1
|
Peters EJ, Frydland MS, Hassager C, Bos LD, van Vught LA, Cremer OL, Møller JE, van den Born BJH, Vlaar AP, Henriques JP. Biomarker patterns in patients with cardiogenic shock versus septic shock. IJC HEART & VASCULATURE 2024; 52:101424. [PMID: 38784047 PMCID: PMC11112335 DOI: 10.1016/j.ijcha.2024.101424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/11/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
Background In cardiogenic shock (CS), contractile failure is often accompanied by a systemic inflammatory response syndrome. In contrast, many patients with septic shock (SS) develop cardiac dysfunction. A similar hemodynamic support strategy is often deployed in both syndromes but it is unclear whether this is justified based on profiles of biomarkers expressing neurohormonal activation and cardiovascular stress. Methods In this prospective, multicenter cohort, 111 patients with acute myocardial infarction related CS were identified, and matched to patients with SS. Clinical parameters were collected and blood samples were obtained on day 1-3 of Intensive Care admission. Results In this shock cohort comprising 222 patients, with a mean age of 61 (±13.5) years and of whom 161 (37 %) were male, we found that despite obvious clinical disparities on admission, mortality at 30-days did not differ (CS: 40.5 % vs. SS 43.1 %, p = 0.56). Overall, plasma concentrations of all biomarkers were higher in SS patients, with the largest difference on the first day. However, only in CS patients the biomarker concentrations were associated with mortality. Conclusion In this prospective, multicenter cohort SS and CS patients showed similarities in baseline conditions and had similar mortality. However, several biomarkers only showed prognostic value in CS.
Collapse
Affiliation(s)
- Elma J. Peters
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin S. Frydland
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lieuwe D.J. Bos
- Intensive Care, Department of Respiratory Medicine, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Lonneke A. van Vught
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Olaf L. Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacob E. Møller
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Bert-Jan H. van den Born
- Department of Internal/vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P.J. Vlaar
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Jose P.S. Henriques
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - on behalf of the MARS consortium
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Intensive Care, Department of Respiratory Medicine, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Internal/vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Zapata L, Gómez-López R, Llanos-Jorge C, Duerto J, Martin-Villen L. Cardiogenic shock as a health issue. Physiology, classification, and detection. Med Intensiva 2024; 48:282-295. [PMID: 38458914 DOI: 10.1016/j.medine.2023.12.009] [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: 11/28/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024]
Abstract
Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.
Collapse
Affiliation(s)
- Luis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Rocío Gómez-López
- Servicio de Medicina Intensiva, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Celina Llanos-Jorge
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Jorge Duerto
- Servicio de Medicina Intensiva, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Luis Martin-Villen
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Seville, Spain
| |
Collapse
|
3
|
Gregers E, Frederiksen PH, Udesen NLJ, Linde L, Banke A, Povlsen AL, Larsen JP, Hassager C, Jensen LO, Lassen JF, Schmidt H, Ravn HB, Heegaard PMH, Møller JE. Immediate inflammatory response to mechanical circulatory support in a porcine model of severe cardiogenic shock. Intensive Care Med Exp 2024; 12:39. [PMID: 38647741 PMCID: PMC11035503 DOI: 10.1186/s40635-024-00625-8] [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: 01/16/2024] [Accepted: 04/14/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND In selected cases of cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is combined with trans valvular micro axial flow pumps (ECMELLA). Observational studies indicate that ECMELLA may reduce mortality but exposing the patient to two advanced mechanical support devices may affect the early inflammatory response. We aimed to explore inflammatory biomarkers in a porcine cardiogenic shock model managed with V-A ECMO or ECMELLA. METHODS Fourteen landrace pigs had acute myocardial infarction-induced cardiogenic shock with minimal arterial pulsatility by microsphere embolization and were afterwards managed 1:1 with either V-A ECMO or ECMELLA for 4 h. Serial blood samples were drawn hourly and analyzed for serum concentrations of interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha, and serum amyloid A (SAA). RESULTS An increase in IL-6, IL-8, and SAA levels was observed during the experiment for both groups. At 2-4 h of support, IL-6 levels were higher in ECMELLA compared to V-A ECMO animals (difference: 1416 pg/ml, 1278 pg/ml, and 1030 pg/ml). SAA levels were higher in ECMELLA animals after 3 and 4 h of support (difference: 401 ng/ml and 524 ng/ml) and a significant treatment-by-time effect of ECMELLA on SAA was identified (p = 0.04). No statistical significant between-group differences were observed in carotid artery blood flow, urine output, and lactate levels. CONCLUSIONS Left ventricular unloading with Impella during V-A ECMO resulted in a more extensive inflammatory reaction despite similar end-organ perfusion.
