Lactate Values and Mortality in Patients With Cardiogenic Shock: Insights From the Altshock-2 Registry.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Machine learning prediction of in-hospital mortality and external validation in patients with cardiogenic shock: the RESCUE score.

Introduction Despite advances in diagnosis and treatment, in-hospital mortality in patients with cardiogenic shock (CS) remains high. Until recently, acute myocardial infarction (AMI) was the cause of CS in more than 80% of cases, however, the results of numerous new studies support the increasing frequency of other causes of CS, with a low percentage of in-hospital survival. Purpose The aim of our study was to determine demographic, laboratory, clinical and therapeutical predictors of in-hospital mortality in patients with CS, independent of etiology. Methods The research was conducted as an observational cohort study on a sample of 110 patients hospitalized at our institute from January 2022 to December 2023 due to CS of various etiologies. CS was defined as systolic blood pressure &amp;lt; 90mmHg with clinical signs of hypoperfusion and lactate ≥ 2mmol/l. Results In the examined group of 110 patients, 64 (58.2%) were men and AMI was the cause of CS in 83 (75%) patients. Overall mortality was 65 (59%). Mortality among patients with CS caused by AMI was 49.4% which was significantly lower compared to 88.9% among patients with other causes of CS (p&amp;lt;0.0005). Age significantly influenced mortality (69.3% among patients ≥ 65 years compared to 37.1% among patients &amp;lt; 65 years; p=0.002). In comparison with survivors, deceased patients had statistically significantly lower average hemoglobin (125.5 mmol/l vs. 134 mmol/l; p=0.001), higher average creatinine (172 umol/l vs. 110.5 umol/l; p&amp;lt;0.0005) and higher average high-sensitivity troponin (11601.3 mmol/l vs. 659.8 mmol/l; p=0.01). Of the clinical parameters, mortality was significantly influenced by SHOCK index &amp;gt;0.7 (64.4% among deceased vs. 35.6% among survivors; p=0.034), Glasgow Coma Score ≤ 8 (70.8% vs. 29.2%; p=0.033), out-of-hospital cardiac arrest (83.1% vs. 3%, p &amp;lt; 0.0005), as well as the time elapsed from the onset of symptoms to admission (80.6% with duration of symptoms &amp;gt;24h vs. 28.6% (12h-24h) vs. 60% (2-12h) vs. 20% (&amp;lt;2h); p&amp;lt;0.0005). According to the SCAI classification, mortality in stage B CS was 0%, in stage C 11.1%, in stage D 20%, and in stage E 98.4%, which represented a statistically significant difference (p&amp;lt;0.0005). Mortality was higher among patients who were not revascularized (96.4% vs. 45.2%; p&amp;lt;0.0005), as well as those who required the use of vasopressors and inotropes (72.5% vs. 51.4%; p=0.043). The application of mechanical circulatory support (MCP) did not significantly affect the in-hospital outcome, given that mortality among patients who did not receive MCP was 51.4% vs. 72.5% among patients who received MCP (p=0.133). Conclusion In our examined group of patients with CS, in-hospital mortality was higher among patients with causes of CS other than AMI, in those with advanced stages of CS, who were not revascularized and who required the use of vasoactive drugs, while the use of MCP failed to improve in-hospital outcome.

Prior studies demonstrated that plasma osmolality may have a predictive value for in-hospital mortality in patients with heart failure and acute coronary syndrome. In addition, plasma glucose and blood urea nitrogen (BUN) levels, the components of plasma osmolality, have been shown to be an important contributor for in-hospital mortality in acute pulmonary embolism (APE) patients. Hence, the objective of the current study is to evaluate the effect of plasma osmolality upon admission with in-hospital mortality in patients with APE. A total of 245 consecutive intermediate or high risk APE patients were enrolled into the study. The study population was divided into three tertile groups (T1, T2 and T3) based on the increased plasma osmolality. The in-hospital mortality was the primary end-point. After adjusting for all risk factors, in-hospital mortality was significantly higher in the T3 group compared to T1 and T2 groups (OR: 3.6, 95% CI: 1.3 to 18.8, P<.001). In addition, the incidence of asystolia, hypotension and cardiogenic shock were significantly higher in the T3 group. An area under the receiver operating characteristic curve value of plasma osmolality for the in-hospital mortality was 0.76 with sensitivity 67.2% and specificity 74.1% 95% CI: (0.66-0.87, P<.001). This is the first study to demonstrate that elevated levels of plasma osmolality may have a predictive value for in-hospital mortality in APE patients. Our findings are novel and deserve further studies whether the treatment of higher plasma osmolality may reduce the risk of in-hospital mortality in APE patients.

