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Jung C, Bruno RR, Jumean M, Price S, Krychtiuk KA, Ramanathan K, Dankiewicz J, French J, Delmas C, Mendoza AA, Thiele H, Soussi S. Management of cardiogenic shock: state-of-the-art. Intensive Care Med 2024:10.1007/s00134-024-07618-x. [PMID: 39254735 DOI: 10.1007/s00134-024-07618-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 08/18/2024] [Indexed: 09/11/2024]
Abstract
The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.
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Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
- Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany.
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | | | - Susanna Price
- Division of Heart, Lung and Critical Care, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Cardiology, Lund, Sweden
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia
| | - Clement Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
- REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | | | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network (UHN), Women's College Hospital, University of Toronto, Toronto Western Hospital, Toronto, Canada
- University of Paris Cité, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Paris, France
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2
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Quien M, Bae JY, Jang SJ, Davila C. Short term outcomes and resource utilization in de-novo versus acute on chronic heart failure related cardiogenic shock: a nationwide analysis. Front Cardiovasc Med 2024; 11:1454884. [PMID: 39314766 PMCID: PMC11416976 DOI: 10.3389/fcvm.2024.1454884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 08/26/2024] [Indexed: 09/25/2024] Open
Abstract
Background There has been growing recognition of non-ischemic etiologies of cardiogenic shock (CS). To further understand this population, we aimed to investigate differences in clinical course between acute on chronic heart failure related (CHF-CS) and de-novo CS (DN-CS). Methods Using the Nationwide Readmission Database, we examined 92,426 CS cases. Outcomes of interest included in-hospital and 30-day outcomes and use of advanced heart failure therapies. Results Patients with DN-CS had higher in-hospital mortality than the CHF-CS cohort (32.6% vs. 30.4%, p < 0.001). Mechanical circulatory support (11.9% vs. 8.6%, p < 0.001) was more utilized in DN-CS. Renal replacement therapy (13.8% vs. 15.5%, p < 0.001) and right heart catheterization (16.0% vs. 21.0%, p < 0.001) were implemented more in the CHF-CS cohort. The CHF-CS cohort was also more likely to undergo LVAD implantation (0.4% vs. 3.6%, p < 0.001) and heart transplantation (0.5% vs. 2.0%, p < 0.001). Over the study period, advanced heart failure therapy utilization increased, but the proportion of patients receiving these interventions remained unchanged. Thirty days after index hospitalization, the CHF-CS cohort had more readmissions for heart failure (1.1% vs. 2.4%, p < 0.001) and all causes (14.1% vs. 21.1%, p < 0.001) with higher readmission mortality (1.1% vs. 2.3%, p < 0.001). Conclusion Our findings align with existing research, demonstrating higher in-hospital mortality in the DN-CS subgroup. After the index hospitalization, however, the CHF-CS cohort performed worse with higher all-cause readmission rate and readmission mortality. The study also underscores the need for further investigation into the underutilization of certain interventions and the observed trends in the management of these CS subgroups.
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Affiliation(s)
- Mary Quien
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, United States
| | - Ju Young Bae
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, United States
| | - Sun-Joo Jang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, United States
| | - Carlos Davila
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, United States
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3
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Park JG, Barnett CF, Daniels LB, Fordyce CB, Ghafghazi S, Goldfarb MJ, Gorder K, Kwon Y, Leibner E, Menon V, Potter BJ, Prasad R, Solomon MA, Teuteberg JJ, Thompson AD, Zakaria S, Katz JN, van Diepen S, Morrow DA. Continuum of Preshock to Classic Cardiogenic Shock in the Critical Care Cardiology Trials Network Registry. JACC. HEART FAILURE 2024; 12:1625-1635. [PMID: 39093257 DOI: 10.1016/j.jchf.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The prognostic implications of phenotypes along the preshock to cardiogenic shock (CS) continuum remain uncertain. OBJECTIVES This study sought to better characterize pre- or early shock and normotensive CS phenotypes and examine outcomes compared to those with conventional CS. METHODS The CCCTN (Critical Care Cardiology Trials Network) is a registry of contemporary cardiac intensive care units. Consecutive admissions (N = 28,703 across 47 sites) meeting specific criteria based on hemodynamic variables, perfusion parameters, and investigator-reported CS were classified into 1 of 4 groups or none: isolated low cardiac output (CO), heart failure with isolated hypotension, normotensive CS, or SCAI (Society of Cardiovascular Angiography and Intervention) stage C CS. Outcomes of interest were in-hospital mortality and incidence of subsequent hypoperfusion among pre- and early shock states. RESULTS A total of 2,498 admissions were assigned to the 4 groups with the following distribution: 4.8% isolated low CO, 4.4% isolated hypotension, 12.1% normotensive CS, and 78.7% SCAI stage C CS. Overall in-hospital mortality was 21.3% (95% CI: 19.7%-23.0%), with a gradient across phenotypes (isolated low CO 3.6% [95% CI: 1.0%-9.0%]; isolated hypotension 11.0% [95% CI: 6.9%-16.6%]; normotensive CS 17.0% [95% CI 13.0%-21.8%]; SCAI stage C CS 24.0% [95% CI: 22.1%-26.0%]; global P < 0.001). Among those with an isolated low CO and isolated hypotension on admission, 47 (42.3%) and 56 (30.9%) subsequently developed hypoperfusion. CONCLUSIONS In a large contemporary registry of cardiac critical illness, there exists a gradient of mortality for phenotypes along the preshock to CS continuum with risk for subsequent worsening of preshock states. These data may inform refinement of CS definitions and severity staging.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Kari Gorder
- The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, Quebec, Canada
| | - Rajnish Prasad
- Wellstar Center for Cardiovascular Care, Marietta, Georgia, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Kyriakopoulos CP, Sideris K, Taleb I, Maneta E, Hamouche R, Tseliou E, Zhang C, Presson AP, Dranow E, Shah KS, Jones TL, Fang JC, Stehlik J, Selzman CH, Goodwin ML, Tonna JE, Hanff TC, Drakos SG. Clinical Characteristics and Outcomes of Patients Suffering Acute Decompensated Heart Failure Complicated by Cardiogenic Shock. Circ Heart Fail 2024; 17:e011358. [PMID: 39206544 DOI: 10.1161/circheartfailure.123.011358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Cardiogenic shock (CS) can stem from multiple causes and portends poor prognosis. Prior studies have focused on acute myocardial infarction-CS; however, acute decompensated heart failure (ADHF)-CS accounts for most cases. We studied patients suffering ADHF-CS to identify clinical factors, early in their trajectory, associated with a higher probability of successful outcomes. METHODS Consecutive patients with CS were evaluated (N=1162). We studied patients who developed ADHF-CS at our hospital (N=562). Primary end point was native heart survival (NHS), defined as survival to discharge without receiving advanced HF therapies. Secondary end points were adverse events, survival, major cardiac interventions, and hospital readmissions within 1 year following index hospitalization discharge. Association of clinical data with NHS was analyzed using logistic regression. RESULTS Overall, 357 (63.5%) patients achieved NHS, 165 (29.2%) died, and 41 (7.3%) were discharged post advanced HF therapies. Of 398 discharged patients (70.8%), 303 (53.9%) were alive at 1 year. Patients with NHS less commonly suffered cardiac arrest, underwent intubation or pulmonary artery catheter placement, or received temporary mechanical circulatory support, had better hemodynamic and echocardiographic profiles, and had a lower vasoactive-inotropic score at shock onset. Bleeding, hemorrhagic stroke, hemolysis in patients with mechanical circulatory support, and acute kidney injury requiring renal replacement therapy were less common compared with patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS likelihood included younger age, history of systemic hypertension, absence of cardiac arrest or acute kidney injury requiring renal replacement therapy, lower pulmonary capillary wedge pressure and vasoactive-inotropic score, and higher tricuspid annular plane systolic excursion at shock onset (all P<0.05). CONCLUSIONS By studying contemporary patients with ADHF-CS, we identified clinical factors that can inform clinical management and provide future research targets. Right ventricular function, renal function, pulmonary artery catheter placement, and type and timing of temporary mechanical circulatory support warrant further investigation to improve outcomes of this devastating condition.