Collapse
Affiliation(s)
- Emilie Gregers
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.
| | | | - Nanna L J Udesen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Ann Banke
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Amalie L Povlsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jeppe P Larsen
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jens F Lassen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Peter M H Heegaard
- Department of Health Technology, Technical University of Denmark, Lyngby, Denmark
| | - Jacob E Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
4
|
Dettling A, Weimann J, Sundermeyer J, Beer BN, Besch L, Becher PM, Brunner FJ, Kluge S, Kirchhof P, Blankenberg S, Westermann D, Schrage B. Association of systemic inflammation with shock severity, 30-day mortality, and therapy response in patients with cardiogenic shock. Clin Res Cardiol 2024; 113:324-335. [PMID: 37982862 PMCID: PMC10850174 DOI: 10.1007/s00392-023-02336-8] [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: 08/03/2023] [Accepted: 10/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Mortality in cardiogenic shock (CS) remains high even when mechanical circulatory support (MCS) restores adequate circulation. To detect a potential contribution of systemic inflammation to shock severity, this study determined associations between C-reactive protein (CRP) concentrations and outcomes in patients with CS. METHODS Unselected, consecutive patients with CS and CRP measurements treated at a single large cardiovascular center between 2009 and 2019 were analyzed. Adjusted regression models were fitted to evaluate the association of CRP with shock severity, 30-day in-hospital mortality and treatment response to MCS. RESULTS The analysis included 1116 patients [median age: 70 (IQR 58-79) years, 795 (71.3%) male, lactate 4.6 (IQR 2.2-9.5) mmol/l, CRP 17 (IQR 5-71) mg/l]. The cause of CS was acute myocardial infarction in 530 (48%) patients, 648 (58%) patients presented with cardiac arrest. Plasma CRP concentrations were equally distributed across shock severities (SCAI stage B-E). Higher CRP concentrations were associated with 30-day in-hospital mortality (8% relative risk increase per 50 mg/l increase in CRP, range 3-13%; p < 0.001), even after adjustment for CS severity and other potential confounders. Higher CRP concentrations were only associated with higher mortality in patients not treated with MCS [hazard ratio (HR) for CRP > median 1.50; 95%-CI 1.21-1.86; p < 0.001], but not in those treated with MCS (HR for CRP > median 0.92; 95%-CI 0.67-1.26; p = 0.59; p-interaction = 0.01). CONCLUSION Elevated CRP concentrations are associated with increased 30-day in-hospital mortality in unselected patients with cardiogenic shock. The use of mechanical circulatory support attenuates this association.
Collapse
Affiliation(s)
- Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jessica Weimann
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Peter M Becher
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| |
Collapse
|
5
|
Garofalo M, Corso R, Tomasoni D, Adamo M, Lombardi CM, Inciardi RM, Gussago C, Di Mario C, Metra M, Pagnesi M. Inflammation in acute heart failure. Front Cardiovasc Med 2023; 10:1235178. [PMID: 38045909 PMCID: PMC10690826 DOI: 10.3389/fcvm.2023.1235178] [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: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Acute heart failure (AHF) represents a common clinical scenario that requires prompt evaluation and therapy and that is characterized by a high risk of mortality or subsequent rehospitalizations. The pathophysiology leading to AHF decompensation is still not fully understood. Significant activation of inflammatory pathways has been identified in patients with AHF, particularly in its most severe forms, and it has been hypothesized that systemic inflammation has a role in AHF pathogenesis. Several inflammatory mediators and cytokines, such as high sensitivity C-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1, soluble suppression of tumorigenicity 2 and galectin-3, have been shown to play a role in the pathogenesis, development and worsening of this condition with an independent prediction of adverse outcomes. This manuscript reviews the prevalence and prognostic value of systemic inflammation in AHF, as well as the potential role of anti-inflammatory therapies, focusing on available evidence from clinical trials and ongoing studies.