BackgroundLymphocyte to monocyte ratio (LMR) has been long implicated in the prediction of many inflammatory-related diseases. However, the possible value as prognostic marker of LMR have not been evaluated in cardiogenic shock (CS) patients. The aim of the study was to assess the relationship between LMR on admission and in-hospital mortality in CS patients.MethodsData on patients diagnosed with CS were extracted from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. We performed a single-institution, retrospective study of 1487 CS patients and determined the optimal cut-off for LMR by X-tile software. Propensity score matching (PSM) and inverse probabilities of treatment weighting (IPTW) were conducted to control confounders. Cox proportional hazards model was performed to evaluate the relationship between LMR and in-hospital mortality. Kaplan–Meier curves and receiver operating characteristics (ROC) analysis were applied to assess the prognostic value of LMR.ResultsThe optimal cut-off value for LMR was 0.9. Cox proportional hazards model demonstrated that lower LMR (< 0.9) was independently associated with in-hospital mortality with hazard ratio (HR) of 1.40 (1.12–1.74, P = 0.003). The results were consistent with survival analyses (P < 0.001, Log rank test). Adding LMR< 0.9 to the sequential organ failure assessment (SOFA) score improved discrimination and risk stratification for in-hospital mortality.ConclusionLower level of LMR is related to higher risk of in-hospital mortality of patients with CS. As an easily available biomarker, LMR can independently predict the in-hospital mortality in CS patients.

Background Cardiogenic shock is associated with a high mortality and morbidity due to organ damage and multi-organ failure including direct damage to the myocardium. Purpose This study aimed to assess troponin as a marker of myocardial damage in patients with cardiogenic shock outside of a myocardial infarction (e.g., non-ischaemic cardiogenic shock). Methods Data from unselected patients with cardiogenic shock not caused by myocardial infarction were anonymised and combined in a multicentre cohort study from 15 centres in 5 European countries (2011-2020). Cardiogenic shock was defined by clinical signs and symptoms, elevated lactate concentrations (arterial &amp;gt;2.0 mmol/l, venous &amp;gt;2.5 mmol/l), and hypotension (systolic &amp;lt;90 mmHg or need for vasopressors). Patients with need for urgent coronary revascularisation, predominant right heart failure, eCPR or cardiogenic shock after cardiotomy were excluded. Baseline was defined to reflect the worst clinical status within 6 hours before/after admission (for patients not treated with mechanical circulatory support) or after device implantation (for patients treated with mechanical circulatory support). Troponin concentrations at baseline as well as after 24 hours were quantified using the Elecsys® Troponin T high-sensitive assay by Roche (99th percentile 14 ng/l). Baseline troponin (displayed per 250 ng/l) and its increase within 24 hours were associated with 30-day mortality by fitting Cox regression models adjusted for age, sex, baseline creatinine, baseline lactate, baseline pH, prior cardiac arrest, duration of CPR, acute-on-chronic or de novo heart failure, and mechanical ventilation. Results Overall, 477 patients were analysed [mean age 62 (±15) years, 144 women (30.2%), acute-on-chronic heart failure in 255 (53.6%)]. Median LVEF was 20% (IQR 15-30%), CPR was performed in 196 cases (41.1%), median lactate at baseline was 7.3 mmol/l (IQR 4.2-10.8 mmol/l) and median baseline troponin T was 164 ng/l (IQR 77-678 ng/l). Patients with a higher troponin T at baseline (e.g., ≥median) more frequently presented with de novo heart failure (54.8 vs. 37.9%, p&amp;lt;0.01) or after prior CPR (47.7 vs. 34.3%, p&amp;lt;0.01) although other parameters reflecting cardiogenic shock severity (e.g., blood pressure, baseline lactate or LVEF) were not significantly different. Finally, troponin T at baseline showed a significant association with 30-day mortality (HR 1.006, 95% CI: 1.0-1.011, p = 0.041) while the relative troponin T increase within 24 hours did not (HR 1.005, 95% CI: 0.997-1.013, p = 0.212) (Figure 1). Conclusion Cardiac organ damage in cardiogenic shock outside of a myocardial infarction (e.g., non-ischaemic cardiogenic shock) is associated with increased risk of death within 30 days. Elevated troponin levels could identify a group of patients with cardiogenic shock in need for cardioprotective therapies.Figure 1

