Cardiac Power Index, Mean Arterial Pressure, and Simplified Acute Physiology Score II Are Strong Predictors of Survival and Response to Revascularization in Cardiogenic Shock

Venous return physiology applied to post-cardiac arrest haemodynamic management: a post hoc analysis of the NEUROPROTECT trial

BACKGROUND

The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups.

RESULTS

Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01).

CONCLUSIONS

Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.

Hemodynamic monitoring and echocardiographic evaluation in cardiogenic shock

Cardiogenic shock (CS) is characterized by the presence of a state of tissue hypoperfusion secondary to ventricular dysfunction. Hemodynamic monitoring allows us to obtain information about cardiovascular pathophysiology that will help us make the diagnosis and guide therapy in CS situations. The most used monitoring system in CS is the pulmonary artery catheter since it provides key hemodynamic variables in CS, such as cardiac output, pulmonary artery pressure, and pulmonary artery occlusion pressure. On the other hand, echocardiography makes it possible to obtain, at the bedside, anatomical and hemodynamic data that complement the information obtained through continuous monitoring devices. CS monitoring can be considered multimodal and integrative by including hemodynamic, metabolic, and echocardiographic parameters that allow describing the characteristics of CS and guiding therapeutic interventions during hemodynamic resuscitation.

Cardiovascular changes induced by targeted mild hypercapnia after out of hospital cardiac arrest. A sub-study of the TAME cardiac arrest trial

AIM

Hypercapnia may elicit detrimental haemodynamic effects in critically ill patients. We aimed to investigate the consequences of targeted mild hypercapnia versus targeted normocapnia on pulmonary vascular resistance and right ventricular function in patients resuscitated from out-of-hospital cardiac arrest (OHCA).

METHODS

Pre-planned, single-centre, prospective, sub-study of the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. Patients were randomised to mild hypercapnia (PaCO2 = 6.7-7.3 kPa) or normocapnia (PaCO2 = 4.7-6.0 kPa) for 24 hours. Haemodynamic assessment was performed with right heart catheterisation and serial blood-gas analyses every4th hour for 48 hours.

RESULTS

We studied 84 patients. Mean pH was 7.24 (95% CI 7.22-7.30) and 7.32 (95% CI 7.31-7.34) with hypercapnia and normocapnia, respectively (P-group < 0.001). Pulmonary vascular resistance index (PVRI), pulmonary artery pulsatility index, and right atrial pressure did not differ between groups (P-group > 0.05). Mean cardiac index was higher with mild hypercapnia (P-group < 0.001): 2.0 (95% CI 1.85-2.1) vs 1.6 (95% CI 1.52-1.76) L/min/m2. Systemic vascular resistance index was 2579 dyne-sec/cm-5/ m2 (95% CI 2356-2830) with hypercapnia, and 3249 dyne-sec/cm-5/ m2 (95% CI 2930-3368) with normocapnia (P-group < 0.001). Stroke volumes (P-group = 0.013) and mixed venous oxygen saturation (P-group < 0.001) were higher in the hypercapnic group.

CONCLUSION

In resuscitated OHCA patients, targeting mild hypercapnia did not increase PVRI or worsen right ventricular function compared to normocapnia. Mild hypercapnia comparatively improved cardiac performance and mixed venous oxygen saturation.

Standardization of the Right Heart Catheterization and the Emerging Role of Advanced Hemodynamics in Heart Failure

The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters.

Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest

AIM

To assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA).

METHODS

In the cohort study of 789 patients included in the "BOX"-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy.

RESULTS

First measured CI was median 1.7 (1.4-2.1) l/min/m2, and first measured SvO2 was median 67 (61-73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84-0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62-0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06-2.23) and renal failure (ORadjusted: 5.87 [2.34-14.73].

CONCLUSION

First measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly.

REGISTRATION

The BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017-30-04, retrospectively registered).

Correlation between severity of obesity and mortality in cardiogenic shock

INTRODUCTION

Cardiogenic shock (CS) is associated with high mortality despite the development of risk stratification tools and new treatment strategies. Obesity, although a risk factor for cardiovascular disease, is not included in current risk stratification tools for CS. A relationship between mortality and obesity has only been shown in subsets populations of CS; there is not yet a clear relationship between severity of obesity and all-cause CS.