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Affiliation(s)
- Christos P Kyriakopoulos
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Konstantinos Sideris
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Eleni Maneta
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Rana Hamouche
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Eleni Tseliou
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine (C.Z., A.P.P.), University of Utah Health and School of Medicine, Salt Lake City
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine (C.Z., A.P.P.), University of Utah Health and School of Medicine, Salt Lake City
| | - Elizabeth Dranow
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Kevin S Shah
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Tara L Jones
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery (C.H.S., M.L.G., J.E.T.), University of Utah Health and School of Medicine, Salt Lake City
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine (C.P.K., K.S., I.T., E.M., R.H., E.T., E.D., K.S.S., T.L.J., J.C.F., J.S., T.C.H., S.G.D.), University of Utah Health and School of Medicine, Salt Lake City
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City (C.P.K., I.T., E.M., R.H., E.T., C.H.S., S.G.D.)
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5
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Patel SM, Lopes MS, Morrow DA, Bellavia A, Bhatt AS, Butler KK, D’Antonio J, Dunn M, Fagundes AA, Jarolim P, Marin EP, Morton L, Olenchock BO, Senman B, da Silva DS, Varshney AS, Bohula EA, Berg DD. Targeted proteomic profiling of cardiogenic shock in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:624-628. [PMID: 38815149 PMCID: PMC11350432 DOI: 10.1093/ehjacc/zuae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 03/13/2024] [Accepted: 05/19/2024] [Indexed: 06/01/2024]
Abstract
AIMS We sought to characterize circulating protein biomarkers associated with cardiogenic shock (CS) using highly multiplex proteomic profiling. METHODS AND RESULTS This analysis employed a cross-sectional case-control study design using a biorepository of patients admitted to a cardiac intensive care unit between 2017 and 2020. Cases were patients adjudicated to have CS, and controls were those presenting for cardiac critical care without shock, including subsets of patients with isolated hypotension or heart failure (HF). The Olink platform was used to analyse 359 biomarkers with Bonferroni correction. The analysis included 239 patients presenting for cardiac critical care (69 cases with CS, 170 non-shock controls). A total of 63 biomarkers (17.7%) were significantly associated with CS after Bonferroni correction compared with all controls. Of these, nine biomarkers remained significantly associated with CS when separately cross-validated in subsets of controls presenting with isolated hypotension and HF: cathepsin D, fibroblast growth factor (FGF)-21 and -23, growth differentiation factor (GDF)-15, insulin-like growth factor-binding protein-1, N-terminal pro-B-type natriuretic peptide, osteopontin, oncostatin-M-specific receptor subunit beta (OSMR), and soluble ST2 protein (sST2). Four biomarkers were identified as providing complementary information for CS diagnosis with development of a multi-marker model: sST2, FGF-23, CTSD, and GDF-15. CONCLUSION In this pilot study of targeted proteomic profiling in CS, we identified nine biomarkers significantly associated with CS when cross-validated against non-shock controls including those with HF or isolated hypotension, illustrating the potential application of a targeted proteomic approach to identify novel candidates that may support the diagnosis of CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Mathew S Lopes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Andrea Bellavia
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Ankeet S Bhatt
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, CA, USA
| | - Kayleigh K Butler
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | | | - Michael Dunn
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Antonio A Fagundes
- IDOR, D’Or Institute for Research and Education, DFStar Hospital, Brasília, DF, Brazil
| | - Petr Jarolim
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Lori Morton
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Balimkiz Senman
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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6
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Buchwald CLV, Jabri A, Fadel R, Alhuneafat L, Wang DD, Mariscal E, Alqarqaz M, Engel P, O'Neill B, Frisoli T, Lee J, Abbas A, O'Neill WW, Villablanca PA. The various perioperative issues of structural heart diseases and cardiogenic shock. Curr Probl Cardiol 2024; 49:102646. [PMID: 38820919 DOI: 10.1016/j.cpcardiol.2024.102646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 06/02/2024]
Abstract
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.
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Affiliation(s)
| | - Ahmad Jabri
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA.
| | - Raef Fadel
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Laith Alhuneafat
- Division of Cardiovascular medicine, University of Minnesota, Minneapolis, USA
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Enrique Mariscal
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Mohammad Alqarqaz
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Pedro Engel
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Brian O'Neill
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Tiberio Frisoli
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - James Lee
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
| | - Amr Abbas
- Division of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA
| | - William W O'Neill
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, USA
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7
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Ton VK, Li S, John K, Li B, Zweck E, Kanwar MK, Sinha SS, Hernandez-Montfort J, Garan AR, Goodman R, Faugno A, Farr M, Hall S, Kataria R, Guglin M, Vorovich E, Pahuja M, Vallabhajosyula S, Nathan S, Abraham J, Harwani NM, Hickey GW, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Sangal P, Kong Q, Walec KD, Zazzali P, Fried J, Burkhoff D, Kapur NK. Serial Shock Severity Assessment Within 72 Hours After Diagnosis: A Cardiogenic Shock Working Group Report. J Am Coll Cardiol 2024; 84:S0735-1097(24)07740-4. [PMID: 39217545 DOI: 10.1016/j.jacc.2024.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/22/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The Cardiogenic Shock Working Group-modified Society for Cardiovascular Angiography and Interventions (CSWG-SCAI) staging was developed to risk stratify cardiogenic shock (CS) severity. Data showing progressive changes in SCAI stages and outcomes are limited. OBJECTIVES We investigated serial changes in CSWG-SCAI stages and outcomes of patients presenting with cardiogenic shock complicating acute myocardial infarction (MI-CS) and heart failure-related CS (HF-CS). METHODS The multicenter CSWG registry was queried. CSWG-SCAI stages were computed at CS diagnosis and 24, 48, and 72 hours. RESULTS A total of 3,268 patients (57% HF-CS; 27% MI-CS) were included. At CS diagnosis, CSWG-SCAI stage breakdown was 593 (18.1%) stage B, 528 (16.2%) stage C, 1,659 (50.8%) stage D, and 488 (14.9%) noncardiac arrest stage E. At 24 hours, >50% of stages B and C patients worsened, but 86% of stage D patients stayed at stage D. Among stage E patients, 54% improved to stage D and 36% stayed at stage E by 24 hours. Minimal SCAI stage changes occurred beyond 24 hours. SCAI stage trajectories were similar between MI-CS and HF-CS groups. Within 24 hours, unadjusted mortality rates of patients with any SCAI stage worsening or improving were 44.6% and 34.2%, respectively. Patients who presented in or progressed to stage E by 24 hours had the worst prognosis. Survivors had lower lactate than nonsurvivors. CONCLUSIONS Most patients with CS changed SCAI stages within 24 hours from CS diagnosis. Stage B patients were at high risk of worsening shock severity by 24 hours, associated with excess mortality. Early CS recognition and serial assessment may improve risk stratification.
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Affiliation(s)
- Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Song Li
- Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, Texas, USA
| | - Kevin John
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Elric Zweck
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shashank S Sinha
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | | | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Goodman
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Anthony Faugno
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Maryjane Farr
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | - Rachna Kataria
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Esther Vorovich
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois, USA
| | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Saraschandra Vallabhajosyula
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | | | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gavin W Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Wissam Khalife
- University of Texas Medical Branch, Galveston, Texas, USA
| | - Claudius Mahr
- Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, Texas, USA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, Texas, USA
| | | | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Qiuyue Kong
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Karol D Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Justin Fried
- Columbia University Medical Center, New York, New York, USA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
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8
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Iorio AM, Lucà F, Pozzi A, Rao CM, Di Fusco SA, Colivicchi F, Grimaldi M, Oliva F, Gulizia MM. Inotropic Agents: Are We Still in the Middle of Nowhere? J Clin Med 2024; 13:3735. [PMID: 38999301 PMCID: PMC11242653 DOI: 10.3390/jcm13133735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/14/2024] Open
Abstract
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.