Lactate Clearance And Mortality In Cardiogenic Shock: A Systematic Review And Meta-Analysis

Background Vasoactive medications and Mechanical Circulatory Support (MCS) are both central to the contemporary management of cardiogenic shock (CS). There are limited data on the interaction between vasoactive medication dosing and MCS in patients with CS. Purpose We investigated the association between in-hospital mortality and vasoactive medication dosing among patients with CS who did and did not receive MCS during hospitalization. Methods We included patients with CS admitted to our cardiac intensive care unit (CICU) between 2007 and 2015. The peak combined vasoactive medication dose during the first 24 hours of CICU admission was recorded and converted to norepinephrine equivalents (NEE)(references 1 &amp; 2). The primary outcome was in-hospital mortality. Multivariable logistic regression was used to adjust for relevant variables and calculate adjusted odds ratios (OR). Results Of 1078 patients with CS (median age 69.0 years [Interquartile Range 59.1-77.3], 36.8% female, 59% with acute myocardial infarction), 721 (66.9%) received vasoactive medications in the first 24 hours and 510 (47.3%) received MCS (87% intra-aortic balloon pump). Among those receiving vasoactive medications during the first 24 hours, the median NEE was 0.16 (Interquartile Range 0.06-0.40) mcg/kg/min. In hospital mortality was 34.4% overall, and was lower among those who received MCS (26.1% versus 41.9%, p&amp;lt;0.001; adjusted OR 0.71 95% CI 0.50-0.99) and higher among those who received vasoactive medications (38.1% versus 26.9%, p&amp;lt;0.001). A gradient of mortality was observed according to the use of vasoactive medications and MCS (Fig. 1). We found a strong incremental association between in-hospital mortality and NEE (adjusted OR 1.11 per 0.1 mcg/kg/min, 95% CI 1.06–1.16, P&amp;lt;0.001; Fig. 2). Mortality was lower across the spectrum of NEE for patients who received MCS (Fig. 2). There was no statistically significant difference in the slope of the relationship between in-hospital mortality and NEE in patients who did and did not receive MCS (p = 0.86). Conclusion Increasing vasoactive medication requirement during the first 24 hours of CICU admission is incrementally associated with in-hospital mortality in CS, representing a simplified marker of shock severity. Patients who received MCS were at lower risk of mortality across the spectrum of vasopressor requirements, emphasizing the potential synergy between these two complementary approaches to hemodynamic support.Figure 1Figure 2

Cardiogenic shock (CS) is the leading cause of in-hospital mortality in patients suffering acute myocardial infarction (AMI). Despite advances in their management, short- and long-term mortality remain unacceptably high. We assessed short and intermediate-term outcomes for a contemporary cohort of patients with AMI-CS managed at a referral centre with a large catchment area, and sought to identify clinical factors portending a favourable prognosis. Of 1162 consecutive, unselected patients with CS we studied 316 with AMI-CS. Our primary endpoint was native heart survival (NHS) defined as survival to discharge without advanced heart failure (HF) therapies. Our secondary endpoints were adverse events, overall survival, and readmissions up to 1 year following discharge. Association of clinical data with NHS was analysed using logistic regression. Of 316 patients, 168 (53.2%) achieved NHS, 140 (44.3%) died, and 8 (2.5%) were discharged after receiving advanced HF therapies. Overall, 181 patients (57.3%) received temporary mechanical circulatory support (MCS), with 78 (24.7%) receiving intra-aortic balloon pump, 107 (33.9%) percutaneous ventricular assist device, and 62 (19.6%) veno-arterial extracorporeal membrane oxygenation. Of 176 discharged patients (55.7%), 170 (53.8%) were alive at 30 days, and 156 (49.4%) at 1-year post-discharge, while 56 (31.8%) had at least one readmission and 30 (17.0%) one HF-related readmission, by 1-year post-discharge. Patients with NHS were younger, had lower CS severity by SCAI stage, less commonly underwent intubation, or received temporary MCS, had a shorter time from CS onset to MCS deployment, and more commonly underwent coronary intervention with fewer stents deployed, compared to patients who died or underwent advanced HF therapies. Bleeding and vascular complications were less common in patients achieving NHS compared to patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS included: younger age, lower vasoactive-inotropic score, lower serum creatinine, and lactate at shock onset, successful coronary intervention with fewer stents deployed, and absence of intubation, or use of veno-arterial extracorporeal membrane oxygenation (all P ≤ 0.05). We studied a contemporary cohort of patients with AMI-CS and high rates of temporary MCS use, and identified clinical factors associated with a higher likelihood for successful outcomes. The need for transfer to an advanced CS centre, the impact and management of adverse events, and the type and timing of temporary MCS as opposed to intensification of pharmacologic therapy, should be studied as clinical practice targets for improving patient outcomes.

