Age shock index and age-modified shock index are strong predictors of outcomes in ST-segment elevation myocardial infarction patients undergoing emergency percutaneous coronary intervention

Age shock index and age-modified shock index are valuable bedside prognostic tools for postdischarge mortality in ST-elevation myocardial infarction patients

BACKGROUND

The incidence of mortality is considerable after ST-elevation myocardial infarction (STEMI) hospitalization; risk assessment is needed to guide postdischarge management. Age shock index (SI) and age modified shock index (MSI) were described as useful prognosis instruments; nevertheless, their predictive effect on short and long-term postdischarge mortality has not yet been sufficiently confirmed.

METHODS

This analysis included 3389 prospective patients enrolled from 2016 to 2018. Endpoints were postdischarge mortality within 30 days and from 30 days to 1 year. Hazard ratios (HRs) were evaluated by Cox proportional-hazards regression. Predictive performances were assessed by area under the curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) and compared with TIMI risk score and GRACE score.

RESULTS

The AUCs were 0.753, 0.746 for age SI and 0.755, 0.755 for age MSI for short- and long-term postdischarge mortality. No significant AUC differences and NRI were observed compared with the classic scores; decreased IDI was observed especially for long-term postdischarge mortality. Multivariate analysis revealed significantly higher short- and long-term postdischarge mortality for patients with high age SI (HR: 5.44 (2.73-10.85), 5.34(3.18-8.96)), high age MSI (HR: 4.17(1.78-9.79), 5.75(3.20-10.31)) compared to counterparts with low indices. DCA observed comparable clinical usefulness for predicting short-term postdischarge mortality. Furthermore, age SI and age MSI were not significantly associated with postdischarge prognosis for patients who received fibrinolysis.

CONCLUSIONS

Age SI and age MSI were valuable instruments to identify high postdischarge mortality with comparable predictive ability compared with the classic scores, especially for events within 30 days after hospitalization.

Shock indices are associated with in-hospital mortality among patients with septic shock and normal left ventricular ejection fraction

BACKGROUND

The understanding of shock indices in patients with septic shock is limited, and their values may vary depending on cardiac function.

METHODS

This prospective cohort study was conducted across 20 university-affiliated hospitals (21 intensive care units [ICUs]). Adult patients (≥19 years) with septic shock admitted to the ICUs during a 29-month period were included. The shock index (SI), diastolic shock index (DSI), modified shock index (MSI), and age shock index (Age-SI) were calculated at sepsis recognition (time zero) and ICU admission. Left ventricular (LV) function was categorized as either normal LV ejection fraction (LVEF ≥ 50%) or decreased LVEF (<50%).

RESULTS

Among the 1,194 patients with septic shock, 392 (32.8%) who underwent echocardiography within 24 h of time zero were included in the final analysis (normal LVEF: n = 246; decreased LVEF: n = 146). In patients with normal LVEF, only survivors demonstrated significant improvement in SI, DSI, MSI, and Age-SI values from time zero to ICU admission; however, no notable improvements were found in all patients with decreased LVEF. The completion of vasopressor or fluid bundle components was significantly associated with improved indices in patients with normal LVEF, but not in those with decreased LVEF. In multivariable analysis, each of the four indices at ICU admission was significantly associated with in-hospital mortality (P < 0.05) among patients with normal LVEF; however, discrimination power was better in the indices for patients with lower lactate levels (≤ 4.0 mmol/L), compared to those with higher lactate levels.

CONCLUSIONS

The SI, DSI, MSI, and Age-SI at ICU admission were significantly associated with in-hospital mortality in patients with septic shock and normal LVEF, which was not found in those with decreased LVEF. Our study emphasizes the importance of interpreting shock indices in the context of LV function in septic shock.

Shock index and modified shock index are predictors of long-term mortality not only in STEMI but also in NSTEMI patients

BACKGROUND

Shock index (SI) and modified shock index (mSI) are useful instruments for early risk stratification in acute myocardial infarction (AMI) patients. They are strong predictors for short-term mortality. Nevertheless, the association between SI or mSI and long-term mortality in AMI patients has not yet been sufficiently examined.

