for urgent revascularization, treated with or without active MCS, were collected. The association between active MCS use and the primary endpoint of 30-day mortality was assessed in a 1:1 propensity-matched cohort. MCS was used in 386 (43%) patients. Patients treated with MCS presented with more severe CS (37% vs. 23% deteriorating CS, 30% vs. 25% in extremis CS) and had a lower left ventricular ejection fraction at baseline (21% vs. 25%). After matching, 267 patients treated with MCS were compared with 267 patients treated without MCS. In the matched cohort, MCS use was associated with a lower 30-day mortality (hazard ratio 0.76, 95% confidence interval 0.59-0.97). This finding was consistent through all tested subgroups except when CS severity was considered, indicating risk reduction especially in patients with deteriorating CS. However, complications occurred more frequently in patients with MCS; e.g. severe bleeding (16.5% vs. 6.4%) and access-site related ischaemia (6.7% vs. 0%).

CONCLUSION

In patients with non-ischaemic CS, MCS use was associated with lower 30-day mortality as compared to medical therapy only, but also with more complications. Randomized trials are needed to validate these findings.

Clinical Presentation and In-Hospital Trajectory of Heart Failure and Cardiogenic Shock

BACKGROUND

Heart failure-related cardiogenic shock (HF-CS) remains an understudied distinct clinical entity.

OBJECTIVES

The authors sought to profile a large cohort of patients with HF-CS focused on practical application of the SCAI (Society for Cardiovascular Angiography and Interventions) staging system to define baseline and maximal shock severity, in-hospital management with acute mechanical circulatory support (AMCS), and clinical outcomes.

METHODS

The Cardiogenic Shock Working Group registry includes patients with CS, regardless of etiology, from 17 clinical sites enrolled between 2016 and 2020. Patients with HF-CS (non-acute myocardial infarction) were analyzed and classified based on clinical presentation, outcomes at discharge, and shock severity defined by SCAI stages.

RESULTS

A total of 1,767 patients with HF-CS were included, of whom 349 (19.8%) had de novo HF-CS (DNHF-CS). Patients were more likely to present in SCAI stage C or D and achieve maximum SCAI stage D. Patients with DNHF-CS were more likely to experience in-hospital death and in- and out-of-hospital cardiac arrest, and they escalated more rapidly to a maximum achieved SCAI stage, compared to patients with acute-on-chronic HF-CS. In-hospital cardiac arrest was associated with greater in-hospital death regardless of clinical presentation (de novo: 63% vs 21%; acute-on-chronic HF-CS: 65% vs 17%; both P < 0.001). Forty-five percent of HF-CS patients were exposed to at least 1 AMCS device throughout hospitalization.

CONCLUSIONS

In a large contemporary HF-CS cohort, we identified a greater incidence of in-hospital death and cardiac arrest as well as a more rapid escalation to maximum SCAI stage severity among DNHF-CS. AMCS use in HF-CS was common, with significant heterogeneity among device types. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483).

Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction

Cardiogenic shock is an extreme manifestation of acute decompensated heart failure. Cardiogenic shock is often caused by-and has traditionally been studied in the setting of-acute myocardial infarction (AMI CS); however, there is increasing incidence and recognition of cardiogenic shock not associated with acute myocardial infarction (non-AMI CS) as a distinct entity. Despite decades of study and technologic advancements, cardiogenic shock mortality remains as high as 50%, regardless of etiology. New approaches to shock phenotyping and classification have emerged, with a focus on appropriately matching patient physiology to a growing list of available interventions. Further study is needed to determine whether these efforts will lead to more nuanced use of mechanical circulatory support and improved patient outcomes, especially in non-AMI CS. In the meantime, models of care incorporating multidisciplinary decision making, such as shock teams, may improve patient selection and outcomes.

Keep the Right in Mind-A Focused Approach to Right Ventricle-Predominant Cardiogenic Shock

Cardiogenic shock (CS) remains a highly lethal condition despite many efforts and new interventions. Patients presenting with a rapid onset of hemodynamic instability and subsequent collapse require prompt and appropriate multimodality treatment. Multiple etiologies can lead to heart failure and subsequent shock. As the case prevalence of heart failure increases worldwide, it is of great importance to explore all manners and protocols of presentation and treatment present. With research primarily focusing on CS due to cardiac left-sided pathology, few assessments of right-sided pathology and the subsequent clinical state and treatment have been conducted. This review aims to present an in-depth assessment of the currently available literature, assessing the pathophysiology, presentation and management of CS patients due to right heart failure.