Aim. To study risk factors for in-hospital mortality in patients with acute myocardial infarction (MI) with ST-segment elevation (STEMI) aged ≥75 years.Material and methods. This retrospective analysis analyzed medical records of 174 patients aged ≥75 years hospitalized at the regional cardiology clinic due to STEMI in 2020-2021. There were 52 (29,9%) men. The median age for all patients was 81 [79; 85] year.Results. Inhospital mortality was 24,1%. Binary logistic regression revealed the following factors increasing the risk of inhospital mortality: cardiogenic shock (CS) — odds ratio (OR) 39,04; 95% confidence interval (CI): 8,87-171,74 (p&lt;0,001); ventricular tachycardia (VT) — OR=60,52; 95% CI: 5,21-703,45 (p=0,001); white blood cell (WBC) count — for each increase by 1×109/l — OR=1,15; 95% CI: 1,05-1,26 (p=0,002). At the same time, history of heart failure (CHF) reduced the death risk (OR=0,04; 95% CI: 0,009-0,21 (p&lt;0,001)). Classification tree found that 100% mortality was predicted in patients with CS and without diabetes and a history of MI and in patients with pulmonary edema and without CS, VT and HF. Mortality of 83,3% was predicted in patients without CS and without VT with a history of HF, WBC count ≥14,5×109/L and body mass index ≤23,7 kg/m2. In addition, mortality of 75,0% was predicted in patients without CS, but with VT, as well as in patients with CS without diabetes and with a history of MI. In patients with CABG and diabetes, the predicted mortality rate was 50,0%.Conclusion. The strongest factors associated with the risk of inhospital death were CS, VT, and high WBC count. The positive effect on the prognosis of pre-existing diseases, in particular HF, is apparently associated with the protective effect of previously taken therapy. This assumption needs to be confirmed based on prospective studies.

Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview

Development and validation of a clinical nomogram for predicting in-hospital mortality in patients with traumatic brain injury prehospital: A retrospective study

To assess the impact of intra-aortic balloon pumps (IABP) on patients with cardiogenic shock in an intensive care unit setting. IABP counterpulsation is a widely used mechanical circulatory support device, but its performance has been questioned. However, current evidence of IABP use in cardiogenic shock is very limited (mainly from the IABP-SHOCK II trial), which was restricted to cardiogenic shock complicating acute myocardial infarction. This was a retrospective, real-world, cohort study based on the Medical Information Mart for Intensive Care III database. Adult patients with a diagnosis of cardiogenic shock were eligible. A total of 1028 patients with cardiogenic shock were assessed, including 384 patients who received IABP and 644 patients who did not. The in-hospital mortality was significantly lower in patients who received IABP (adjusted odds ratio: 0.75, 95% confidence interval: 0.62-0.91, p = 0.009). Analysis of secondary endpoints found that the use of IABP was associated with a significantly lower risk of 1-year mortality. After propensity score matching, the in-hospital mortality remained significantly lower in the IABP group (28.10% vs. 37.59%, p = 0.018). In the current cohort, IABP treatment was associated with a lower risk of in-hospital mortality in patients with cardiogenic shock. Due to the complexity of pathophysiology in cardiogenic shock and the discrepancies in current evidence, our results should be validated through further studies in the future.