Collapse
Affiliation(s)
- Manuel Garofalo
- Department of Cardiology, Careggi University Hospital, Florence, Italy
| | - Rossana Corso
- Department of Internal Medicine, ASST Sette Laghi, Varese, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Carlo M. Lombardi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo M. Inciardi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Cristina Gussago
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Carlo Di Mario
- Department of Cardiology, Careggi University Hospital, Florence, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
6
|
C-Reactive Protein and White Blood Cell Count in Cardiogenic Shock. J Clin Med 2023; 12:jcm12030965. [PMID: 36769613 PMCID: PMC9917886 DOI: 10.3390/jcm12030965] [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: 12/14/2022] [Revised: 01/09/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
This study examines the prognostic impact of C-reactive protein (CRP) and white blood cell (WBC) counts in patients with cardiogenic shock (CS). Data regarding the prognostic impact of inflammatory biomarkers in CS are scarce. All consecutive patients with CS from 2019 to 2021 admitted to a cardiac intensive care unit (ICU) were included at one institution. Laboratory measurements were retrieved from the day of admission (i.e., day 1), as well as days 2, 3, 4, and 8. The primary endpoint was 30-day all-cause mortality. Statistical analyses included univariate t-tests, Spearman's correlations, C-statistics, Kaplan-Meier, and Cox regression analyses. From a total of 240 consecutive patients admitted with CS, 55% died within 30 days. CRP levels on days 3 to 8 were associated with reliable discrimination for 30-day all-cause mortality (area under the curve (AUC): 0.623-0.754), whereas CRP on day 1 was not (AUC = 0.514). In line, CRP > 100 mg/L on day 3 (56% vs. 37%; log-rank p = 0.023; HR = 1.702; 95% CI 1.060-2.735; p = 0.028) and especially a CRP increase of at least 200% from days 1 to day 3 (51% vs. 35%; log-rank p = 0.040; HR = 1.720; 95% CI 1.006-2.943; p = 0.048) were associated with an increased risk of all-cause mortality. Furthermore, WBC on day 1 discriminated 30-day all-cause mortality (AUC = 0.605; p = 0.005) with an increased risk of all-cause mortality in patients admitted with WBC > 10 × 106/mL (59% vs. 40%; log-rank p = 0.036; HR = 1.643; 95% CI 1.010-2.671; p = 0.045). In conclusion, WBC count on admission as well as CRP levels during the course of ICU treatment were associated with 30-day all-cause mortality. Specifically, an increase of CRP levels by at least 200% from day 1 to day 3 during the course of ICU treatment was associated with an increased risk of 30-day all-cause mortality. The present study is one of the first to describe the prognostic value of inflammatory biomarkers in consecutive all-comer CS patients treated at a cardiac ICU.