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Affiliation(s)
- Anna Maria Iorio
- Cardiology Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, 89129 Reggio Calabria, Italy;
| | - Andrea Pozzi
- Cardiology Division, Valduce Hospital, 22100 Como, Italy;
| | | | - Stefania Angela Di Fusco
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy; (S.A.D.F.); (F.C.)
| | - Furio Colivicchi
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy; (S.A.D.F.); (F.C.)
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy;
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9
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Fisher T, Hill N, Kalakoutas A, Lahlou A, Rathod K, Proudfoot A, Warren A. Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis. Crit Care 2024; 28:192. [PMID: 38845019 PMCID: PMC11157877 DOI: 10.1186/s13054-024-04973-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/27/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock. MAIN BODY Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42). CONCLUSION Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.
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Affiliation(s)
- Thomas Fisher
- North Bristol NHS Trust, Southmead Rd, Bristol, BS10 5NB, UK
| | - Nicole Hill
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, Avon, BA1 3NG, UK
| | | | - Assad Lahlou
- Barts Health Library Services, W Smithfield, London, EC1A 7BE, UK
| | - Krishnaraj Rathod
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK
- William Harvey Research Institute, Barts and The London Faculty of Medicine and Dentistry, Queen Mary University of London, W Smithfield, London, EC1A 7BE, UK
| | - Alastair Proudfoot
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK
- Critical Care and Perioperative Medicine Group, School of Medicine and Dentistry, Queen Mary University London, W Smithfield, London, EC1A 7BE, UK
| | - Alex Warren
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK.
- Critical Care and Perioperative Medicine Group, School of Medicine and Dentistry, Queen Mary University London, W Smithfield, London, EC1A 7BE, UK.
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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10
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barsness GW, Chaudhry SP, Chonde MD, Cooper HA, Ginder C, Jentzer JC, Kontos MC, Miller PE, Newby LK, O'Brien CG, Park JG, Pierce MJ, Pisani BA, Potter BJ, Shah KS, Teuteberg JJ, Katz JN, van Diepen S, Morrow DA. Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2024; 17:e011736. [PMID: 38587438 DOI: 10.1161/circheartfailure.124.011736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). CONCLUSIONS Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | | | - Meshe D Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (H.A.C.)
| | - Curtis Ginder
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond (M.C.K.)
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (P.E.M.)
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco (C.G.O.B.)
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Matthew J Pierce
- Department of Cardiology, Northwell Health, Zucker School of Medicine, New Hyde Park, NY (M.J.P.)
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (B.A.P.)
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, Quebec, QC, Canada (B.J.P.)
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City (K.S.S.)
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (J.J.T.)
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York (J.N.K.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D.)
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
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11
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Garan AR, Kataria R, Li B, Sinha S, Kanwar MK, Hernandez-Montfort J, Li S, Ton VANK, Blumer V, Grandin EW, Harwani N, Zazzali P, Walec KD, Hickey G, Abraham J, Mahr C, Nathan S, Vorovich E, Guglin M, Hall S, Khalife W, Sangal P, Zhang Y, Kim JH, Schwartzman A, Vishnevsky A, Burkhoff D, Kapur NK. Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis. J Card Fail 2024; 30:564-575. [PMID: 37820897 DOI: 10.1016/j.cardfail.2023.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
| | - Rachna Kataria
- Brown University, Lifespan Cardiovascular Center, Providence, RI
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Shashank Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | | | - Song Li
- University of Washington Medical Center, Seattle, WA
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Neil Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Karol D Walec
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | | | | | - Maya Guglin
- Indiana University Health Advanced Heart and Lung Care, Indianapolis, IN
| | - Shelley Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, TX
| | | | - Paavni Sangal
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | | | | | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA.
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12
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Laghlam D, Benghanem S, Ortuno S, Bouabdallaoui N, Manzo-Silberman S, Hamzaoui O, Aissaoui N. Management of cardiogenic shock: a narrative review. Ann Intensive Care 2024; 14:45. [PMID: 38553663 PMCID: PMC10980676 DOI: 10.1186/s13613-024-01260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/06/2024] [Indexed: 04/02/2024] Open
Abstract
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.
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Affiliation(s)
- Driss Laghlam
- Research & Innovation Department, RIGHAPH, Service de Réanimation polyvalente, CMC Ambroise Paré-Hartmann, 48 Ter boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
| | - Sarah Benghanem
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre & Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- AfterROSC, Paris, France
| | - Sofia Ortuno
- Service Médecine intensive-réanimation, Hopital Européen Georges Pompidou, Paris, France
- Université Sorbonne, Paris, France
| | - Nadia Bouabdallaoui
- Institut de cardiologie de Montreal, Université de Montreal, Montreal, Canada
| | - Stephane Manzo-Silberman
- Université Sorbonne, Paris, France
- Sorbonne University, Institute of Cardiology- Hôpital Pitié-Salpêtrière (AP-HP), ACTION Study Group, Paris, France
| | - Olfa Hamzaoui
- Service de médecine intensive-réanimation polyvalente, Hôpital Robert Debré, CHU de Reims, Reims, France
- Unité HERVI "Hémostase et Remodelage Vasculaire Post-Ischémie" - EA 3801, Reims, France
| | - Nadia Aissaoui
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre & Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- AfterROSC, Paris, France
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13
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Blumer V, Kanwar MK, Psotka MA. Rethinking the Nomenclature of Heart Failure Cardiogenic Shock: Do We Need to Start De Novo? Circ Heart Fail 2024; 17:e011180. [PMID: 38420773 DOI: 10.1161/circheartfailure.123.011180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Vanessa Blumer
- Inova Schar Heart and Vascular, Falls Church, VA (V.B., M.A.P.)
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA (M.K.K.)
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14
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Kanwar MK, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Baran DA. Heart failure related cardiogenic shock: An ISHLT consensus conference content summary. J Heart Lung Transplant 2024; 43:189-203. [PMID: 38069920 DOI: 10.1016/j.healun.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varinder Randhawa
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Cowger
- Department of Cardiology, Henry Ford Health Heart and Vascular Institute, Detroit, Michigan
| | - Christopher M Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Hoong S Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center, New York, New York
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Maria F Renedo
- Department of Heart Failure and Thoracic Transplantation, Fundacion Favaloro, Buenos Aires, Argentina
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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15
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Randhawa VK, Baran DA. Unraveling heart failure cardiogenic shock profiles and pathways. Eur J Heart Fail 2024; 26:445-447. [PMID: 38124463 DOI: 10.1002/ejhf.3113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Varinder Kaur Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Cardiology, St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David A Baran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
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16
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Modi SP, Hong Y, Sicke MM, Hess NR, Klass WJ, Ziegler LA, Rivosecchi RM, Hickey GW, Kaczorowski DJ, Ramanan R. Concomitant use of extracorporeal membrane oxygenation and percutaneous microaxial assist device support for cardiogenic shock. JTCVS OPEN 2024; 17:152-161. [PMID: 38420544 PMCID: PMC10897678 DOI: 10.1016/j.xjon.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/21/2023] [Accepted: 12/11/2023] [Indexed: 03/02/2024]
Abstract
Objectives Venoarterial extracorporeal membrane oxygenation (VA-ECMO) with concomitant percutaneous microaxial left ventricular assist device support is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with this support strategy have not been well described. Methods This study was a retrospective, single-center analysis of patients with CS due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support from December 2020 to January 2023. Results A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival at 90 days postdischarge (P = .267) with similar destinations after support (P = .220). Patients with AMI-CS initially supported with VA-ECMO were less likely to survive 90 days postdischarge (P = .038) when compared with other cohorts. Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (P =.013; P = .030). Subanalysis of ADHF-CS patients into acute-on-chronic decompensated HF and de novo HF demonstrated no difference in survival or destination. Conclusions VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS with this support strategy. AMI-CS patients with initial VA-ECMO support have increased mortality in comparison to other cohorts. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with this support strategy.
