Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry

OBJECTIVE

The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI).

BACKGROUND

Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients.

METHODS

Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching.

RESULTS

273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528).

CONCLUSION

AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Predictors and Prognostic Impact of Early Acute Kidney Injury in Cardiogenic Shock: Results from a Monocentric, Prospective Registry

INTRODUCTION

The presence of acute kidney injury (AKI) was shown to increase the risk of mortality following acute myocardial infarction; however, data regarding the prognostic impact of early AKI in patients with concomitant cardiogenic shock (CS) is limited. The study investigates predictors and the prognostic impact of AKI in patients with CS.

METHODS

Consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. Predictors for AKI (defined as an increase of plasma creatinine >50% within 48 h referring to pre-admission or baseline creatinine on day 1 and/or the need for continuous veno-venous hemodiafiltration [CVVHDF]) and the prognostic impact of early AKI with regard to 30-day all-cause mortality were assessed. Statistical analyses included t test, Spearman's correlation, C-statistics, Kaplan-Meier, and Cox proportional regression analyses.

RESULTS

A total of 219 CS patients were included with an incidence of early CS-related AKI of 52%. With an area under the curve of up to 0.689 (p = 0.001), creatine discriminated 30-day mortality in CS. Increasing lactate levels (OR = 1.194; 95% CI: 1.083-1.316; p = 0.001; per increase of 1 mmol/L) was associated with the occurrence of AKI. The presence of AKI was associated with an increased risk of 30-day all-cause mortality (63% vs. 36%; HR = 2.138; 95% CI: 1.441-3.171; p = 0.001), even after multivariable adjustment (HR = 1.861; 95% CI: 1.207-2.869; p = 0.005). Finally, highest risk of all-cause mortality was observed in patients with AKI requiring CVVHDF (75% vs. 44%; log rank p = 0.001; HR = 2.211; 95% CI: 1.315-3.718; p = 0.003).

CONCLUSION

Early AKI affects more than half of patients with CS and is independently associated with 30-day all-cause mortality in CS, with highest risk of death among patients with AKI requiring CVVHDF.

C-reactive protein and procalcitonin during course of sepsis and septic shock

OBJECTIVE

The study investigates the diagnostic and prognostic value of C-reactive protein (CRP) and procalcitonin (PCT) in patients with sepsis and septic shock.

BACKGROUND

Limited data regarding the prognostic value of CRP and PCT during the course of sepsis or septic shock is available.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 were included monocentrically. Blood samples were retrieved from the day of disease onset (day 1), day 2, 3, 5, 7, and 10. Firstly, the diagnostic value of CRP and PCT for the diagnosis of a septic shock, as well as for the discrimination of positive blood cultures, was tested. Secondly, the prognostic value of the CRP and PCT was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, and Kaplan-Meier analyses.

RESULTS

A total of 349 patients were included, of which 56% had a sepsis and 44% a septic shock on day 1. The overall rate of all-cause mortality at 30 days was 52%. With an area under the curve (AUC) of 0.861 on day 7 and 0.833 on day 10, the PCT revealed a superior AUC than the CRP (AUC 0.440-0.652) with regard to the discrimination between patients with sepsis and septic shock. In contrast, the prognostic AUCs for 30-day all-cause mortality were poor. Both higher CRP (HR = 0.999; 95% CI 0.998-1.001; p = 0.203) and PCT levels (HR = 0.998; 95% CI 0.993-1.003; p = 0.500) were not associated with the risk of 30-day all-cause mortality. During the first 10 days of ICU treatment, both CRP and PCT declined irrespective of clinical improvement or impairment.

CONCLUSION

PCT was a reliable diagnostic tool for the diagnosis of septic shock compared to CRP. Both CRP and PCT were shown to have poor predictive value with regard to 30-day all-cause mortality and were not associated with the risk of all-cause mortality in patients admitted with sepsis or septic shock.

Effect of Admission and Onset Time on the Prognosis of Patients With Cardiogenic Shock

BACKGROUND

The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated.

RESEARCH QUESTION

Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days?

STUDY DESIGN AND METHODS

This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses.

RESULTS

Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI.

INTERPRETATION

Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT05575856; URL: www.

CLINICALTRIALS

gov.

Platelet Count During Course of Cardiogenic Shock

The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.

Does Atrial Fibrillation Deteriorate the Prognosis in Patients With Septic or Cardiogenic Shock?