Funding Acknowledgements Type of funding sources: None. Background Mortality from cardiogenic shock (CS) shows great disparities (1). This evidence reflects variations in access to care and medical practice, related to the lack of clear guidelines for appropriate patient selection for mechanical circulatory support (MCS) application. In this regard, the results of most trials or meta-analyses were neutral on survival, and the costs in terms of patient morbidity/mortality are high and unproven (2). Accordingly, a judicious use of MCS is crucial for an adequate resource allocation and to avoid futility. Purpose To characterize trends in use of support devices and compare outcomes between CS patients included in a contemporary national Cardiac Intensive Care Units (CICUs) registry, treated or not with MCS. Methods 324 sequential patients admitted with CS at a CICUs network between March 2020 and August 2022 were identified. We categorized patients according to treatment with MCS (n=204; 63%) and medical therapy (n=120; 37%). We investigated differences in clinical, laboratory, hemodynamics, echocardiographic and prognostic scores on admission, at 24-hours and at discharge. In-hospital outcome and mid-term survival were described for each treatment cohort. Comparison of continuous variables was performed using Student’s t-test. For categorical variables, the χ2 statistic was used. Results CS was a complication of acute myocardial infarction in 141 patients (44%) and of acute on chronic heart failure in 124 patients (38%); 58 patients (18%) presented with other diagnosis. In MCS cohort, we reported more advanced Society for Cardiovascular Angiography and Interventions (SCAI) shock stages and MCS implantation was more prevalent within 24-hours in SCAI C (48,6% on admission; 51,2% at 24-hours). In-hospital mortality did not differ between the two groups (38% in MCS and 37% in medically treated patients, p=0,874). Chronic kidney disease (OR 2.1, 95%CI 1.2-3.5, p=0,009), elevated lactates and SCAI stage at 24-hours (OR and 95%CI were, respectively, 3.45, 1.99-5.97 and 3.67, 2.46-5.47, p&amp;lt;0,001) emerged as major independent predictors of in-hospital mortality in MCS subgroup. A significant protective association persisted for those monitored with pulmonary artery catheter (OR 0.61, 95%CI 0.51-0.92, p=0.001). Among the 196 patients evaluated at mid-term follow up MCS treatment had not markedly improved cumulative survival compared to medical treatment (51,9% in MCS subgroup versus 55,6% in medical therapy, p=0,806). Palliative care team was rarely engaged (14% in MCS cohort vs 27% in medical therapy, p=0,83). Conclusions In this nation-wide study, mortality in MCS patients was high and no statistically significant difference on in-hospital and mid-term survival emerged between patients receiving MCS compared to medical therapy. Hence, a prompt and constant risk-stratification is mandatory to exclude patients too sick to derive any benefits from invasive therapies, avoiding futility.

Despite rising rates of cardiogenic shock (CS), data on trends and in-hospital outcomes of short-term non-durable mechanical circulatory support (MCS) are limited. Thus, we aimed to identify recent national trends in MCS utilisation in the USA, patient-level predictors of MCS use, and in-hospital outcomes in CS inclusive of extracorporeal membrane oxygenation (ECMO). Hospitalisations of US adults with a discharge diagnosis of CS, from January 2004 to December 2014, in the National Inpatient Sample were included. Rates of MCS were stratified by device type and clinical presentation. Outcomes included in-hospital mortality, hospitalisation costs, and number of procedures. A total of 183,516 hospitalisations with CS (47,636 [25.9%] involving MCS) were included. MCS recipients were younger, less frequently female, received more procedures, had higher costs, and more frequently presented with MI (MCS vs. non-MCS: 71.6% vs. 42.9%; p<0.0001). Growth in CS hospitalisations (214.4%) outpaced annual MCS use (160.0%), with relative declines in intra-aortic balloon pump use starting in 2008. Right heart catheterisation rates for both groups remained low (MCS vs. non-MCS: 5.9% vs. 3.3%; p<0.0001). In-hospital mortality declined but remained high in both groups (MCS vs. non-MCS [2014]: 32.7% vs. 41.5%; p<0.0001). In-hospital mortality for CS has declined but remains high. Rates of CS have outpaced MCS utilisation which remains uncommon in non-MI hospitalisations with shock. MCS is associated with utilisation of other procedures during hospitalisation.