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Affiliation(s)
- Shan P. Modi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - McKenzie M. Sicke
- School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Nicholas R. Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Wyatt J. Klass
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Luke A. Ziegler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ryan M. Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Gavin W. Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - David J. Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
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17
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Sundermeyer J, Kellner C, Beer BN, Besch L, Dettling A, Bertoldi LF, Blankenberg S, Dauw J, Dindane Z, Eckner D, Eitel I, Graf T, Horn P, Jozwiak-Nozdrzykowska J, Kirchhof P, Kluge S, Linke A, Landmesser U, Luedike P, Lüsebrink E, Majunke N, Mangner N, Maniuc O, Möbius Winkler S, Nordbeck P, Orban M, Pappalardo F, Pauschinger M, Pazdernik M, Proudfoot A, Kelham M, Rassaf T, Reichenspurner H, Scherer C, Schulze PC, Schwinger RHG, Skurk C, Sramko M, Tavazzi G, Thiele H, Villanova L, Morici N, Winzer EB, Westermann D, Gustafsson F, Schrage B. Clinical presentation, shock severity and mortality in patients with de novo versus acute-on-chronic heart failure-related cardiogenic shock. Eur J Heart Fail 2024; 26:432-444. [PMID: 37940139 DOI: 10.1002/ejhf.3082] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/22/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
AIMS Heart failure-related cardiogenic shock (HF-CS) accounts for a significant proportion of CS cases. Whether patients with de novo HF and those with acute-on-chronic HF in CS differ in clinical characteristics and outcome remains unclear. The aim of this study was to evaluate differences in clinical presentation and mortality between patients with de novo and acute-on-chronic HF-CS. METHODS AND RESULTS In this international observational study, patients with HF-CS from 16 tertiary care centres in five countries were enrolled between 2010 and 2021. To investigate differences in clinical presentation and 30-day mortality, adjusted logistic/Cox regression models were fitted. Patients (n = 1030) with HF-CS were analysed, of whom 486 (47.2%) presented with de novo HF-CS and 544 (52.8%) with acute-on-chronic HF-CS. Traditional markers of CS severity (e.g. blood pressure, heart rate and lactate) as well as use of treatments were comparable between groups. However, patients with acute-on-chronic HF-CS were more likely to have a higher CS severity and also a higher mortality risk, after adjusting for relevant confounders (de novo HF 45.5%, acute-on-chronic HF 55.9%, adjusted hazard ratio 1.38, 95% confidence interval 1.10-1.72, p = 0.005). CONCLUSION In this large HF-CS cohort, acute-on-chronic HF-CS was associated with more severe CS and higher mortality risk compared to de novo HF-CS, although traditional markers of CS severity and use of treatments were comparable. These findings highlight the vast heterogeneity of patients with HF-CS, emphasize that HF chronicity is a relevant disease modifier in CS, and indicate that future clinical trials should account for this.
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Affiliation(s)
- Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt N Beer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeroen Dauw
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Zouhir Dindane
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Joanna Jozwiak-Nozdrzykowska
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Linke
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Norman Mangner
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | | | - Alastair Proudfoot
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London
| | - Matthew Kelham
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Hermann Reichenspurner
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Carsten Skurk
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Marek Sramko
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Luca Villanova
- Intensive Cardiac Care Unit and De Gasperis Cardio-Center, Niguarda Hospital, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi, ONLUS, Milan, Italy
| | - Ephraim B Winzer
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Finn Gustafsson
- Rigshospitalet and Department of Clinical Medicine, University of Copenhagen Copenhagen, Copenhagen, Denmark
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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18
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Sarma D, Jentzer JC. Cardiogenic Shock: Pathogenesis, Classification, and Management. Crit Care Clin 2024; 40:37-56. [PMID: 37973356 DOI: 10.1016/j.ccc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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19
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Bertaina M, Morici N, Frea S, Garatti L, Briani M, Sorini C, Villanova L, Corrada E, Sacco A, Moltrasio M, Ravera A, Tedeschi M, Bertoldi L, Lettino M, Saia F, Corsini A, Camporotondo R, Colombo CNJ, Bertolin S, Rota M, Oliva F, Iannaccone M, Valente S, Pagnesi M, Metra M, Sionis A, Marini M, De Ferrari GM, Kapur NK, Pappalardo F, Tavazzi G. Differences between cardiogenic shock related to acute decompensated heart failure and acute myocardial infarction. ESC Heart Fail 2023; 10:3472-3482. [PMID: 37723131 PMCID: PMC10682868 DOI: 10.1002/ehf2.14510] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 04/13/2023] [Accepted: 08/08/2023] [Indexed: 09/20/2023] Open
Abstract
AIMS The present analysis from the multicentre prospective Altshock-2 registry aims to better define clinical features, in-hospital course, and management of cardiogenic shock complicating acutely decompensated heart failure (ADHF-CS) as compared with that complicating acute myocardial infarction (AMI-CS). METHODS AND RESULTS All patients with AMI-CS or ADHF-CS enrolled in the Altshock-2 registry between March 2020 and February 2022 were selected. The primary objective was the characterization of ADHF-CS patients as compared with AMI-CS. In-hospital length of stay and mortality were secondary endpoints. One-hundred-ninety of the 238 CS patients enrolled in the aforementioned period were considered for the present analysis: 101 AMI-CS (80% ST-elevated myocardial infarction and 20% non-ST-elevated myocardial infarction) and 89 ADHF-CS. As compared with AMI-CS, ADHF-CS patients were younger [63 (IQR 59-76) vs. 67 (IQR 54-73) years, P = 0.01], but presented with higher creatinine [1.6 (IQR 1.0-2.6) vs. 1.2 (IQR 1.0-1.4) mg/dL, P < 0.001], bilirubin [1.3 (IQR 0.9-2.3) vs. 0.6 (IQR 0.4-1.1) mg/dL, P = 0.01], and central venous pressure values [14 mmHg (IQR 8-12) vs. 10 mmHg (IQR 7-14),P = 0.01]. Norepinephrine was the most common catecholamine used in AMI-CS (79.3%), whereas epinephrine was used more commonly in ADHF-CS (65.5%); 75.8% vs. 46.6% received a temporary mechanical support in AMI-CS and ADHF-CS, respectively (P < 0.001). Length of hospital stay was longer in the latter [28 (IQR 13-48) vs. 17 (IQR 9-29) days, P = 0.001]. Heart replacement therapies were more frequently used in the ADHF-CS group (heart transplantation 13.5% vs. 0% and left ventricular assist device 11% vs. 2%, P < 0.01 and 0.01, respectively). In-hospital mortality was 41.1% (38.6% AMI-CS vs. 43.8% ADHF-CS, P = 0.5). CONCLUSIONS ADHF-CS is characterized by a higher prevalence of end-organ and biventricular dysfunction at presentation, a longer hospital length of stay, and higher need of heart replacement therapies when compared with AMI-CS. In-hospital mortality was similar between the two aetiologies. Our data warrant development of new management protocols focused on CS aetiology.