MATERIAL AND METHODS

For this study, a total of 10,174 patients with AMI was included. All cases were prospectively recorded by the population-based Augsburg Myocardial Infarction Registry from 2000 until 2017. Endpoint was all-cause mortality with a median observational time of 6.5 years [IQR: 3.5-7.4]. Using ROC analysis and calculating Youden-Index, the sample was dichotomized into a low and a high SI and mSI group, respectively. Moreover, multivariable adjusted COX regression models were calculated. All analyses were performed for the total sample as well as for STEMI and NSTEMI cases separately.

RESULTS

Optimal cut-off values were 0.580 for SI and 0.852 for mSI (total sample). AUC values were 0.6382 (95% CI: 0.6223-0.6549) for SI and 0.6552 (95% CI: 0.6397-0.6713) for mSI. Fully adjusted COX regression models revealed significantly higher long-term mortality for patients with high SI and high mSI compared to patients with low indices (high SI HR: 1.42 [1.32-1.52], high mSI HR: 1.46 [1.36-1.57]). Furthermore, the predictive ability was slightly better for mSI compared to SI and more reliable in NSTEMI cases compared to STEMI cases (for SI and mSI).

CONCLUSION

High SI and mSI are useful tools for early risk stratification including long-term outcome especially in NSTEMI cases, which can help physicians to make decision on therapy. NSTEMI patients with high SI and mSI might especially benefit from immediate invasive therapy.Key messagesShock index and modified shock index are predictors of long-term mortality after acute myocardial infarction.Both indices predict long-term mortality not only for STEMI cases, but even more so for NSTEMI cases.

Heart rate and diastolic arterial pressure in cardiac arrest patients: A nationwide, multicenter prospective registry

Background

Guidelines have recommended monitoring mean arterial pressure (MAP) and systolic arterial pressure (SAP) in cardiac arrest patients, but there has been relatively little regard for diastolic arterial pressure (DAP) and heart rate (HR). We aimed to determine the prognostic significance of hemodynamic parameters at all time points during targeted temperature management (TTM).

Methods

We reviewed the SAP, DAP, MAP, and HR data in out-of-hospital cardiac arrest (OHCA) survivors from the prospective multicenter registry of 22 teaching hospitals. This study included 1371 patients who underwent TTM among 10,258 cardiac arrest patients. The hemodynamic parameters were recorded every 6 hours from the return of spontaneous circulation (ROSC) to 4 days. The risks of those according to time points during TTM were compared.

Results

Of the included patients, 943 (68.8%) had poor neurological outcomes. The predictive ability of DAP surpassed that of SAP and MAP at all time points, and among the hemodynamic variables HR/DAP was the best predictor of the poor outcome. The risks in patients with DAP < 55 to 70 mmHg and HR > 70 to 100 beats/min were steeply increased for 2 days after ROSC and correlated with the poor outcome at all time points. Bradycardia showed lower risks only at 6 hours to 24 hours after ROSC.

Conclusion

Hemodynamic parameters should be intensively monitored especially for 2 days after ROSC because cardiac arrest patients may be vulnerable to hemodynamic instability during TTM. Monitoring HR/DAP can help access the risks in cardiac arrest patients.

Prognostic Performance of Shock Index, Diastolic Shock Index, Age Shock Index, and Modified Shock Index in COVID-19 Pneumonia

OBJECTIVE

We aimed to compare the prognostic accuracy of shock indexes in terms of mortality in patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia.

METHODS

Hospitalized patients whose COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) test results were positive, had thoracic computed tomography (CT) scan performed, and had typical thoracic CT findings for COVID-19 were included in the study.

RESULTS

Eight hundred one patients were included in the study. Chronic obstructive pulmonary disease, congestive heart failure, chronic neurological diseases, chronic renal failure, and a history of malignancy were found to be chronic diseases that were significantly associated with mortality in patients with COVID-19 pneumonia. White blood cell, neutrophil, lymphocyte, C reactive protein, creatinine, sodium, aspartate aminotransferase, alanine aminotransferase, total bilirubin, high sensitive troponin, d-dimer, hemoglobin, and platelet had a statistically significant relationship with in-hospital mortality in patients with COVID-19 pneumonia. The area under the curve (AUC) values of shock index (SI), age shock index (aSI), diastolic shock index (dSI), and modified shock index (mSI) calculated to predict mortality were 0.772, 0.745, 0.737, 0.755, and Youden Index J (YJI) values were 0.523, 0.396, 0.436, 0.452, respectively.

