RESUMEN
BACKGROUND: Triglyceride-glucose (TyG) index, a dependable indicator of insulin resistance, has been identified as a valid marker regarding multiple cardiovascular diseases. Nevertheless, the correlation of TyG index with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains uncertain. Our study aims for elucidating this relationship by comprehensively analyzing two large-scale cohorts. METHODS: Utilizing records from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care IV, the link between TyG and the incidence and prognosis of AMICS was assessed multicentrally and retrospectively by logistic and correlation models, as well as restricted cubic spline (RCS). Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and overlap weighting (OW) were employed to balance the potential confounders. Subgroup analyses were performed according to potential modifiers. RESULTS: Overall, 5208 AMI patients, consisting of 375 developing CS were finally included. The TyG index exhibited an apparently higher level in AMI populations developing CS than in those who did not experienced CS [9.2 (8.8-9.7) vs. 9.0 (8.5-9.5)], with a moderate discrimination ability to recognize AMICS from the general AMI (AUC: 0.604). Logistic analyses showed that the TyG index was significantly correlated with in-hospital and ICU mortality. RCS analysis demonstrated a linear link between elevated TyG and increased risks regarding in-hospital and ICU mortality in the AMICS population. An increased mortality risk remains evident in PSM-, OW- and IPTW-adjusted populations with higher TyG index who have undergone CS. Correlation analyses demonstrated an apparent link between TyG index and APS score. Subgroup analyses presented a stable link between elevated TyG and mortality particularly in older age, females, those who are overweight or hypertensive, as well as those without diabetes. CONCLUSIONS: Elevated TyG index was related to the incidence of CS following AMI and higher mortality risks in the population with AMICS. Our findings pointed a previously undisclosed role of TyG index in regard to AMICS that still requires further validation.
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Biomarcadores , Glucemia , Bases de Datos Factuales , Infarto del Miocardio , Valor Predictivo de las Pruebas , Choque Cardiogénico , Triglicéridos , Humanos , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/mortalidad , Choque Cardiogénico/sangre , Choque Cardiogénico/epidemiología , Femenino , Masculino , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/epidemiología , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Glucemia/metabolismo , Pronóstico , Biomarcadores/sangre , Medición de Riesgo , Triglicéridos/sangre , Incidencia , Factores de Riesgo , China/epidemiología , Factores de Tiempo , Mortalidad Hospitalaria , Anciano de 80 o más AñosRESUMEN
Myocarditis is a potentially life-threatening inflammatory disease of the myocardium, often resulting from infectious and immune-mediated responses. Clinical presentation in severe cases often results in a devastating illness requiring extracorporeal membrane oxygenation support as a result of cardiogenic shock. Although endomyocardial biopsy is still considered the gold standard for diagnosis, it often reveals nonspecific lymphocytic infiltration. Because the precise cause is usually unknown, the initial treatment typically involves immunosuppression and frequent assessment of myocardial contractility. This report presents 3 rare cases of autoimmune diseases (polymyositis, immunoglobulin G4-related disease, and systemic lupus erythematosus) that require extracorporeal membrane oxygenation support as a result of fulminant myocarditis, including their follow-up periods.
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Oxigenación por Membrana Extracorpórea , Miocarditis , Humanos , Miocarditis/terapia , Miocarditis/diagnóstico , Miocarditis/fisiopatología , Miocarditis/inmunología , Oxigenación por Membrana Extracorpórea/métodos , Masculino , Femenino , Adulto , Biopsia , Persona de Mediana Edad , Enfermedades Autoinmunes/diagnóstico , Enfermedades Autoinmunes/terapia , Enfermedades Autoinmunes/inmunología , Enfermedades Autoinmunes/complicaciones , Miocardio/patología , Miocardio/inmunología , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnóstico , Lupus Eritematoso Sistémico/terapia , Choque Cardiogénico/terapia , Choque Cardiogénico/etiología , Choque Cardiogénico/diagnóstico , Resultado del Tratamiento , Enfermedad Relacionada con Inmunoglobulina G4/diagnóstico , Enfermedad Relacionada con Inmunoglobulina G4/terapia , Enfermedad Relacionada con Inmunoglobulina G4/complicacionesRESUMEN
INTRODUCTION: Sinus of Valsalva aneurysm (SOVA), a rare cardiac malformation, is usually congenital and rarely acquired and most commonly occurring in the right coronary sinus. The clinical presentation of patients with SOVA varies. It is usually asymptomatic when it has not ruptured, and when it compresses neighboring structures or ruptures, it can lead to heart failure or shock, at which point urgent surgical intervention is usually required. Rupture of the sinus of Valsalva aneurysm (RSOVA) during pregnancy is really hard to come by, especially if the clinical presentations resemble that of an acute myocardial infarction. This report describes a pregnant woman with severe chest pain and hypotension with aVR and V1 ST-segment elevation due to RSOVA. PATIENT CONCERNS: Effects of RSOVA on the fetus, disease survival, and prognosis. DIAGNOSIS: RSOVA. INTERVENTIONS: Open SOVA repair. OUTCOMES: The patient's blood pressure returned to normal range and clinical symptoms disappeared after the surgery. After 3 months of follow-up, the patient was hemodynamically stable without chest discomfort, and an echocardiogram showed a normal aortic sinus. CONCLUSION: Progressive aneurysm dilatation or rupture has a poor prognosis. A thorough history and physical examination are fundamental, with echocardiography being the initial diagnostic tool of choice, and other ancillary tests (e.g., computed tomography) being used to complement and confirm the diagnosis. Surgery remains the current treatment of choice for patients with RSOVA, while the continuation of pregnancy in pregnant patients with RSOVA remains a case-by-case measure.