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Affiliation(s)
- Maurizio Bertaina
- Division of CardiologySan Giovanni Bosco Hospital, ASL Città di TorinoTurinItaly
| | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUSMilanItaly
| | - Simone Frea
- Intensive Cardiac Care UnitCittà della Salute e della Scienza di TorinoTurinItaly
| | - Laura Garatti
- Cardiology Department and De Gasperis Cardio CenterASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | | | - Carlotta Sorini
- Division of Cardiology, Department of Medical BiotechnologiesUniversity of SienaSienaItaly
| | - Luca Villanova
- Cardiology Department and De Gasperis Cardio CenterASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Elena Corrada
- Humanitas Research Hospital, IRCCS RozzanoMilanItaly
| | - Alice Sacco
- Cardiology Department and De Gasperis Cardio CenterASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | | | - Amelia Ravera
- Cardiology Department, Intensive Care UnitS. Giovanni Di Dio e Ruggi D'Aragona HospitalSalernoItaly
| | - Michele Tedeschi
- Cardiology Department, Intensive Care UnitS. Giovanni Di Dio e Ruggi D'Aragona HospitalSalernoItaly
| | | | | | - Francesco Saia
- Cardiology UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Anna Corsini
- Cardiology UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Rita Camporotondo
- Intensive Cardiac Care UnitFondazione Policlinico San Matteo Hospital IRCCSPaviaItaly
| | | | - Stephanie Bertolin
- Cardiothoracic and Vascular Anesthesia and Intensive CareAO SS. Antonio e Biagio e Cesare ArrigoAlessandriaItaly
| | - Matteo Rota
- Units of Biostatistics and Biomathematics and Bioinformatics, Department of Molecular and Translational MedicineUniversity of BresciaBresciaItaly
| | - Fabrizio Oliva
- Cardiology Department and De Gasperis Cardio CenterASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Mario Iannaccone
- Division of CardiologySan Giovanni Bosco Hospital, ASL Città di TorinoTurinItaly
| | - Serafina Valente
- Division of Cardiology, Department of Medical BiotechnologiesUniversity of SienaSienaItaly
| | - Matteo Pagnesi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of Brescia, Cardiothoracic Department, Civil HospitalsBresciaItaly
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of Brescia, Cardiothoracic Department, Civil HospitalsBresciaItaly
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology DepartmentHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Marco Marini
- Division of Cardiology and ICCU, Department of Cardiovascular SciencesOspedali RiunitiAnconaItaly
| | - Gaetano Maria De Ferrari
- Intensive Cardiac Care UnitCittà della Salute e della Scienza di TorinoTurinItaly
- Department of Medical SciencesUniversity of TorinoTurinItaly
| | | | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive CareAO SS. Antonio e Biagio e Cesare ArrigoAlessandriaItaly
| | - Guido Tavazzi
- Department of Clinical‐Surgical, Diagnostic and Paediatric SciencesUniversity of Pavia ItalyPaviaItaly
- Anesthesia and Intensive CareFondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione IPaviaItaly
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20
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Metkus TS. Acute Coronary Syndrome and Heart Failure: Another Piece of the Puzzle. J Card Fail 2023; 29:1615-1616. [PMID: 37689108 DOI: 10.1016/j.cardfail.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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21
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Ton VK, Kanwar MK, Li B, Blumer V, Li S, Zweck E, Sinha SS, Farr M, Hall S, Kataria R, Guglin M, Vorovich E, Hernandez-Montfort J, Garan AR, Pahuja M, Vallabhajosyula S, Nathan S, Abraham J, Harwani NM, Hickey GW, Wencker D, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Sangal P, Zhang Y, Walec KD, Zazzali P, Burkhoff D, Kapur NK. Impact of Female Sex on Cardiogenic Shock Outcomes: A Cardiogenic Shock Working Group Report. JACC. HEART FAILURE 2023; 11:1742-1753. [PMID: 37930289 DOI: 10.1016/j.jchf.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Song Li
- University of Washington Medical Center, Seattle, Washington, USA
| | - Elric Zweck
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Maryjane Farr
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | - Rachna Kataria
- Lifespan Cardiovascular Center, Brown University, Providence, Rhode Island, USA
| | - Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Esther Vorovich
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois, USA
| | | | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | | | | | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gavin W Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Wissam Khalife
- University of Texas Medical Branch, Galveston, Texas, USA
| | - Claudius Mahr
- University of Washington Medical Center, Seattle, Washington, USA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, Texas, USA
| | | | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Yijing Zhang
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Karol D Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
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22
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Malik A, Basu T, VanAken G, Aggarwal V, Lee R, Abdul-Aziz A, Birati EY, Basir MB, Nallamothu BK, Shore S. National Trends for Temporary Mechanical Circulatory Support Utilization in Patients With Cardiogenic Shock From Decompensated Chronic Heart Failure: Incidence, Predictors, Outcomes, and Cost. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101177. [PMID: 39131060 PMCID: PMC11307713 DOI: 10.1016/j.jscai.2023.101177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 08/13/2024]
Abstract
Background Trends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS. Methods We included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs. Results We studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality. Conclusions The use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.
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Affiliation(s)
- Aroosa Malik
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tanima Basu
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Vikas Aggarwal
- Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Ran Lee
- Division of Cardiology, Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Ahmad Abdul-Aziz
- Division of Cardiology, Department of Internal Medicine, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Edo Y. Birati
- Division of Cardiology, Department of Internal Medicine, Poriya Medical Center, Bar-Ilan University, Israel
| | - Mir Babar Basir
- Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Brahmajee K. Nallamothu
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Supriya Shore
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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23
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Fraccaro C, Karam N, Möllmann H, Bleiziffer S, Bonaros N, Teles RC, Carrilho Ferreira P, Chieffo A, Czerny M, Donal E, Dudek D, Dumonteil N, Esposito G, Fournier S, Hassager C, Kim WK, Krychtiuk KA, Mehilli J, Pręgowski J, Stefanini GG, Ternacle J, Thiele H, Thielmann M, Vincent F, von Bardeleben RS, Tarantini G. Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:634-651. [PMID: 37624587 PMCID: PMC10587846 DOI: 10.4244/eij-d-23-00473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.
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Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicole Karam
- Heart Valves Unit, Georges Pompidou European Hospital, Université Paris Cité, INSERM, Paris, France
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | | | - Nikolaos Bonaros
- Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental (HSC), Carnaxide, Portugal and Comprehensive Health Research Center (CHRC), Nova Medical School, Lisbon, Portugal
| | - Pedro Carrilho Ferreira
- Cardiology Department, Santa Maria University Hospital, CHULN, CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre, Freiburg University, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erwan Donal
- Service de Cardiologie, CCP CHU de Rennes, University of Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Giovanni Esposito
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland and University of Lausanne, Lausanne, Switzerland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Won-Keun Kim
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Konstantin A Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, German Centre for Cardiovascular Research (DZHK), Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Jerzy Pręgowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warszawa, Poland
| | - Giulio G Stefanini
- Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada and Université Laval, Quebec, QC, Canada
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany and University of Leipzig, Leipzig, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Flavien Vincent
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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24
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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25
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Jentzer JC, Pöss J, Schaubroeck H, Morrow DA, Hollenberg SM, Mebazaa A. Advances in the Management of Cardiogenic Shock. Crit Care Med 2023; 51:1222-1233. [PMID: 37184336 DOI: 10.1097/ccm.0000000000005919] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Janine Pöss
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Alexandre Mebazaa
- Department of Anesthesia & Critical Care, Université Paris Cité, APHP, Inserm MASCOT, FHU PROMICE, Paris, France
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26
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Blumer V, Sinha SS. Heart Failure Under Pressure: Harnessing the Power of Hemodynamic Insights Across the Spectrum of Disease. J Card Fail 2023; 29:1231-1233. [PMID: 37709383 DOI: 10.1016/j.cardfail.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Affiliation(s)
- Vanessa Blumer
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.
| | - Shashank S Sinha
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
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27
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Modi SP, Hong Y, Sicke MM, Hess NR, Klass WJ, Ziegler LA, Rivosecchi RM, Hickey GW, Kaczorowski DJ, Ramanan R. Concomitant Use of VA-ECMO and Impella Support for Cardiogenic Shock. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.24.23293127. [PMID: 37546750 PMCID: PMC10402237 DOI: 10.1101/2023.07.24.23293127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background VA-ECMO with concomitant Impella support (ECpella) is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with ECpella support have not been well-described. Methods This study was a retrospective, single-center analysis of patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with ECpella from December 2020 to January 2023. Primary outcomes included 90-day survival post-discharge and destination after support. Secondary outcomes included complications post-ECpella support. Results A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival 90 days post-discharge (p = .267) with similar destinations after ECpella support (p = .220). Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (p=.013; p = .030). Patients with initial Impella support were more likely to survive ECpella support and be bridged to transplant (p=.033) and less likely to have a cerebrovascular accident (p=.016). Sub-analysis of ADHF-CS patients into acute-on-chronic decompensated heart failure and de novo heart failure demonstrated no difference in survival or destination. Conclusion ECpella can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS in patients with ECpella support. Patients with initial Impella support are more likely to survive ECpella support and bridge to transplant. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with ECpella support.