OBJECTIVES

In this study we evaluate the relationship between rising body mass index (BMI) and mortality in all-cause CS.

METHODS

All patients with BMI measurements and hospitalizations complicated by CS from 2014 to 2019 at a single quaternary care institution were identified. Patients were grouped by obesity classification. Multivariate logistic regression was performed to determine a relationship between higher obesity classifications with 30-day mortality in patients with CS.

RESULTS

Seventy-two patients were available for analysis. Mean BMI for those who survived compared to those who did not was 29.7 ± 8 kg/m2 vs 33.7 ± 7.6 kg/m2 (p = 0.04). The odds ratio for mortality with incremental increase in obesity classification was 1.6 (95% CI 1.1 - 2.6, p = 0.03) after adjusting for etiology of CS and other common associations with CS mortality.

CONCLUSION

This study suggests that the higher mortality risk with incremental increases in BMI should be taken into account when risk stratifying these patients.

Predictive value of SII and sd-LDL for contrast-induced acute kidney injury in STEMI patients undergoing percutaneous coronary intervention

Aim: To investigate the relationship between the incidence of contrast-induced acute kidney injury (CI-AKI) and the level of small dense low-density lipoprotein (sd-LDL) and systemic immune-inflammation index (SII) in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI), and to further compare the predictive values of SII, sd-LDL and their combination for CI-AKI. Methods: A total of 674 patients were assigned to a training and a validation cohort according to their chronological sequence. The baseline characteristics of the 450 patients in the training cohort were considered as candidate univariate predictors of CI-AKI. Multivariate logistic regression was then used to identify predictors of CI-AKI and develop a prediction model. The predictive values of SII, sd-LDL and their combination for CI-AKI were also evaluated. Results: Multivariate logistic regression analysis showed that age, left ventricular ejection fraction (LVEF), sd-LDL, uric acid, estimated glomerular filtration rate (eGFR) and SII were predictors of CI-AKI. The area under the curve (AUC) of the prediction model based on the above factors was 0.846 [95% confidence interval (CI) 0.808–0.884], and the Hosmer-Lemeshow test (P = 0.587, χ2 = 6.543) proved the goodness of fit of the model. The AUC combining SII with sd-LDL to predict CI-AKI was 0.785 (95% CI 0.735–0.836), with a sensitivity of 72.8% and a specificity of 79.8%, and was statistically significant when compared with SII and sd-LDL, respectively. The predictive efficiency of combining SII with sd-LDL and SII were evaluated by improved net reclassification improvement (NRI, 0.325, P < 0.001) and integrated discrimination improvement (IDI, 0.07, P < 0.001). Conclusions: Both SII and sd-LDL can be used as predictors of CI-AKI in STEMI patients undergoing emergency PCI, and their combination can provide more useful value for early assessment of CI-AKI.

Utility of Cardiac Power Hemodynamic Measurements in the Evaluation and Risk Stratification of Cardiovascular Conditions

Despite numerous advancements in prevention, diagnosis and treatment, cardiovascular disease has remained the leading cause of mortality globally for the past 20 years. Part of the explanation for this trend is persistent difficulty in determining the severity of cardiac conditions in order to allow for the deployment of prompt therapies. This review seeks to determine the prognostic importance of cardiac power (CP) measurements, including cardiac power output (CPO) and cardiac power index (CPI), in various cardiac pathologies. CP was evaluated across respective disease-state categories which include cardiogenic shock (CS), septic shock, transcatheter aortic valve replacement (TAVR), heart failure (HF), post-myocardial infarction (MI), critical cardiac illness (CCI) and an "other" category. Literature review was undertaken of articles discussing CP in various conditions and this review found utility and prognostic significance in the evaluation of TAVR patients with a significant correlation between one-year mortality and CPI; in HF patients showing CPI and CPO as valuable tools to assess cardiac function in the acute setting; and, additionally, CPO was found to be an essential tool in patients with CCI, as the literature showed that CPO was statistically correlated with mortality. Cardiac power and the derived measures obtained from this relatively easily obtained variable can allow for essential estimations of prognostic outcomes in cardiac patients.