Atrial fibrillation (AF) is associated with increased risk of mortality in various clinical conditions. However, the prognostic role of preexisting and new-onset AF in critically ill patients, such as patients with septic or cardiogenic shock remains unclear. This study investigates the prognostic impact of preexisting and new-onset AF on 30-day all-cause mortality in patients with septic or cardiogenic shock. Consecutive patients with sepsis, or septic or cardiogenic shock were enrolled in 2 prospective, monocentric registries from 2019 to 2021. Statistical analyses included Kaplan-Meier, multivariable logistic, and Cox proportional regression analyses. In total, 644 patients were included (cardiogenic shock: n = 273; sepsis/septic shock: n = 361). The prevalence of AF was 41% (29% with preexisting AF, 12% with new-onset AF). Within the entire study cohort, neither preexisting AF (log-rank p = 0.542; hazard ratio [HR] 1.075, 95% confidence interval [CI] 0.848 to 1.363, p = 0.551) nor new-onset AF (log-rank p = 0.782, HR = 0.957, 95% CI 0.683 to 1.340, p = 0.797) were associated with 30-day all-cause mortality compared with non-AF. In patients with AF, ventricular rates >120 beats/min compared with ≤120 beats/min were shown to increase the risk of reaching the primary end point in AF patients with cardiogenic shock (log-rank p = 0.006, HR 1.886, 95% CI 1.164 to 3.057, p = 0.010). Furthermore, logistic regression analyses suggested increased age was the only predictor of new-onset AF (odds ratio 1.042, 95% CI 1.018 to 1.066, p = 0.001). In conclusion, neither the presence of preexisting AF nor the occurrence of new-onset AF was associated with the risk of 30-day all-cause mortality in consecutive patients admitted with cardiogenic shock.

D-Dimer Levels and the Risk of 30-Day All-Cause Mortality in Cardiogenic Shock Stratified by Etiology

BACKGROUND

The study investigates the prognostic impact of D-dimer levels in patients with cardiogenic shock (CS). Although D-dimer levels were found to be associated with prognosis in various clinical settings such as heart failure or acute myocardial infarction (AMI), the prognostic role of D-dimer levels in CS patients has not yet been clarified.

METHODS

Consecutive CS patients with and without concomitant AMI were prospectively included from 2019 to 2021. The prognostic impact of D-dimer levels was tested for 30-day all-cause mortality within the entire study cohort and stratified by the presence or absence of AMI. Statistical analyses included C-statistics, Kaplan-Meier, and multivariate Cox regression analyses.

RESULTS

One hundred and twenty-three consecutive CS patients were included with an overall all-cause mortality at 30 days of 55%. The median D-dimer level on admission was 8.44 mg/L, whereas D-dimer levels were higher in 30-day non-survivors compared to survivors (median 13.0 vs. 5.2 mg/L; p = 0.011). D-dimer levels above the median were associated with an increased risk of 30-day all-cause mortality compared to patients with lower D-dimer levels (66% vs. 54%, log rank p = 0.050; HR = 1.594; 95% CI 0.979 - 2.594; p = 0.061), especially in patients with non-AMI-related CS (65% vs. 30%, log rank p = 0.010). The prognostic value of D-dimer levels was still demonstrated after multivariate adjustment (HR = 1.024; 95% CI 1.004 - 1.045; p = 0.020).

CONCLUSIONS

D-dimer measurement may be a reliable biomarker to predict the risk of 30-day mortality in CS patients, especially in patients with non-AMI related CS.

The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock

OBJECTIVE

The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock.

BACKGROUND

Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available.

METHODS

All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses.

RESULTS

Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P  = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P  = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P  = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P  = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P  = 0.019).

CONCLUSION

Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.

Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock

This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.

Prognostic Value of the AST/ALT Ratio versus Bilirubin in Patients with Cardiogenic Shock

This study investigates the prognostic value of the aspartate-to-alanine aminotransferase ratio (i.e., AST/ALT ratio) and bilirubin in patients with cardiogenic shock (CS). Despite ongoing improvements regarding the treatment of CS patients, invasive care unit (ICU) mortality in CS patients remains unacceptably high. Limited data regarding the prognostic value of the AST/ALT ratio and bilirubin in patients suffering from CS is available. The authors hypothesize the measurement of liver enzymes during the course of CS may be an easy and feasible method to assess right-heart dysfunction and prognosis in patients with CS. Consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from the day of disease onset (day 1), days 2, 3, 4 and 8. The prognostic value of the AST/ALT ratio and bilirubin was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses. A total of 157 CS patients were included, with an overall rate of all-cause mortality at 30 days of 51%. The median AST/ALT ratio on day 1 was 1.4, and the median bilirubin was 0.63 mg/dL. No association of the baseline AST/ALT ratio (HR = 1.005; 95% CI 0.649-1.558; p = 0.981) and bilirubin (HR = 1.320; 95% CI 0.834-2.090; p = 0.236) with the risk of 30-day all-cause mortality was found. In contrast, the AST/ALT ratio on day 4 was associated with the risk of 30-day all-cause mortality (HR = 2.826; 95% CI 1.227-6.510; p = 0.015), which was still evident after the multivariable adjustment (HR = 2.830; 95% CI 1.054-7.690; p = 0.039). The AST/ALT ratio during the course of ICU hospitalization from day 4-but not the baseline AST/ALT ratio and bilirubin-was associated with an increased risk of 30-day all-cause mortality in CS patients.

Effect of Hemoglobin Levels in Patients with Cardiogenic Shock of Any Cause: Insights from a Single-Centre, Prospective Registry

BACKGROUND

Data regarding the short-term prognostic impact of hemoglobin levels in cardiogenic shock (CS) patients is limited. The study examines the prognostic impact of hemoglobin levels in patients with CS.