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Affiliation(s)
- Shan P Modi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - McKenzie M Sicke
- School of Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Wyatt J Klass
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Luke A Ziegler
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center Pittsburgh, PA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
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28
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van Diepen S, Arias-Mendoza A, Sinha SS. The North American perspective on short-term mechanical circulatory support for cardiogenic shock: could differences in policy be driving differences in temporary mechanical circulatory support use? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:486-489. [PMID: 37319359 DOI: 10.1093/ehjacc/zuad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, Division of Cardiology, Department of Medicine, University of Alberta, 8440-11 St, Edmonton, AB T6G 2B7, Canada
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
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29
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Eftychiou S, Kalakoutas A, Proudfoot A. The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review. JOURNAL OF INTENSIVE MEDICINE 2023; 3:89-103. [PMID: 37188124 PMCID: PMC10175707 DOI: 10.1016/j.jointm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.
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Affiliation(s)
| | - Antonis Kalakoutas
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0AG, UK
- Barts and the London School of Medicine and Dentistry, London E1 2AD, UK
| | - Alastair Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
- Queen Mary University of London, London EC1M 6BQ, UK
- Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin 13353, Germany
- Corresponding author: Alastair Proudfoot, Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
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Singam NSV, Tabi M, Wiley B, Anavekar N, Jentzer J. Echocardiographic findings in cardiogenic shock due to acute myocardial infarction versus heart failure. Int J Cardiol 2023:S0167-5273(23)00595-8. [PMID: 37116757 DOI: 10.1016/j.ijcard.2023.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/11/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is the prototypical cause of cardiogenic shock (CS), yet CS due to heart failure (HF-CS) is increasingly common. Little is known regarding cardiac function in AMI-CS versus HF-CS. We compared transthoracic echocardiography (TTE) findings in AMI-CS versus HF-CS and identified predictors of mortality in AMI-CS patients. METHODS We performed a single-center, retrospective analysis of CS admissions between 2007 and 2018. We compared baseline demographic and TTE parameters in patients with AMI-CS and HF-CS as well as ST elevation myocardial infarction (STEMI)-CS versus non-ST elevation myocardial infarction (NSTEMI)-CS. RESULTS We included 893 unique patients, including 581 (65%) with AMI-CS. AMI-CS patients were older but had lower illness severity and non-cardiac comorbidity burden. AMI-CS patients had better left ventricular function (LVEF 35% versus 28%), lower biventricular filling pressures, and higher stroke volume versus those with HF-CS. Among TTE measurements, myocardial contraction fraction had the highest discrimination for mortality in AMI-CS (AUC: 0.64); AUC values for LVEF and SOFA score were 0.61 and 0.65, respectively. Differences in TTE findings between STEMI-CS versus NSTEMI-CS were modest. There were no significant differences in unadjusted or adjusted in-hospital mortality between AMI-CS and HF-CS (31% versus 35%) or STEMI-CS and NSTEMI-CS (31% versus 30%) groups (all p > 0.05). CONCLUSIONS Patients with HF-CS and AMI-CS differ in terms of clinical and TTE variables yet have similar prognoses. TTE is useful in determining prognosis of patients admitted with AMI-CS and may allow for early triage and directed therapy.
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Affiliation(s)
- Narayana Sarma V Singam
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States of America; Department of Critical Care Medicine, Washington Hospital Center, Washington, DC, United States of America; Division of Cardiology, Washington Hospital Center, Washington, DC, United States of America.
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Brandon Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Nandan Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
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Khariton Y, Hassan OA, Hernandez-Montfort JA. Update on cardiogenic shock: from detection to team management. Curr Opin Cardiol 2023; 38:108-115. [PMID: 36718620 DOI: 10.1097/hco.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Varshney AS, Berg DD, Zhou G, Sinnenberg L, Hirji S, DeFilippis EM, Mallidi HR, Morrow DA, Rinewalt D, Givertz MM. Bridging strategies and cardiac replacement outcomes in patients with acute decompensated heart failure-related cardiogenic shock. Eur J Heart Fail 2023; 25:425-435. [PMID: 36597721 PMCID: PMC10065926 DOI: 10.1002/ejhf.2762] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 12/20/2022] [Accepted: 12/24/2022] [Indexed: 01/05/2023] Open
Abstract
AIMS To describe outcomes associated with bridging strategies in patients with acute decompensated heart failure-related cardiogenic shock (ADHF-CS) bridged to durable left ventricular assist device (LVAD) or heart transplantation (HTx). METHODS AND RESULTS Durable LVAD or HTx recipients from 2014 to 2019 with pre-operative ADHF-CS were identified in the Society of Thoracic Surgeons Adult Cardiac Surgery Database and stratified by bridging strategy. The primary outcome was operative or 30-day post-operative mortality. Secondary outcomes included post-operative major bleeding. Exploratory comparisons between bridging strategies and outcomes were performed using overlap weighting with and without covariate adjustment. Among 9783 patients with pre-operative CS, 8777 (89.7%) had ADHF-CS. Medical therapy (n = 5013) was the most common bridging strategy, followed by intra-aortic balloon pump (IABP; n = 2816), catheter-based temporary mechanical circulatory support (TMCS; n = 417), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO; n = 465). Mortality was highest in patients bridged with VA-ECMO (22%), followed by catheter-based TMCS (10%), IABP (9%), and medical therapy (7%). Adverse post-operative outcomes were more frequent in LVAD recipients compared with HTx recipients. CONCLUSION Among patients with ADHF-CS bridged to HTx or durable LVAD, the highest rates of death and adverse events during index hospitalization were observed in those bridged with VA-ECMO, followed by catheter-based TMCS, IABP, and medical therapy. Patients who received durable LVAD had higher rates of post-operative complications compared with HTx recipients. Prospective trials are needed to define optimal bridging strategies in patients with ADHF-CS.
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Affiliation(s)
- Anubodh S. Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, CA
| | - David D. Berg
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Levine Cardiac Intensive Care Unit and Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA
| | - Guohai Zhou
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, MA
| | - Lauren Sinnenberg
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sameer Hirji
- Division of Cardiothoracic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Hari R. Mallidi
- Division of Cardiothoracic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Levine Cardiac Intensive Care Unit and Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA
| | - Daniel Rinewalt
- Cardiovascular and Thoracic Surgery, AdventHealth, Orlando, FL
| | - Michael M. Givertz
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Hernandez-Montfort J, Kanwar M, Sinha SS, Garan AR, Blumer V, Kataria R, Whitehead EH, Yin M, Li B, Zhang Y, Thayer KL, Baca P, Dieng F, Harwani NM, Guglin M, Abraham J, Hickey G, Nathan S, Wencker D, Hall S, Schwartzman A, Khalife W, Li S, Mahr C, Kim J, Vorovich E, Pahuja M, Burkhoff D, Kapur NK. Clinical Presentation and In-Hospital Trajectory of Heart Failure and Cardiogenic Shock. JACC. HEART FAILURE 2023; 11:176-187. [PMID: 36342421 DOI: 10.1016/j.jchf.2022.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
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).
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Affiliation(s)
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vanessa Blumer
- Duke University Medical Center, Durham, North Carolina, USA
| | - Rachna Kataria
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Michael Yin
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Katherine L Thayer
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paulina Baca
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Fatou Dieng
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Neil M Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Maya Guglin
- Indiana University Health Advanced Heart and Lung Care, Indianapolis, Indiana, USA
| | | | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Detlef Wencker
- Baylor Scott and White Health, Advanced Heart Disease Program, Temple, Texas, USA
| | - Shelley Hall
- Baylor Scott and White Advanced Heart Failure Clinic, Dallas, Texas, USA
| | | | - Wissam Khalife
- University of Texas Medical Branch, Galveston, Texas, USA
| | - Song Li
- University of Washington Medical Center, Seattle, Washington, USA
| | - Claudius Mahr
- University of Washington Medical Center, Seattle, Washington, USA
| | - Ju Kim
- Houston Methodist Research Institute, Houston, Texas, USA
| | | | - Mohit Pahuja
- Medstar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | | | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
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Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction. Can J Cardiol 2023; 39:406-419. [PMID: 36731605 DOI: 10.1016/j.cjca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/01/2023] Open
Abstract
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.