Machine Learning for Prediction of Outcomes in Cardiogenic Shock

Objective

The management of cardiogenic shock (CS) in the elderly remains a major clinical challenge. Existing clinical prediction models have not performed well in assessing the prognosis of elderly patients with CS. This study aims to build a predictive model, which could better predict the 30-day mortality of elderly patients with CS.

Methods

We extracted data from the Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III) as the training set and the data of validation sets were collected from the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. Three models, including the cox regression model, the Least Absolute Shrinkage and Selection Operator (LASSO) regression model, and the CoxBoost model, were established using the training set. Through the comparison of area under the receiver operating characteristic (ROC) curve (AUC), C index, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and median improvement in risk score, the best model was selected. Then for external validation, compared the best model with the simplified acute physiology score II (SAPSII) and the CardShock risk score.

Results

A total of 919 patients were included in the study, of which 804 patients were in the training set and 115 patients were in the verification set. Using the training set, we built three models: the cox regression model including 6 predictors, the LASSO regression model including 4 predictors, and the CoxBoost model including 16 predictors. Among them, the CoxBoost model had good discrimination [AUC: 0.730; C index: 0.6958 (0.6657, 0.7259)]. Compared with the CoxBoost model, the NRI, IDI, and median improvement in risk score of other models were all<0. In the validation set, the CoxBoost model was also well-discriminated [AUC: 0.770; C index: 0.7713 (0.6751, 0.8675)]. Compared with the CoxBoost model, the NRI, IDI, and median improvement in risk score of SAPS II and the CardShock risk score were all < 0. And we constructed a dynamic nomogram to visually display the model.

Conclusion

In conclusion, this study showed that in predicting the 30-day mortality of elderly CS patients, the CoxBoost model was superior to the Cox regression model, LASSO regression model, SAPS II, and the CardShock risk score.

A Review of Prognosis Model Associated With Cardiogenic Shock After Acute Myocardial Infarction

Objective: Cardiogenic shock seriously affects the survival rate of patients. However, few prognostic models are concerned with the score of cardiogenic shock, and few clinical studies have validated it. In order to optimize the diagnosis and treatment of myocardial infarction complicated with cardiogenic shock and facilitate the classification of clinical trials, the prognosis score model is urgently needed. Methods: Cardiogenic shock, severe case, prognosis score, myocardial infarction and external verification were used as the search terms to search PubMed, Embase, Web of Science, Cochrane, EBSCO (Medline), Scopus, BMC, NCBI, Oxford Academy, Science Direct, and other databases for pertinent studies published up until 1 August 2021. There are no restrictions on publication status and start date. Filter headlines and abstracts to find articles that may be relevant. The list of references for major studies was reviewed to obtain more references. Results and Conclusions: The existing related models are in urgent need of more external clinical verifications. In the meanwhile, with the development of molecular omics and the clinical need for optimal treatment of CS, it is urgent to establish a prognosis model with higher differentiation and coincidence rates.

Ulinastatin as an Adjuvant Therapy to Restricting Volumes of Resuscitation Fluid Strategy for Patients with Septic Shock after Initial Management

Septic shock is the most serious complication of sepsis, leading to unacceptably high morbidity and mortality worldwide. Fluid resuscitation using crystalloids has become the mainstay of early and aggressive treatment of severe sepsis and septic shock, while increased daily fluid balances from day 2 until day 7 have been related with increased mortality. Recently, pharmacological management has been recommended to combine with appropriate fluid resuscitation for the treatment of septic shock. In this study, we compared the clinical efficacy of restricting volumes of resuscitation fluid strategy with or without intravenous infusion of ulinastatin (UTI) in treating patients with septic shock and additionally examined the patient's changes of the extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), systemic vascular resistance index (SVRI), cardiac function, lactic acid (LA) level, coagulation function, and renal function. The study included 182 patients with septic shock, among which 89 patients had undergone restricting volumes of resuscitation fluid strategy with intravenous infusion of UTI and 93 patients had undergone restricting volumes of resuscitation fluid strategy alone. It was found that patients with septic shock after restricting volumes of resuscitation fluid strategy with intravenous infusion of UTI showed an increased SVRI concomitant with declined PVPI and EVLWI, increased mean artery pressure (MAP), cardiac output (CO), left ventricular ejection fraction (LVEF), stroke volume (SV), and heart rate (HR), declined levels of cardiac troponin I (cTnI), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP), reduced LA level along with shortened prothrombin time (PT) and partially activated thrombin time (PATT), and decreased levels of blood urea nitrogen (BUN), creatinine (Cr), and uric acid (UA) when comparable to those after restricting volumes of resuscitation fluid strategy alone (P < 0.05). We also observed fewer scores of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the sequential organ failure assessment (SOFA) in patients undergoing restricting volumes of resuscitation fluid strategy with intravenous infusion of UTI than those undergoing restricting volumes of resuscitation fluid strategy alone (P < 0.05). According to the above data, it is concluded that UTI as an adjuvant therapy for restricting volumes of resuscitation fluid strategy in treating septic shock may decrease the LA level, attenuate the inflammatory response, reduce vascular permeability, prevent pulmonary edema, and restore cardiac and renal functions.

Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study

BACKGROUND

The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (P_msa ) and derived variables to explain the response to a fluid bolus.

METHODS

The P_msa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as P_msa  - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over P_msa , the volume efficiency (E_vol ), were studied to assess fluid responsiveness. Changes between P_msa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression.

RESULTS

Data were analysed for 235 patients who received 489 fluid boluses. The P_msa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P = .03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P = .04). Hierarchical cluster analysis only identified E_vol and the change in CO within one cluster. The multiple linear regression between P_msa and its derived variables and the change in CO (overall r²  = .48, P < .001) demonstrated the best partial regression between the continuous change in CO and the concurrent E_vol (r = .55, P < .001).

CONCLUSION

The mean systemic filling P_msa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.

Association between neutrophil-to-albumin ratio and mortality in patients with cardiogenic shock: a retrospective cohort study

OBJECTIVES

To investigate the prognostic value of neutrophil-to-albumin ratio (NAR) in critically ill patients with cardiogenic shock (CS).

DESIGN

A retrospective cohort study.

SETTING

A single centre in Boston, USA.

PARTICIPANTS

475 patients with CS were included, among which 272 (57.3%) were men and 328 (69.1%) were white.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 90-day mortality and the secondary outcomes were 30-day and 365-day mortality.

RESULTS

A significant positive correlation between NAR levels and 90-day, 30-day or 365-day mortality was observed. For 90-day mortality, the adjusted HR (95% CI) values given NAR levels 23.54-27.86 and >27.86 were 1.71 (1.14 to 2.55) and 1.93 (1.27 to 2.93) compared with the reference (NAR<23.47). Receiver operator characteristic curve analysis showed that NAR had a certain prognostic value in predicting 90-day mortality of CS, which was more sensitive than the neutrophil percentage or the serum albumin level alone (0.651 vs 0.509, 0.584). For the secondary outcomes, the upward trend remained statistically significant.

CONCLUSIONS

NAR level was associated with the mortality of CS patients. The prognostic value of NAR was more sensitive than the neutrophil percentage or the serum albumin level alone, but not as good as Sequential Organ Failure Assessment or Simplified Acute Physiology Score.

Prognostic Value of Neutrophil-Lymphocyte Ratio in Cardiogenic Shock: A Cohort Study

BACKGROUND Inflammation plays an important part in the pathogenesis of cardiogenic shock (CGS). Whether the neutrophil-lymphocyte ratio (NLR), an integrated biomarker of inflammation, is associated with the outcome of CGS patients remains unknown. This retrospective cohort study was performed to identify the utility of using NLR among patients with CGS. MATERIAL AND METHODS Data were extracted from the MIMIC database. We applied smooth curve fitting to define the NLR cutoff values. The primary outcome was 30-day mortality. Cox proportional hazards models, subgroup analysis, and receiver operator characteristic (ROC) curve analysis were performed. RESULTS A total of 1470 CGS patients were extracted, among which 801 (54.5%) were men. The mean age of the population was 70.37 years. An inverse U-shaped relationship was observed between NLR and mortality in CGS patients, with the highest risk being at values ranging from 9.4 to 15. For the primary outcome of 30-day mortality, the adjusted HR (95% CI) values of the middle tertile (NLR 9.4-15) and the upper tertile (NLR >15) were 1.47 (1.14, 1.88) and 1.22 (0.94, 1.57) compared with the reference of lower tertile (NLR <9.4). ROC curve analysis showed that NLR had a more sensitive prognostic value in predicting 30-day mortality of CGS than the neutrophil or lymphocyte percentage alone (0.660 vs. 0.540, 0.549). CONCLUSIONS An inverse U-shaped curve was presented between NLR and the mortality of CGS. NLR seemed to be a readily available and independent prognostic biomarker for patients with CGS. The prognostic value of NLR was more sensitive than the neutrophil or lymphocyte percentage alone, but not as good as SOFA or SAPSII score.