Differences in the Clinical Outcome of Ischemic and Nonischemic Cardiomyopathy in Heart Failure With Concomitant Opioid Use Disorder

Heart Failure (HF) and Opioid Use Disorder (OUD) independently have significant impact on patients and the United States (US) health system. In the setting of the opioid epidemic, research on the effects of OUD on cardiovascular diseases is rapidly evolving. However, no study exists on differential outcomes of ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) in patients with HF with OUD. We performed a retrospective, observational cohort study using National Inpatient Sample (NIS) 2018-2020 databases. Patients aged 18 years and above with diagnoses of HF with concomitant OUD were included. Patients were further classified into ICM and NICM. Primary outcome of interest was differences in all- cause in-hospital mortality. Secondary outcome was incidence of cardiogenic shock. We identified 99,810 hospitalizations that met inclusion criteria, ICM accounted for 27%. Mean age for ICM was higher compared to NICM (63 years vs 56 years, P < 0.01). Compared to NICM, patients with ICM had higher cardiovascular disease risk factors and comorbidities; type 2 diabetes mellitus (46.3 % vs 30.1%, P < 0.01), atrial fibrillation/flutter (33.5% vs 29.9%, P < 0.01), hyperlipidemia (52.5% vs 28.9%, P < 0.01), and Charlson comorbidity index ≥5 was 46.7% versus 29.7%, P < 0.01. After controlling for covariates and potential confounders, we observed higher odds of all-cause in-hospital mortality in patients with NICM (aOR = 1.36; 95% CI:1.03-1.78, P = 0.02). There was no statistical significant difference in incidence of cardiogenic shock between ICM and NICM (aOR = 0.86;95% CI 0.70-1.07, P = 0.18). In patients with HF with concomitant OUD, we found a 36% increase in odds of all-cause in-hospital mortality in patients with NICM compared to ICM despite being younger in age with less comorbidities. There was no difference in odds of in-hospital cardiogenic shock in this study population. This study contributes to the discussion of OUD and cardiovascular diseases which is rapidly developing and requires further prospective studies.

Pharmacological treatment of cardiogenic shock - A state of the art review

Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.

SCAI Cardiogenic Shock Classification for Predicting In-Hospital and Long-Term Mortality in Acute Heart Failure

Background

SCAI classification in cardiogenic shock is simple and suitable for rapid assessment. Its predictive behavior in patients with primary acute heart failure (AHF) is not fully known. We aimed to evaluate the ability of the SCAI classification to predict in-hospital and long-term mortality in AHF.

Methods

We conducted a single-center study and performed a retrospective analysis of prospectively collected data of consecutive patients admitted with AHF between 2015 and 2020. The primary end points were in-hospital and long-term mortality from all causes.

Results

In total, 856 patients were included. The unadjusted in-hospital mortality was as follows: A, 0.6%; B, 2.7%; C, 21.5%; D 54.3%; and E, 90.6% (log rank, P < .0001), and long-term mortality was as follows: A, 24.9%; B, 24%; C, 49.6%; D, 62.9%; and E, 95.5% (log rank, P < .0001). After multivariable adjustment, each SCAI SHOCK stage remained associated with increased mortality (all P < .001 compared with stage A). With the exception of the long-term end point, there were no differences between stages A and B for adjusted mortality (P = .1).

Conclusions

In a cohort of patients with AHF, SCAI cardiogenic shock classification was associated with in-hospital and long-term mortality. This finding supports the rationale of the classification in this setting.

A Standardized and Regionalized Network of Care for Cardiogenic Shock

BACKGROUND

The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood.

OBJECTIVES

The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network.

METHODS

The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events.

RESULTS

Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44).

CONCLUSIONS

Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.

Left Ventricular Unloading in Acute on Chronic Heart Failure: From Statements to Clinical Practice

Cardiogenic shock remains a deadly complication of acute on chronic decompensated heart failure (ADHF-CS). Despite its increasing prevalence, it is incompletely understood and therefore often misdiagnosed in the early phase. Precise diagnosis of the underlying cause of CS is fundamental for undertaking the correct therapeutic strategy. Temporary mechanical circulatory support (tMCS) is the mainstay of management: identifying and selecting optimal patients through understanding of the hemodynamics and a prompt profiling and timing, is key for success. A recent statement from the American Heart Association provided pragmatic suggestions on tMCS device selection, escalation, and weaning strategies. However, several areas of uncertainty still remain in clinical practice. Accordingly, we present an overview of the main pitfalls that can occur during patients' management with tMCS through a clinical case. This case illustrates the strict interdependency between left ventricular unloading and right ventricular dysfunction in the case of low filling pressures. Moreover, it further illustrates the pivotal role of stepwise escalation of therapy in a patient with an ADHF-CS and its peculiarities as compared to other forms of acute heart failure.