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Barssoum K, Patel HP, Abdelmaseih R, Hassib M, Victor V, Mohamed A, Jazar DA, Mai S, Ibrahim F, Patel B, Baeni AE, Khalife W, Bandyopadhay D, Rai D, Chatila K. Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database. Curr Probl Cardiol 2023; 48:101584. [PMID: 36642353 DOI: 10.1016/j.cpcardiol.2023.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.
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Affiliation(s)
- Kirolos Barssoum
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Harsh P Patel
- Department cardiology, Southern Illinois University, Carbondale, IL
| | - Ramy Abdelmaseih
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Mohab Hassib
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Ahmed Mohamed
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Deaa Abu Jazar
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Steven Mai
- Department of internal medicine, University of Texas Medical Branch, Galveston, TX
| | - Fadi Ibrahim
- American University of Antigua, Antigua & Barbuda
| | - Bhavin Patel
- Department of internal medicine, Saint Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Aiham El Baeni
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | - Wissam Khalife
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
| | | | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY.
| | - Khaled Chatila
- Department of cardiology, University of Texas Medical Branch, Galveston, TX
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barnett CF, Barsness GW, Chaudhry SP, Daniels LB, van Diepen S, Ghafghazi S, Goldfarb MJ, Jentzer JC, Katz JN, Kenigsberg BB, Lawler PR, Miller PE, Papolos AI, Park JG, Potter BJ, Prasad R, Singam NSV, Sinha SS, Solomon MA, Teuteberg JJ, Morrow DA. Clinician and Algorithmic Application of the 2019 and 2022 Society of Cardiovascular Angiography and Intervention Shock Stages in the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2023; 16:e009714. [PMID: 36458542 PMCID: PMC9851990 DOI: 10.1161/circheartfailure.122.009714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/20/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Algorithmic application of the 2019 Society of Cardiovascular Angiography and Intervention (SCAI) shock stages effectively stratifies mortality risk for patients with cardiogenic shock. However, clinician assessment of SCAI staging may differ. Moreover, the implications of the 2022 SCAI criteria update remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Between 2019 and 2021, participating centers (n=32) contributed at least a 2-month snapshot of consecutive medical CICU admissions. In-hospital mortality was assessed across 3 separate staging methods: clinician assessment, Critical Care Cardiology Trials Network algorithmic application of the 2019 SCAI criteria, and a revision of the Critical Care Cardiology Trials Network application using the 2022 SCAI criteria. RESULTS Of 9612 admissions, 1340 (13.9%) presented with cardiogenic shock with in-hospital mortality of 35.2%. Both clinician and algorithm-based staging using the 2019 SCAI criteria identified a stepwise gradient of mortality risk (stage C-E: 19.0% to 83.7% and 14.6% to 52.2%, respectively; Ptrend<0.001 for each). Clinician assignment of SCAI stages identified higher risk patients compared with algorithm-based assignment (stage D: 49.9% versus 29.3%; stage E: 83.7% versus 52.2%). Algorithmic application of the 2022 SCAI criteria, with incorporation of the vasoactive-inotropic score, more closely approximated clinician staging (mortality for stage C-E: 21.9% to 70.5%; Ptrend<0.001). CONCLUSIONS Both clinician and algorithm-based application of the 2019 SCAI stages identify a stepwise gradient of mortality risk, although clinician-staging may better allocate higher risk patients into advanced SCAI stages. Updated algorithmic staging using the 2022 SCAI criteria and vasoactive-inotropic score further refines risk stratification.
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Affiliation(s)
- Siddharth M. Patel
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A. Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M. Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher F. Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lori B. Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N. Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Benjamin B. Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Elliot Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexander I. Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian J. Potter
- Centre Hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | | | - N. Sarma V. Singam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Michael A. Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey J. Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - David A. Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Schurtz G, Delmas C, Fenouillet M, Roubille F, Puymirat E, Bonello L, Leurent G, Verdier B, Levy B, Ternacle J, Harbaoui B, Vanzetto G, Combaret N, Lattuca B, Bruel C, Bourenne J, Labbé V, Henry P, Bonnefoy-Cudraz É, Lamblin N, Lemesle G. Impact of Pre-Existing History of Heart Failure on Patient Profile, Therapeutic Management, and Prognosis in Cardiogenic Shock: Insights from the FRENSHOCK Registry. Life (Basel) 2022; 12:life12111844. [PMID: 36430979 PMCID: PMC9698880 DOI: 10.3390/life12111844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/25/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
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 < 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 < 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.
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Affiliation(s)
- Guillaume Schurtz
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, 59000 Lille, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital/Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), 1 Avenue Jean Poulhes, 31059 Toulouse, France
| | - Margaux Fenouillet
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, 59000 Lille, France
| | - François Roubille
- Cardiology Department, INI-CRT, CHU de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, 34000 Montpellier, France
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique des Hôpitaux de Paris, 75000 Paris, France
| | - Laurent Bonello
- Cardiology Department, APHM, Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Centre for CardioVascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM 1263, INRA 1260, 13000 Marseille, France
| | - Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, University Rennes 1, 35000 Rennes, France
| | - Basile Verdier
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, 59000 Lille, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, Université de Lorraine, 54000 Nancy, France
| | - Julien Ternacle
- Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, 33318 Pessac, France
| | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, 69000 Lyon, France
- CREATIS UMR5220, INSERM U1044, INSA-15, University of Lyon, 69000 Lyon, France
| | - Gerald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, 38000 Grenoble, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, 63000 Clermont-Ferrand, France
| | - Benoît Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, 30000 Nîmes, France
| | - Cedric Bruel
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, 75000 Paris, France
| | - Jeremy Bourenne
- Service de Réanimation des Urgences, CHU La Timone 2, Aix Marseille Université, 13000 Marseille, France
| | - Vincent Labbé
- Medical Intensive Care Unit, AP-HP, Tenon University Hospital, 75000 Paris, France
| | - Patrick Henry
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, INSERM U942, University of Paris, 75000 Paris, France
| | - Éric Bonnefoy-Cudraz
- Intensive Cardiological Care Division, Hospices Civils de Lyon-Hôpital Cardiovasculaire et Pulmonaire, 69000 Lyon, France
| | - Nicolas Lamblin
- Cardiology Department, Heart and Lung Institute, University Hospital of Lille, 59000 Lille, France
- INSERM U1167, Institut Pasteur of Lille, 59000 Lille, France
| | - Gilles Lemesle
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, 59000 Lille, France
- Heart and Lung Institute, University Hospital of Lille, 59000 Lille, France
- Inserm U1011, Institut Pasteur of Lille, 59000 Lille, France
- FACT (French Alliance for Cardiovascular Trials), 75000 Paris, France
- Correspondence: ; Tel.: +33-320445330; Fax: +33-320444898
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Metkus TS, Baird-Zars VM, Alfonso CE, Alviar CL, Barnett CF, Barsness GW, Berg DD, Bertic M, Bohula EA, Burke J, Burstein B, Chaudhry SP, Cooper HA, Daniels LB, Fordyce CB, Ghafghazi S, Goldfarb M, Katz JN, Keeley EC, Keller NM, Kenigsberg B, Kontos MC, Kwon Y, Lawler PR, Leibner E, Liu S, Menon V, Miller PE, Newby LK, O'Brien CG, Papolos AI, Pierce MJ, Prasad R, Pisani B, Potter BJ, Roswell RO, Sinha SS, Shah KS, Smith TD, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, van Diepen S, Zakaria S, Morrow DA. Critical Care Cardiology Trials Network (CCCTN): a cohort profile. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:703-708. [PMID: 36029517 PMCID: PMC9603535 DOI: 10.1093/ehjqcco/qcac055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022]
Abstract
AIMS The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness. METHODS AND RESULTS The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterised utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicentre collaboration, the CCCTN has established a robust research network to facilitate multicentre registry-based randomised trials in patients with cardiac critical illness. CONCLUSION The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomised controlled trials in this important patient population.