Correlation Between Echocardiographic and Hemodynamic Variables in Cardiothoracic Intensive Care Unit

OBJECTIVES

The echocardiographic indices have not been validated in critically ill population. The authors investigated the correlation between some echocardiographic and hemodynamic parameters.

DESIGN

Prospective, spontaneous, noninterventional observational study.

SETTING

Adult cardiothoracic intensive care unit, single center (Royal Brompton Hospital, London, United Kingdom).

PARTICIPANTS

Consecutive adult patients admitted to the cardiothoracic intensive care unit for severe respiratory failure, primary cardiocirculatory failure, and post-aortic surgery.

INTERVENTIONS

Clinical hemodynamic parameters (stroke volume [SV], cardiac output [CO], mean arterial pressure [MAP], and cardiac power index [CPI]) and echocardiographic indices of ventricular function (left ventricular total isovolumic time [t-IVT], mitral annular plane systolic excursion [MAPSE], and left ventricular fraction [LVEF]) were evaluated offline.

MEASUREMENTS AND MAIN RESULTS

The study comprised 117 patients (age 57.2 ± 19; 60.6% male). The t-IVT showed an inverse correlation with SV, CO, MAP, and CPI (r -67%; -38%; -45%; -51%, respectively). MAPSE exhibited a positive correlation with SV, CO, MAP, and CPI (r 43%; 44%; 34%; 31%, respectively). LVEF did not show any correlation. In the multivariate analysis the association between t-IVT and hemodynamics was confirmed for SV, CO, MAP, and CPI, with the highest partial correlation between t-IVT and MAP (R = -58%).

CONCLUSIONS

MAPSE and t-IVT are 2 reproducible and reliable echocardiographic indices of systolic function and ventricular efficacy associated with hemodynamic variables in cardiothoracic critically ill patients, whereas LVEF did not show any correlation.

Association of shock index with short-term and long-term prognosis after ST-segment elevation myocardial infarction

BACKGROUND

The association of shock index with long-term mortality after ST-segment elevation myocardial infarction (STEMI) remains poorly investigated. We aimed to assess the association between shock index and eight-year mortality after STEMI.

METHODS

The study included 1369 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). Patients were categorized into three groups: a group with shock index in the first tertile (shock index, 0.21 to 0.52; n = 458), a group with shock index in the second tertile (shock index > 0.52 to 0.67; n = 457) and a group with shock index in the third tertile (shock index > 0.67 to 2.80; n = 454). The primary outcome was eight-year mortality.

RESULTS

In patients with shock index in the first to third tertiles, inhospital cardiogenic shock (n = 153) occurred in 3.5, 3.9 and 26.2% of patients, respectively [adjusted odds ratio = 1.54, 95% confidence interval (CI) 1.40 to 1.69, P < 0.001]; 30-day deaths (n = 122) occurred in 2.8, 5.5 and 18.5% of patients, respectively [adjusted hazard ratio = 1.06 (1.01-1.12); P = 0.024]; eight-year deaths (n = 300) occurred in 22.9, 21.6 and 36.1% of patients, respectively [adjusted hazard ratio = 1.06 (1.02-1.11); P = 0.007] with all risk estimates calculated per 0.1 unit increment in shock index values. From 30 days to 8 years, deaths (n = 178) occurred in 20.7, 17.0 and 21.5% of patients in the first to third shock index tertiles, respectively (the difference was nonsignificant for all intertertile comparisons).