CONCLUSIONS

The results of this study show that SI, dSI, mSI, and aSI are effective in predicting in-hospital mortality.

Usefulness of a Novel Risk Score to Predict In-Hospital Mortality in Patients ≥ 60 Years of Age with ST Elevation Myocardial Infarction

Numerous algorithms are available to predict short-term mortality in ST elevation myocardial infarction (STEMI) but none are focused on elderly patients or include invasive hemodynamics. A simplified risk score (LASH score) including left ventricular end diastolic pressure > 20 mm Hg, age > 75 years, systolic blood pressure < 100 mm Hg and heart rate > 100 bpm was tested in a retrospective, single-center study of 346 patients ≥ 60 years old who underwent primary percutaneous coronary intervention (PPCI). The median age was 70 years [IQR: 64, 79], 60.1% were men, and 77.8% identified as White. In-hospital all-cause mortality was 10.1%. Patients with a LASH score ≥ 3 (n = 34) had an in-hospital mortality rate of 44.1% compared to 6.4% for LASH score ≤ 2 (p < 0.0001). The odds ratio for in-hospital mortality for patients with LASH score ≥ 3 was 13.2 (95% CI 5.3-33.1) compared to patients with a LASH score ≤ 2 when adjusted for sex, cardiac arrest, heart failure, and prior cerebrovascular event. The LASH score had an area under the ROC curve for predicting in-hospital mortality of 0.795 [CI 0.716-0.872], as compared to TIMI-STEMI (0.881, CI 0.829-0.931; p = 0.01), GRACE (0.849, CI 0.778-0.920; p = 0.19), shock index (0.769, CI 0.667-0.871; p = 0.51) and modified shock index (0.765, CI 0.716-0.873; p = 0.48). In summary, a simplified, easy to calculate risk score that incorporates age and invasive hemodynamics predicts in-hospital mortality in patients ≥ 60 years old undergoing PPCI for STEMI.

In-hospital mortality of acute pulmonary embolism: Predictive value of shock index, modified shock index, and age shock index scores

OBJECTIVE

The shock index (SI), modified shock index (MSI), and age shock index (ASI) have been reported to predict adverse outcomes in patients with different acute cardiovascular conditions. This study aimed to investigate the association between these indexes and in-hospital mortality in patients with acute pulmonary embolism.

METHODS

The medical records of all adult patients who were hospitalized with acute pulmonary embolism between June 2014 and June 2019, were examined. Collected data included vital signs, demographic characteristics, comorbidities, and laboratory values on presentation. The predictive value of SI, MSI, ASI, and pulmonary embolism severity index (PESI) for predicting in-hospital mortality were compared by C-statistics.

RESULTS

A total of 602 consecutive patients (mean age 66.7±13.2 years, 55% female) were included, and 62 (10.3%) of the patients died during their in-hospital course. The admission SI, MSI, ASI, and PESI were significantly higher in the deceased patients. After adjusting for other factors, the SI, MSI, PESI, and ASI were independent predictors of in-hospital mortality. The prognostic performance of ASI (C-statistics 0.74) was better than MSI (C-statistics 0.71), SI (C-statistics 0.68), and PESI (C-statistics 0.65).

CONCLUSION

The ASI may be used to identify patients at risk for in-hospital mortality following acute pulmonary embolism.

Ability of a novel shock index that incorporates invasive hemodynamics to predict mortality in patients with ST-elevation myocardial infarction

OBJECTIVE

To determine whether the use of invasively measured hemodynamics improves the prognostic ability of a shock index (SI).

BACKGROUND

SI such as Admission-SI, Age-SI, Modified SI (MSI), and Age-MSI predict short-term mortality in ST-elevation myocardial infarction (STEMI).

METHODS

Single-center study of 510 patients who underwent primary percutaneous coronary intervention. STEMI SI was defined as age × heart rate (HR) divided by coronary perfusion pressure (CPP).