[Pharmaceutical therapy of infarct-related cardiogenic shock]

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.

A Holistic View of Advanced Heart Failure

Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.

Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association

The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.

The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design

BACKGROUND

Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients.

METHODS

The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies.

CONCLUSIONS

The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.

Criteria for Defining Stages of Cardiogenic Shock Severity

BACKGROUND

Risk-stratifying patients with cardiogenic shock (CS) is a major unmet need. The recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) staging system for CS severity lacks uniform criteria defining each stage.

OBJECTIVES

The purpose of this study was to test parameters that define SCAI stages and explore their utility as predictors of in-hospital mortality in CS.

METHODS

The CS Working Group registry includes patients from 17 hospitals enrolled between 2016 and 2021 and was used to define clinical profiles for CS. We selected parameters of hypotension and hypoperfusion and treatment intensity, confirmed their association with mortality, then defined formal criteria for each stage and tested the association between both baseline and maximum Stage and mortality.

RESULTS

Of 3,455 patients, CS was caused by heart failure (52%) or myocardial infarction (32%). Mortality was 35% for the total cohort and higher among patients with myocardial infarction, out-of-hospital cardiac arrest, and treatment with increasing numbers of drugs and devices. Systolic blood pressure, lactate level, alanine transaminase level, and systemic pH were significantly associated with mortality and used to define each stage. Using these criteria, baseline and maximum stages were significantly associated with mortality (n = 1,890). Lower baseline stage was associated with a higher incidence of stage escalation and a shorter duration of time to reach maximum stage.

CONCLUSIONS

We report a novel approach to define SCAI stages and identify a significant association between baseline and maximum stage and mortality. This approach may improve clinical application of the staging system and provides new insight into the trajectory of hospitalized CS patients. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483).

Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes

BACKGROUND

Little is known about clinical characteristics, hospital course, and longitudinal outcomes of patients with cardiogenic shock (CS) related to heart failure (HF-CS) compared to acute myocardial infarction (AMI; CS related to AMI [AMI-CS]).

METHODS

We examined in-hospital and 1-year outcomes of 520 (219 AMI-CS, 301 HF-CS) consecutive patients with CS (January 3, 2017-December 31, 2019) in a single-center registry.

RESULTS

Mean age was 61.5±13.5 years, 71% were male, 22% were Black patients, and 63% had chronic kidney disease. The HF-CS cohort was younger (58.5 versus 65.6 years, P<0.001), had fewer cardiac arrests (15.9% versus 35.2%, P<0.001), less vasopressor utilization (61.8% versus 82.2%, P<0.001), higher pulmonary artery pulsatility index (2.14 versus 1.51, P<0.01), lower cardiac power output (0.64 versus 0.77 W, P<0.01) and higher pulmonary capillary wedge pressure (25.4 versus 22.2 mm Hg, P<0.001) than patients with AMI-CS. Patients with HF-CS received less temporary mechanical circulatory support (34.9% versus 76.3% P<0.001) and experienced lower rates of major bleeding (17.3% versus 26.0%, P=0.02) and in-hospital mortality (23.9% versus 39.3%, P<0.001). Postdischarge, 133 AMI-CS and 229 patients with HF-CS experienced similar rates of 30-day readmission (19.5% versus 24.5%, P=0.30) and major adverse cardiac and cerebrovascular events (23.3% versus 28.8%, P=0.45). Patients with HF-CS had lower 1-year mortality (n=123, 42.6%) compared to the patients with AMI-CS (n=110, 52.9%, P=0.03). Cumulative 1-year mortality was also lower in patients with HF-CS (log-rank test, P=0.04).

CONCLUSIONS

Patients with HF-CS were younger, and despite lower cardiac power output and higher pulmonary capillary wedge pressure, less likely to receive vasopressors or temporary mechanical circulatory support. Although patients with HF-CS had lower in-hospital and 1-year mortality, both cohorts experienced similarly high rates of postdischarge major adverse cardiovascular and cerebrovascular events and 30-day readmission, highlighting that both cohorts warrant careful long-term follow-up.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03378739.