CONCLUSIONS

In patients with STEMI, elevated shock index is associated with the risk of inhospital cardiogenic shock and mortality up to 8 years after PPCI. The long-term adverse prognosis was almost entirely driven by events within the first 30 days.

Non-invasive hemodynamic profiling of patients undergoing hemodialysis - a multicenter observational cohort study

Background

Intradialytic blood pressure (BP) measurement is currently the main parameter used for monitoring hemodynamics during hemodialysis (HD). Since BP is dependent on cardiac output and total peripheral resistance, knowledge of these parameters throughout the HD treatment would potentially be valuable.

Methods

The use of a novel non-invasive monitoring system for profiling hemodynamic response patterns during HD was explored: a whole-body bio-impedance system was used to assess cardiac index (CI), total peripheral resistance index (TPRI), cardiac power index (CPI) among other parameters in chronic HD patients from 4 medical centers. Measurements were made pre, during and post dialysis. Patients were grouped into 5 hemodynamic profiles based on their main hemodynamic response during dialysis i.e. high TPRI; high CPI; low CPI; low TPRI and those with normal hemodynamics. Comparisons were made between the groups for baseline characteristics and 1-year mortality.

Results

In 144 patients with mean age of 67.3 ± 12.1 years pre-dialysis hemodynamic measurements were within normal limits in 35.4% but only 6.9% overall remained hemodynamically stable during dialysis. Intradialytic BP decreased in 65 (45.1%) in whom, low CPI (47 (72.3%)) and low TPRI (18 (27.7%) were recorded. At 1-year follow-up, mortality rates were highest in patients with low CPI (23.4%) and low TPRI (22.2%).

Conclusions

Non-invasive assessment of patients’ response to HD provides relevant hemodynamic information that exceeds that provided by currently used BP measurements. Use of these online analyses could potentially improve the safety and performance standards of dialysis by guiding appropriate interventions, particularly in responding to hypertension and hypotension.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1542-4) contains supplementary material, which is available to authorized users.

Assessment of volume status and volume responsiveness in the ICU: Protocol for an observational, multicentre cohort study

BACKGROUND

Expansion of the intravascular compartment is common to treat haemodynamic instability in ICU patients. The most useful and accurate variables to guide and evaluate a fluid challenge remain debated and incompletely investigated resulting in significant variability in practice. The analogue mean systemic pressure has been reported as a measure of the intravascular volume state.

METHODS

This is a protocol and statistical analysis plan for a review of the application of an analogue of the mean systemic pressure and the use of derived variables to assess the volume state and volume responsiveness. A pulmonary artery catheter was used in 286 postoperative cardiac surgical patients to monitor cardiac output before and after a fluid bolus in addition to arterial and central venous pressures. With otherwise similar monitoring, echocardiography was used in 540 general ICU patients to determine cardiac outputs and indices related to intravascular filling. The responses to a fluid bolus or the passive leg raising manoeuvre will be investigated using continuous and dichotomous definitions of volume responsiveness. The results will be stratified according to the method of monitoring cardiac output.

CONCLUSIONS

This study investigating 2 cohorts that encompass a wide variety of reasons for haemodynamic instability will illustrate the applicability of the analogue mean systemic pressure and derived variables to assess the volume state and responsiveness. The results may guide the rationale and design of interventional studies.

Hemodynamics of Cardiogenic Shock

Cardiogenic shock (CS) represents an advanced state of morbidity along the pathophysiologic pathway of end-organ hypoperfusion caused by reduced cardiac output and blood pressure. Acute coronary syndromes remain the most common cause of CS. The spectrum of hypoperfusion states caused by low cardiac output ranges from pre-CS to refractory CS and can be characterized by an array of hemodynamic parameters. This review provides the foundation for a hemodynamic understanding of CS including the use of hemodynamic monitoring for diagnosis and treatment, the cardiac and vascular determinants of CS, and a hemodynamic approach to risk stratification and management of CS.

Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.

The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients

AIM

Which haemodynamic variable is the best predictor of neurological outcome remains unclear. We investigated the association of several haemodynamic variables with neurological outcome in CA patients.