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Affiliation(s)
- Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Carlos E Alfonso
- Division of Cardiology, Department of Medicine; University of Miami Hospital & Clinics, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York 10016 NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Mia Bertic
- University of Toronto Etobicoke,Toronto ON, Canada
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, PA 18103, USA
| | | | | | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla NY 10901, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine La Jolla, UCSD, San Diego, CA 92037, USA
| | - Christopher B Fordyce
- UBC Centre for Cardiovascular Innovation, Cardiovascular Health Program, UBC Centre for Health Evaluation & Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Norma M Keller
- Department of Medicine at NYU Grossman School of Medicine, Bellevue Hospital, New York NY 10016, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA 98104, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto ON, Canada
| | - Evan Leibner
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Shuangbo Liu
- Max Rady College of Medicine St. Boniface Hospital Winnipeg, Manitoba, Canada
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - L Kristin Newby
- Divison of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Connor G O'Brien
- Department of Medicine, Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Matthew J Pierce
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY 11549, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, GA 30060, USA
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA 22042, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
| | - Timothy D Smith
- The Christ Hospital and Lindner Institute for Research and Education Cincinnati, OH 45219, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, WI 53792, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, CA 94305, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Jentzer JC, Rayfield C, Soussi S, Berg DD, Kennedy JN, Sinha SS, Baran DA, Brant E, Mebazaa A, Billia F, Kapur NK, Henry TD, Lawler PR. Advances in the Staging and Phenotyping of Cardiogenic Shock: Part 1 of 2. JACC. ADVANCES 2022; 1:100120. [PMID: 38939719 PMCID: PMC11198663 DOI: 10.1016/j.jacadv.2022.100120] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/30/2022] [Accepted: 08/11/2022] [Indexed: 06/29/2024]
Abstract
Cardiogenic shock (CS) is a heterogeneous syndrome reflecting a broad spectrum of shock severity, diverse etiologies, variable cardiac function, different hemodynamic trajectories, and concomitant organ dysfunction. These factors influence the clinical presentation, management, response to therapy, and outcomes of CS patients, necessitating a tailored approach to care. To better understand the variability inherent to CS populations, recent algorithms for staging the severity of CS have been described and validated. This paper is part 1 of a 2-part state-of-the-art review. In this first article, we consider the context for clinical staging and stratification in CS with a focus on established severity staging systems for CS and their use for risk stratification and clinical care. We describe the use of staging for predicting outcomes in populations with or at risk for CS, including risk modifiers that provide more nuanced risk stratification, and highlight how these approaches may allow individualized care.
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Affiliation(s)
- Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Corbin Rayfield
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Sabri Soussi
- Department of Anesthesiology and Critical Care, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP–HP Nord, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
- Interdepartmental Division of Critical Care, Faculty of Medicine, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - David D. Berg
- TIMI Study Group, Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jason N. Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania, USA
| | - Shashank S. Sinha
- INOVA Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - David A. Baran
- Cleveland Clinic Heart Vascular and Thoracic Institute, Weston, Florida, USA
| | - Emily Brant
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP–HP Nord, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Filio Billia
- Peter Munk Cardiac Center and Ted Roger’s Center for Heart Research, Toronto, Ontario, Canada
| | - Navin K. Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, Ohio, USA
| | - Patrick R. Lawler
- Peter Munk Cardiac Center and Ted Roger’s Center for Heart Research, Toronto, Ontario, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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40
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Kapur NK, Kanwar M, Sinha SS, Thayer KL, Garan AR, Hernandez-Montfort J, Zhang Y, Li B, Baca P, Dieng F, Harwani NM, Abraham J, Hickey G, Nathan S, Wencker D, Hall S, Schwartzman A, Khalife W, Li S, Mahr C, Kim JH, Vorovich E, Whitehead EH, Blumer V, Burkhoff D. Criteria for Defining Stages of Cardiogenic Shock Severity. J Am Coll Cardiol 2022; 80:185-198. [PMID: 35835491 DOI: 10.1016/j.jacc.2022.04.049] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 11/19/2022]
Abstract
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).
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Affiliation(s)
- Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, Virginia, USA
| | - Katherine L Thayer
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paulina Baca
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Fatou Dieng
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Neil M Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence Research Network, Portland, Oregon, USA
| | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Detlef Wencker
- Baylor Scott and White Advanced Heart Failure Clinic, Dallas, Texas, USA
| | - Shelley Hall
- Baylor Scott and White Advanced Heart Failure Clinic, Dallas, Texas, USA
| | | | - Wissam Khalife
- University of Texas Medical Branch, Galveston, Texas, USA
| | - Song Li
- University of Washington Medical Center, Seattle, Washington, USA
| | - Claudius Mahr
- University of Washington Medical Center, Seattle, Washington, USA
| | - Ju H Kim
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | | | | | - Vanessa Blumer
- Duke University Medical Center, Durham, North Carolina, USA
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Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS. Basic mechanisms in cardiogenic shock: part 1-definition and pathophysiology. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:356-365. [PMID: 35218350 DOI: 10.1093/ehjacc/zuac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/17/2022] [Accepted: 02/07/2022] [Indexed: 05/23/2023]
Abstract
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, the most widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Part 1 of this two-part educational review defines cardiogenic shock and discusses current treatment strategies. In addition, we summarize current knowledge on basic mechanisms in the pathophysiology of cardiogenic shock, focusing on inflammation and microvascular disturbances, which may ultimately be translated into diagnostic or therapeutic approaches to improve the outcome of our patients.
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Affiliation(s)
- Konstantin A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christiaan Vrints
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Core Facilities, Medical University of Vienna, Vienna, Austria
| | - Kurt Huber
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Unit, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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Ostrominski JW, Vaduganathan M. Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction. Clin Cardiol 2022; 45 Suppl 1:S40-S51. [PMID: 35789014 PMCID: PMC9254675 DOI: 10.1002/clc.23849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.
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Affiliation(s)
- John W. Ostrominski
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
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Sinha SS, Rosner CM, Tehrani BN, Maini A, Truesdell AG, Lee SB, Bagchi P, Cameron J, Damluji AA, Desai M, Desai SS, Epps KC, deFilippi C, Flanagan MC, Genovese L, Moukhachen H, Park JJ, Psotka MA, Raja A, Shah P, Sherwood MW, Singh R, Tang D, Young KD, Welch T, O'Connor CM, Batchelor WB. Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes. Circ Heart Fail 2022; 15:e009279. [PMID: 35510546 DOI: 10.1161/circheartfailure.121.009279] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Carolyn M Rosner
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Behnam N Tehrani
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Aneel Maini
- Georgetown University Medical School' Washington' DC (A.M.)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Seiyon Ben Lee
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Pramita Bagchi
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - James Cameron
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Abdulla A Damluji
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mehul Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Shashank S Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Christopher deFilippi
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - M Casey Flanagan
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Leonard Genovese
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - James J Park
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Anika Raja
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Palak Shah
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Matthew W Sherwood
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Daniel Tang
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Karl D Young
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Timothy Welch
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Wayne B Batchelor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
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45
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van Diepen S, Katz JN. A Call to Move from Point-in-Time towards Comprehensive Dynamic Risk Prediction in Critically Ill Patients with Heart Failure. J Card Fail 2022; 28:1100-1103. [PMID: 35561895 DOI: 10.1016/j.cardfail.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
| | - Jason N Katz
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
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46
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Yerasi C, Case BC, Pahuja M, Ben-Dor I, Waksman R. The Need for Additional Phenotyping When Defining Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:890-895. [PMID: 35450689 DOI: 10.1016/j.jcin.2021.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/12/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Mohit Pahuja
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
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