Collapse
|
7
|
Szekely Y, Luk A, Lawler PR. Emerging biomarkers for risk stratification in cardiogenic shock: steps closer to precision? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:739-741. [PMID: 36166348 DOI: 10.1093/ehjacc/zuac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Yishay Szekely
- Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 585 University Ave, Toronto, ON M5G 2N2, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
- Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, 6 Weizmann St, Tel Aviv, 6423906, Israel
| | - Adriana Luk
- Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 585 University Ave, Toronto, ON M5G 2N2, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 585 University Ave, Toronto, ON M5G 2N2, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, ON, M5S 3H2, Canada
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Picod A, Morisson L, de Roquetaillade C, Sadoune M, Mebazaa A, Gayat E, Davison BA, Cotter G, Chousterman BG. Systemic Inflammation Evaluated by Interleukin-6 or C-Reactive Protein in Critically Ill Patients: Results From the FROG-ICU Study. Front Immunol 2022; 13:868348. [PMID: 35634339 PMCID: PMC9134087 DOI: 10.3389/fimmu.2022.868348] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
BackgroundThe prognostic impact of high concentration of interleukin-6 (IL-6) or C-reactive protein (CRP), two routinely available markers of systemic inflammation in the general population of critically ill patients, remains unclear. In a large cohort of critically ill patients including septic and non-septic patients, we assessed the relationship between baseline IL-6 or CRP and mortality, organ dysfunction, and the need for organ support.MethodsThis was an ancillary analysis of the prospective French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) study including patients with a requirement for invasive mechanical ventilation and/or vasoactive drug support for more than 24 h following intensive care unit (ICU) admission. The primary objective was to determine the association between baseline IL-6 or CRP concentration and survival until day 90. Secondary outcomes included organ dysfunction as evaluated by the Sequential Organ Failure Assessment (SOFA) score, and the need for organ support, including vasopressors/inotropes and/or renal replacement therapy (RRT).ResultsMedian IL-6 and CRP concentrations (n = 2,076) at baseline were 100.9 pg/ml (IQR 43.5–261.7) and 143.7 mg/L (IQR 78.6–219.8), respectively. Day-90 mortality was 30%. High IL-6 or CRP was associated with worse 90-day survival (hazard ratios 1.92 [1.63–2.26] and 1.21 [1.03–1.41], respectively), after adjustment on the Simplified Acute Physiology Score II (SAPS-II). High IL-6 was also associated with the need for organ-support therapies, such as vasopressors/inotropes (OR 2.67 [2.15–3.31]) and RRT (OR 1.55 [1.26–1.91]), including when considering only patients independent from those supports at the time of IL-6 measurement. Associations between high CRP and organ support were inconsistent.ConclusionIL-6 appears to be preferred over CRP to evaluate critically ill patients’ prognoses.
Collapse
Affiliation(s)
- Adrien Picod
- Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, AP-HP, Paris, France
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
- Sorbonne University, Paris, France
- *Correspondence: Adrien Picod,
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Ile de Montréal, Montréal, QC, Canada
| | - Charles de Roquetaillade
- Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, AP-HP, Paris, France
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
| | - Malha Sadoune
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, AP-HP, Paris, France
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, AP-HP, Paris, France
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
| | - Beth A. Davison
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
- Momentum Research Inc., Durham, NC, United States
| | - Gad Cotter
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
- Momentum Research Inc., Durham, NC, United States
| | - Benjamin Glenn Chousterman
- Department of Anesthesiology, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, AP-HP, Paris, France
- UMR-S 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Markers in Stressed Conditions (MASCOT), Paris University, Paris, France
| |
Collapse
|
10
|
Lassus J, Tarvasmäki T, Tolppanen H. Biomarkers in cardiogenic shock. Adv Clin Chem 2022; 109:31-73. [DOI: 10.1016/bs.acc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
11
|