METHODS

Retrospective analysis of adult comatose survivors of CA admitted to the intensive care unit (ICU) of a University Hospital. Exclusion criteria were early death due to withdrawal of care, missing haemodynamic data and use of intra-aortic balloon pump or extracorporeal membrane oxygenation. We retrieved CA characteristics; lactate concentration and cardiovascular sequential organ failure assessment (cSOFA) score on admission; systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), and the use of vasopressors and inotropic agents during the first 6 h of ICU stay. Unfavourable neurological outcome (UO) was defined as a 3-month cerebral performance category score of 3-5.

RESULTS

Among the 170 patients (median age 63 years, 67% male, 60% out-of-hospital CA), 106 (63%) had UO. Admission lactate was higher in patients with UO than in those with favourable neurological outcome (4.0[2.4-7.3] vs. 2.5[1.4-6.0] mEq/L; p = 0.003) as was the cSOFA (3 [1-4] vs. 2[0-3]; p = 0.007). The lowest DAP during the first 6 h after ICU admission was significantly lower in patients with unfavourable neurological outcome, notably in patients with high cSOFA scores. In multivariable analysis, high adrenaline doses and the lowest value of DAP during the first 6 h after ICU admission was significantly associated with unfavourable neurological outcome.

CONCLUSIONS

In CA patients admitted to the ICU, low DAP during the first 6 h is an independent predictor of unfavourable neurological outcome at 3 months.

Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock

OBJECTIVES

To characterize patient profile and hemodynamic profile of those undergoing intra-aortic balloon pump (IABP) for cardiogenic shock and define predictors of hemodynamic failure of IABP support.

BACKGROUND

Clinical characteristics of IABP support in cardiogenic shock not related to acute myocardial infarction (AMI) remain poorly characterized.

METHODS

We retrospectively studied a cohort of 74 patients from 2010 to 2015 who underwent IABP insertion for cardiogenic shock complicating acute decompensated heart failure not due to AMI.

RESULTS

In the overall cohort, which consisted primarily of patients with chronic systolic heart failure (89%), IABP significantly augmented cardiac index and lowered systemic vascular resistance (P<.05). Despite this improvement, 28% of these patients died (24%) or require urgent escalation in mechanical circulatory support (MCS) (4%). Multivariable regression revealed that baseline left ventricular cardiac power index (LVCPI), a measure of LV power output derived from cardiac index and mean arterial pressure (P=.01), and history of ischemic cardiomyopathy (P=.003) were significantly associated with the composite adverse-event endpoint of death or urgent MCS escalation. An IABP Failure risk score using baseline LVCPI <0.28 W/m² and ischemic history predicted 28-day adverse events with excellent discrimination.

CONCLUSION

Despite hemodynamic improvements with IABP support, patients with non-AMI cardiogenic shock still suffer poor outcomes. Patients with ischemic cardiomyopathy and low LVPCI fared significantly worse. These patients may warrant closer observation or earlier consideration of more advanced hemodynamic support.

Renal autoregulation and blood pressure management in circulatory shock

The importance of personalized blood pressure management is well recognized. Because renal pressure–flow relationships may vary among patients, understanding how renal autoregulation may influence blood pressure control is essential. However, much remains uncertain regarding the determinants of renal autoregulation in circulatory shock, including the influence of comorbidities and the effects of vasopressor treatment. We review published studies on renal autoregulation relevant to the management of acutely ill patients with shock. We delineate the main signaling pathways of renal autoregulation, discuss how it can be assessed, and describe the renal autoregulatory alterations associated with chronic disease and with shock.

Suppressed MMP-9 Activity in Myocardial Infarction-Related Cardiogenic Shock Implies Diminished Rage Degradation

BACKGROUND

Receptor for advanced glycation end products (RAGE) and its cleavage fragment soluble RAGE (sRAGE) are opposite players in inflammation. Enhanced monocytic RAGE expression and decreased plasma sRAGE levels are associated with higher mortality in infarction-related cardiogenic shock. Active matrix metalloproteinase-9 (MMP-9) has been implied in RAGE ectodomain cleavage and subsequently sRAGE shedding in vitro. We investigated MMP-9 activity in myocardial infarction-induced cardiogenic shock with regard to RAGE/sRAGE regulation.

