Characteristics, management, and mid-term prognosis of older adults with cardiogenic shock admitted to intensive care units: Insights from the FRENSHOCK registry

BACKGROUND

The incidence of heart failure and cardiogenic shock (CS) in older adults is continually increasing due to population aging. To date, prospective data detailing the specific characteristics, management and outcomes of CS in this population are scarce.

METHODS

FRENSHOCK is a prospective registry including 772 CS patients from 49 centers. We studied 1-month and 1-year mortality among patients over 75-year-old, adjusted for independent predictors of 1-month and 1-year mortalities.

RESULTS

Out of 772 patients included, 236 (30.6%) were 75 years old or more (mean age 81.9 ± 4.7 years, 63.6% male). Compared to patients <75 years old, older adults had a higher prevalence of comorbidities including hypertension, dyslipidemia, chronic kidney disease, and history of heart disease. Older adults were characterized by a lower blood pressure, as well as higher creatinine and lower haemoglobin levels at presentation. Yet, they were less likely to be treated with norepinephrine, epinephrine, invasive ventilation, and renal replacement therapy. They showed a higher 1-month (aHR: 2.5 [1.86-3.35], p < 0.01) and 1-year mortality (aHR: 2.01 [1.58-2.56], p < 0.01). Analysis of both 1-month and 1-year mortality stratified by age quartiles showed a gradual relationship between aging and mortality in CS patients.

CONCLUSION

A third of patient with CS in critical care unit are older than 75 years and their risk of death at one month and one year is more than double compared to the younger ones. Further research is essential to identify best therapeutic strategy in this population. NCT02703038.

Exploration de la perfusion tissulaire microcirculatoire au cours du choc septique

Au cours des infections graves, les travaux chez l’animal et chez l’homme ont mis en évidence une altération de la perfusion microcirculatoire à l’origine des défaillances viscérales et potentiellement du décès. La sévérité des anomalies microcirculatoires ainsi que leur persistance sont des facteurs prédictifs de mortalité indépendamment du débit cardiaque ou de la pression artérielle. Il est donc indispensable de développer des outils permettant d’évaluer la perfusion microcirculatoire au lit du malade. De nombreux travaux au cours du sepsis suggèrent que l’analyse de la perfusion cutanée au travers de sa température (et/ou du gradient), du temps de recoloration cutané, de l’étendue des marbrures et de l’indice de perfusion périphérique constitue un outil simple qui permet au réanimateur une évaluation rapide des anomalies microcirculatoires.

Mottling score predicts survival in septic shock

BACKGROUND

Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock.

METHODS

We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa = 0.87, 95% CI (0.72-0.97)].

RESULTS

Sixty patients were included. The SOFA score was 11.5 (8.5-14.5), SAPS II was 59 (45-71) and the 14-day mortality rate 45% [95% CI (33-58)]. Six hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p = 0.001], arterial lactate level [<1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7-29.5); >3 OR 9.6 (2.1-70.6), p = 0.01] and mottling score [score 0-1 OR 1; score 2-3 OR 16, 95% CI (4-81); score 4-5 OR 74, 95% CI (11-1,568), p < 0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p < 0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p = 0.0005).

CONCLUSION

The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.

[Case report and review of a voluminous right atrial myxoma revealed by heart failure]

Right atrial myxoma is a rare disease and its clinical presentation is not specific. The usual mode of revelation is heart failure. The most frequent complications are pulmonary embolism and atrioventricular valve obstruction by the tumor. A 49-year-old woman was admitted to intensive care unit for heart failure. The echocardiogram showed a voluminous right atrial myxoma, appending to the interatrial septum. Its surgical excision under extracorporeal circulation was successfully performed. Histology confirmed the final diagnosis of myxoma. No complication was observed at 6 months follow-up.

Percutaneous vascular stent: experimental studies and preliminary clinical results in peripheral arterial diseases

A new pattern of metallic intravascular stent has been experimentally and clinically tested. When the stent is percutaneously placed through a six french introducer, it is held against the vessel wall by its natural elastic properties. In 28 animals, 47 stents of different sizes (from 3 to 5 mm of luminal diameter and from 1.5 to 5 cm of length) have been implanted in the femoro-popliteal (16), the coronary (20), the carotid (3) and the renal arteries (5) and in 3 femoral veins. Angiographic and histological results have shown the stent's low thrombogenicity when it is well fit to the vessel's caliber. Moreover, they have shown its incorporation to the vessel wall by intimalisation as early as the third week after its implantation. The collateral vessels which covered by the stent remain permeable. At the end of this experimentation, 10 implants have been achieved in 8 patients (4 recurrences of iliac stenosis and 6 femoral stenosis). The angiographic results show the perfect tolerance of the organism at 6 months. This good tolerance is revealed by a thin intraluminal border which does not change the artery's diameter. This confirms the experimental results. The permeability is good except for two patients who had an obliteration after one month (one iliac and one femoral obliteration).

[Annual cycle of plasma testosterone and thyroxine in the European badger (Meles meles L.)]

In the male European Badger there are important variations in the plasma testosterone and thyroxine levels during the annual cycle. During the summer, plasma testosterone concentrations are low while plasma thyroxine rises to a very high level. In winter, when the thyroid activity is minimal, testicular activity increases. From February to May, the plasma testosterone remains at a high level, and then, after a sudden fall, a second peak occurs in June at which time the concentration of thyroxine is low.

[Mechanisms of placental iron transfer in mustelids]

In the mustelids which have a placenta of an endotheliochorial type, the mineral necessary for the foetal erythropoiesis comes to the foetus after the breakdown of the erythrocytes by the trophoblast, in placental hematoma. This experimental study, with 59Fe, shows that the main source of iron for the foetus is the maternal hemoglobin iron.

[Demonstration of a seasonal thyroid cycle in the male badger (Meles meles L) using iodine 131 fixation]

A seasonal cycle of thyroid activity has been determined in male adult badger by the thyroid 131I uptake. This cycle is characterized by maximal activity in autumn and minimal activity in winter and at the beginning of summer. There is no difference between animals recently caught and those living in captivity.