Chaftari P, Qdaisat A, Chaftari AM, Maamari J, Li Z, Lupu F, Raad I, Hachem R, Calin G, Yeung SCJ. Prognostic Value of Procalcitonin, C-Reactive Protein, and Lactate Levels in Emergency Evaluation of Cancer Patients with Suspected Infection. Cancers (Basel) 2021; 13:cancers13164087. [PMID: 34439240 PMCID: PMC8393196 DOI: 10.3390/cancers13164087] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/31/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Cancer patients are at increased risk of infections and related complications, including sepsis. We developed a scoring system for mortality prediction based on readily available clinical and laboratory data, including the quick sequential organ failure assessment (qSOFA) score, cancer subtype, and several laboratory markers (procalcitonin, C-reactive protein, lactate dehydrogenase, and albumin) that can be used in emergency departments for cancer patients with suspected infection. The prediction score, which stratifies patients into four different risk groups (from low risk to very high risk), achieved excellent performance in predicting 14-day mortality, with an area under the receiver operating characteristic curve value of 0.88 (95% confidence interval 0.85–0.91). The score was also effective in predicting intensive care unit admission and 30-day mortality. Abstract Cancer patients have increased risk of infections, and often present to emergency departments with infection-related problems where physicians must make decisions based on a snapshot of the patient’s condition. Although C-reactive protein, procalcitonin, and lactate are popular biomarkers of sepsis, their use in guiding emergency care of cancer patients with infections is unclear. Using these biomarkers, we created a prediction model for short-term mortality in cancer patients with suspected infection. We retrospectively analyzed all consecutive patients who visited the emergency department of MD Anderson Cancer Center between 1 April 2018 and 30 April 2019. A clinical decision model was developed using multiple logistic regression for various clinical and laboratory biomarkers; coefficients were used to generate a prediction score stratifying patients into four groups according to their 14-day mortality risk. The prediction score had an area under the receiver operating characteristic curve value of 0.88 (95% confidence interval 0.85–0.91) in predicting 14-day mortality. The prediction score also accurately predicted intensive care unit admission and 30-day mortality. Our simple new scoring system for mortality prediction, based on readily available clinical and laboratory data, including procalcitonin, C-reactive protein, and lactate, can be used in emergency departments for cancer patients with suspected infection.
Collapse
Affiliation(s)
- Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (P.C.); (A.Q.)
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (P.C.); (A.Q.)
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.-M.C.); (I.R.); (R.H.)
| | - Julian Maamari
- School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon;
| | - Ziyi Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA;
| | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.-M.C.); (I.R.); (R.H.)
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.-M.C.); (I.R.); (R.H.)
| | - George Calin
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (P.C.); (A.Q.)
- Correspondence: ; Tel.: +1-(713)-745-9911
| |
Collapse
|
12
|
Diagnostic yield of routine daily blood culture in patients on veno-arterial extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:241. [PMID: 34238367 PMCID: PMC8264470 DOI: 10.1186/s13054-021-03658-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bloodstream infections (BSIs) are frequent on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Performing routine blood cultures (BCs) may identify early paucisymptomatic BSIs. We investigated the contribution of systematic daily BCs to detect BSIs on V-A ECMO. METHODS This was a retrospective study including all adult patients requiring V-A ECMO and surviving more than 24 h. Our protocol included routine daily BCs, from V-A ECMO insertion up to 5 days after withdrawal; other BCs were performed on-demand. RESULTS On the 150 V-A ECMO included, 2146 BCs were performed (1162 routine and 984 on-demand BCs); 190 (9%) were positive, including 68 contaminants. Fifty-one (4%) routine BCs revealed BSIs; meanwhile, 71 (7%) on-demand BCs revealed BSIs (p = 0.005). Performing routine BCs was negatively associated with BSIs diagnosis (OR 0.55, 95% CI [0.38; 0.81], p = 0.002). However, 16 (31%) BSIs diagnosed by routine BCs would have been missed by on-demand BCs. Independent variables for BSIs diagnosis after routine BCs were: V-A ECMO for cardiac graft failure (OR 2.43, 95% CI [1.20; 4.92], p = 0.013) and sampling with on-going antimicrobial therapy (OR 2.15, 95% CI [1.08; 4.27], p = 0.029) or renal replacement therapy (OR 2.05, 95% CI [1.10; 3.81], p = 0.008). Without these three conditions, only two BSIs diagnosed with routine BCs would have been missed by on-demand BCs sampling. CONCLUSIONS Although routine daily BCs are less effective than on-demand BCs and expose to contamination and inappropriate antimicrobial therapy, a policy restricted to on-demand BCs would omit a significant proportion of BSIs. This argues for a tailored approach to routine daily BCs on V-A ECMO, based on risk factors for positivity.
Collapse
|