METHODS AND RESULTS

We determined MMP-9 serum activity by zymography and tissue inhibitor of matrix metalloproteinases (TIMP-1) expression by Western blot and correlated it to RAGE/sRAGE data in patients with cardiogenic shock after acute myocardial infarction (CS, n = 30), in patients with acute myocardial infarction without shock (AMI, n = 20) and in healthy volunteers (n = 20).MMP-9 activity is increased in AMI (P = 0.02 versus controls), but significantly decreased in CS with lowest levels in non-survivors (n = 13, P = 0.02 versus AMI). In all patients, MMP-9 activity correlated inversely with RAGE expression on circulating monocytes (r = -0.57; P = 0.0001; n = 50).TIMP-1 levels showed an inverse regulation in comparison to active MMP-9 with significantly decreased levels in AMI as compared with controls (P = 0.02 versus controls) and highest levels in non-survivors of CS (P <0.001 versus AMI).

CONCLUSIONS

Serum MMP-9 activity is increased in acute myocardial infarction, but markedly suppressed in cardiogenic shock. Maintaining MMP-9 activity could be a therapeutic target to limit RAGE-induced deleterious inflammation in cardiogenic shock.

Clinical outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction requiring the intensive care unit

Background

Outcomes for patients with ST-segment elevation myocardial infarction continue to improve, largely due to timely provision of reperfusion by primary percutaneous coronary intervention (PPCI). However, despite prompt and successful PPCI, a small proportion of patients require ventilatory and hemodynamic support in an intensive care unit (ICU). The outcome of these patients remains poorly defined.

Methods

A retrospective review of all consecutive admissions post-PPCI pathway to a single ICU between January 2009 and May 2014 was performed. Patients were analysed based on survival and indication for admission. Preadmission characteristics and ICU course were reviewed. Univariate and multivariable regression analysis was performed to determine predictors of outcome.

Results

During the study period 2902 PPCI were performed and 101 patients were admitted to ICU following PPCI (incidence 3.5%). ICU mortality post-PPCI was 33.7%. Pre-ICU admission factors in a multivariable logistic regression analysis associated with increased mortality included requirement for an intra-aortic balloon pump and a high SOFA score.

Conclusions

ICU admission post PPCI is associated with significant mortality. Mortality was related to high presenting SOFA score and need for IABP. These results provide important prognostic information and an acceptable method for risk-stratifying patients with acute myocardial infarction requiring intensive care.

Simplified Acute Physiology Score II as Predictor of Mortality in Intensive Care Units: A Decision Curve Analysis

Background

End-of-life decision-making in Intensive care Units (ICUs) is difficult. The main problems encountered are the lack of a reliable prediction score for death and the fact that the opinion of patients is rarely taken into consideration. The Decision Curve Analysis (DCA) is a recent method developed to evaluate the prediction models and which takes into account the wishes of patients (or surrogates) to expose themselves to the risk of obtaining a false result. Our objective was to evaluate the clinical usefulness, with DCA, of the Simplified Acute Physiology Score II (SAPS II) to predict ICU mortality.

Methods

We conducted a retrospective cohort study from January 2011 to September 2015, in a medical-surgical 23-bed ICU at University Hospital. Performances of the SAPS II, a modified SAPS II (without AGE), and age to predict ICU mortality, were measured by a Receiver Operating Characteristic (ROC) analysis and DCA.

Results

Among the 4.370 patients admitted, 23.3% died in the ICU. Mean (standard deviation) age was 56.8 (16.7) years, and median (first-third quartile) SAPS II was 48 (34–65). Areas under ROC curves were 0.828 (0.813–0.843) for SAPS II, 0.814 (0.798–0.829) for modified SAPS II and of 0.627 (0.608–0.646) for age. DCA showed a net benefit whatever the probability threshold, especially under 0.5.

Conclusion

DCA shows the benefits of the SAPS II to predict ICU mortality, especially when the probability threshold is low. Complementary studies are needed to define the exact role that the SAPS II can play in end-of-life decision-making in ICUs.

Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal

BACKGROUND

Acute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, "acute" connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals.

OBJECTIVES, METHODS

Since data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150 mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of "acute" connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection.

RESULTS

Comparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049).

CONCLUSIONS

TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a "post-RRT volume change" to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.