METHODS

Consecutive patients with CS of any etiology from 2019 to 2021 were included at one institution. Hemoglobin levels were retrieved from the day of admission (i.e., day 1), and on days 2, 3, 4, and 8 of intensive care unit (ICU) treatment thereafter. The primary endpoint was 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman´s correlations, C-statistics, Kaplan-Meier analyses as well as multivariable logistic and Cox regression analyses.

RESULTS

From a total of 250 consecutive patients admitted with CS, 54% died within 30 days. Hemoglobin levels on day 4 and on day 8 were associated with moderate discrimination for 30-day all-cause mortality (area under the curve (AUC) 0.598 - 0.666), whereas hemoglobin level on day 1 was not predictive for 30-day all-cause mortality (AUC = 0.504). There was no association with 30-day all-cause mortality when stratified by the presence of anemia (defined as hemoglobin level < 12 g/dL) on day 1 (54% vs. 55%; log rank p = 0.906; HR = 0.981; 95% CI 0.698 - 1.378; p = 0.910). However, a decrease of hemoglobin by > 2 g/dL from day 1 to day 3 of ICU treatment was associated with an increased risk of 30-day all-cause mortality (56% vs. 41%; log rank p = 0.014; HR = 1.831; 95% CI 1.108 - 3.026; p = 0.018).

CONCLUSIONS

Hemoglobin levels on day 1 were not associated with prognosis in CS. However, an early decrease of hemoglobin levels from day 1 to day 3 indicated impaired short-term prognosis in CS patients.

The Neutrophil-to-Lymphocyte-Ratio as Diagnostic and Prognostic Tool in Sepsis and Septic Shock

BACKGROUND

Studies investigating the diagnostic and prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in sepsis or septic shock commonly included preselected subgroups of patients or were published prior to the current sepsis-3 criteria. Therefore, this study investigates the diagnostic and prognostic impact of the NLR in patients with sepsis and septic shock.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 from the prospective "MARSS-registry" were included monocentrically. First, the diagnostic value of the NLR compared to established sepsis scores was tested for septic shock compared to sepsis. Second, the diagnostic value of the NLR with regard to positive blood cultures was tested. Thereafter, the prognostic value of the NLR was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman´s correlations, C-statistics, Kaplan-Meier analyses, Cox proportional regression analyses as well as uni- and multivariate logistic regression models.

RESULTS

A total of 104 patients were included, of which 60% were admitted with sepsis and 40% with septic shock. The overall rate of all-cause mortality at 30 days was 56%. With an area under the curve (AUC) of 0.492, the NLR was shown to have a poor diagnostic value with regard to the diagnosis of septic shock compared to sepsis. However, the NLR was shown to be a reliable parameter to discriminate between patients with negative and positive blood cultures when admitted with septic shock (AUC = 0.714). This was still evident after multivariable adjustment (OR = 1.025; 95% CI 1.000 - 1.050; p = 0.048). In contrast, the NLR revealed a poor prognostic accuracy (AUC = 0.507) with regard to 30-day all-cause mortality. Finally, a higher NLR was not associated with an increased risk of 30-day all-cause mortality (log rank p-value = 0.775).

CONCLUSIONS

The NLR was a reliable diagnostic tool for the identification of patients with blood culture confirmed sepsis. Yet, the NLR was not a reliable parameter to discriminate between patients with sepsis and septic shock nor between 30-day survivors and non-survivors.

Does Albumin Predict the Risk of Mortality in Patients with Cardiogenic Shock?

This study investigates the prognostic impact of albumin levels in patients with cardiogenic shock (CS). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Limited data regarding the prognostic value of albumin in patients with CS is available. All consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from the day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. The prognostic impact of albumin was tested for 30-day all-cause mortality. Moreover, the prognostic performance of albumin decline during ICU treatment was examined. Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, multivariable mixed analysis of variance (ANOVA), C-Statistics, and Cox proportional regression analyses. In total, 230 CS patients were included, with an overall all-cause mortality at 30 days of 54%. The median albumin on day 1 was 30.0 g/L. Albumin on day 1 was able to discriminate between 30-day survivors and non-survivors (area under the curve (AUC) 0.607; 0.535-0.680; p = 0.005). CS patients with albumin < 30.0 g/L were associated with an increased risk of 30-day all-cause mortality (63% vs. 46%; log-rank p = 0.016; HR = 1.517; 95% CI 1.063-2.164; p = 0.021), which was demonstrated even after multivariable adjustment. Moreover, a decrease of albumin levels by ≥20% from day 1 to day 3 was accompanied by a higher risk of 30-days all-cause mortality (56% vs. 39%; log-rank p = 0.036; HR = 1.645; 95% CI 1.014-2.669; p = 0.044). Especially when combined with lactate, creatinine, and cardiac troponin I, reliable discrimination of 30-day all-cause mortality was observed, including albumin in CS risk stratification models (AUC = 0.745; 95% CI 0.677-0.814; p = 0.001). In conclusion, low baseline albumin levels as well as a decay of albumin levels during the course of ICU treatment, deteriorate prognostic outcomes in CS patients. The additional assessment of albumin levels may further improve risk stratification in CS patients.