RESULTS

The mean age was 62 ± 14 years, 66% were males with hypertension (69%), tobacco use (38%), diabetes (28%) and chronic kidney disease (6%). The mean HR, systolic blood pressure (SBP), and CPP were 81 ± 18 bpm, 124 ± 28 mmHg, and 52.8 ± 16.3 mmHg, respectively. Patients with STEMI SI ≥182 (n = 51) were more likely to experience a cardiac arrest in the catheterization laboratory (9.8% vs. 2.0%; p = .001), require mechanical circulatory support (47.1% vs. 8.5%; p < .0001) and be treated with vasopressors (56.9% vs. 10.7%; p < .0001) compared to STEMI SI < 182 (n = 459). After multivariate adjustment, patients with STEMI SI ≥182 were 10, 10.1 and 4.8 times more likely to die during hospitalization, at 30 days and at 5 years, respectively. The C statistic of STEMI SI was 0.870, similar to GRACE score (AUC = 0.902; p = .29) and TIMI STEMI score (AUC = 0.895; p = .36).

CONCLUSION

STEMI SI is an easy to calculate risk score that identifies STEMI patients at high risk of in-hospital death.

Comparison of shock index-based risk indices for predicting in-hospital outcomes in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

Objective

We aimed to determine whether the prognostic value of the shock index (SI) and its derivatives is better than that of the Thrombolysis In Myocardial Infarction risk index (TRI) for predicting adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 257 patients with STEMI undergoing primary PCI from January 2018 to June 2019 were analyzed in a retrospective cohort study. The SI, modified shock index (MSI), age SI (age × the SI), age MSI (age × the MSI), and TRI at admission were calculated. Clinical endpoints were in-hospital complications, including all-cause mortality, acute heart failure, cardiac shock, mechanical complications, re-infarction, and life-threatening arrhythmia.

Results

Multivariate analyses showed that a high SI, MSI, age SI, age MSI, and TRI at admission were associated with a significantly higher rate of in-hospital complications. The predictive value of the age SI and age MSI was comparable with that of the TRI (area under the receiver operating characteristic curve: z = 1.313 and z = 0.882, respectively) for predicting in-hospital complications.

Conclusions

The age SI and age MSI appear to be similar to the TRI for predicting in-hospital complications in patients with STEMI undergoing primary PCI.

Association of the age shock index with coronary plaque characteristics in ST-segment elevation myocardial infarction: A 3-vessel optical coherence tomography study

OBJECTIVES

We investigated whether the age shock index (SI) was associated with coronary plaque characteristics in patients with ST-segment elevation myocardial infarction (STEMI) using optical coherence tomography (OCT).

BACKGROUND

The age SI is a simple clinical parameter that effectively predicts poor clinical outcomes among patients with STEMI.

METHODS

This retrospective study evaluated 408 STEMI patients who underwent 3-vessel OCT during emergency percutaneous coronary interventions at a single center between January 2017 and October 2018. Patients were divided into groups with low or high age SI values (<41 vs. ≥41). Plaque characteristics were compared between the two groups for both culprit lesions (n = 408) and non-culprit lesions (n = 1,077).

RESULTS

In culprit lesions, patients with a high age SI (≥41) were more likely to have plaque rupture (61.0% vs. 56.8%, p = .002) and thinner fibrous caps (fibrous cap thickness [FCT]: 40.0 [33.0-53.0] μm vs. 46.0 [36.0-63.8] μm, p = .021). In non-culprit lesions, patients with a high age SI were more likely to have high-risk plaques (29.9% vs. 17.8%, p = .018; simultaneous presence of a minimal lumen area of <3.5 mm² , maximum lipid arc of >180°, FCT of <75 μm, and macrophage accumulation). Plaque-based analyses revealed that patients with a high age SI had larger lipid cores and lesser FCT.

CONCLUSIONS

Patients with STEMI and a high age SI had increased risks of culprit plaque rupture and high-risk non-culprit plaques, and vulnerable plaque features at the culprit and non-culprit lesions. Therefore, a high age SI in patients with STEMI may indicate greater pancoronary vulnerability.