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Complicaciones Cardiovasculares del Embarazo , Choque Cardiogénico , Seno Aórtico , Humanos , Embarazo , Femenino , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Adulto , Choque Cardiogénico/etiología , Choque Cardiogénico/diagnóstico , Seno Aórtico/diagnóstico por imagen , Seno Coronario/anomalías , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/complicaciones , Rotura de la Aorta/cirugía , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/cirugía , Electrocardiografía , EcocardiografíaRESUMEN
BACKGROUND: Stress-induced hyperglycemia (SIH) is associated with poor outcomes in cardiogenic shock (CS), and there have been inconsistent results among patients with or without diabetes mellitus (DM). The glycemic gap (GG) is derived by subtracting A1c-derived average glucose from blood glucose levels; it is a superior indicator of SIH. We aimed to explore the role of GG in the outcomes of patients with CS. METHODS: Data on patients diagnosed with CS were extracted from the MIMIC-IV v2.0 database to investigate the relationship between GG and 30-day mortality (Number of absolute GG subjects = 359; Number of relative GG subjects = 357). CS patients from the Second Affiliated Hospital of Wenzhou Medical University were enrolled to explore the correlation between GG and lactic acid (Number of absolute GG subjects = 252; Number of relative GG subjects = 251). Multivariate analysis, propensity score-matched (PSM) analysis, inverse probability treatment weighting (IPTW), and Pearson correlation analysis were applied. RESULTS: Absolute GG was associated with 30-day all-cause mortality in CS patients (HRadjusted: 1.779 95% CI: 1.137-2.783; HRPSM: 1.954 95% CI: 1.186-3.220; HRIPTW: 1.634 95% CI: 1.213-2.202). The higher the absolute GG level, the higher the lactic acid level (ßadjusted: 1.448 95% CI: 0.474-2.423). A similar trend existed in relative GG (HRadjusted: 1.562 95% CI: 1.003-2.432; HRPSM: 1.790 95% CI: 1.127-2.845; HRIPTW: 1.740 95% CI: 1.287-2.352; ßadjusted:1.294 95% CI: 0.369-2.219). Subgroup analysis showed that the relationship existed irrespective of DM. The area under the curve of GG combined with the Glasgow Coma Scale (GCS) for 30-day all-cause mortality was higher than that of GCS (absolute GG: 0.689 vs. 0.637; relative GG: 0.688 vs. 0.633). GG was positively related to the triglyceride-glucose index. Kaplan-Meier curves revealed that groups of higher GG with DM had the worst outcomes. The outcomes differed among races and GG levels (all P < 0.05). CONCLUSIONS: Among patients with CS, absolute and relative GGs were associated with increased 30-day all-cause mortality, regardless of DM. The relationship was stable after multivariate Cox regression analysis, PSM, and IPTW analysis. Furthermore, they reflect the severity of CS to some extent. Hyperlactatemia and insulin resistance may underlie the relationship between stress-induced hyperglycemia and poor outcomes in CS patients. They both improve the predictive efficacy of the GCS.
Asunto(s)
Biomarcadores , Glucemia , Hemoglobina Glucada , Hiperglucemia , Ácido Láctico , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/sangre , Choque Cardiogénico/terapia , Choque Cardiogénico/etiología , Masculino , Femenino , Estudios Retrospectivos , Glucemia/metabolismo , Persona de Mediana Edad , Anciano , Biomarcadores/sangre , Factores de Riesgo , Factores de Tiempo , Hiperglucemia/diagnóstico , Hiperglucemia/mortalidad , Hiperglucemia/sangre , Pronóstico , Hemoglobina Glucada/metabolismo , Ácido Láctico/sangre , China/epidemiología , Bases de Datos Factuales , Valor Predictivo de las Pruebas , Medición de Riesgo , Diabetes Mellitus/sangre , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidadRESUMEN
ABSTRACT: Cardiogenic shock (CS) is a life-threatening condition. The aim of this study is to evaluate the clinical characteristics, management, and complication rate of patients with CS admitted to a high-volume hospital in Italy. We retrospectively reviewed the clinical, echocardiographic, and laboratory data, therapeutic management, and outcomes of patients with CS admitted to the Policlinico Gemelli (Rome) between January 1, 2020, and January 1, 2023. We included 96 patients [median age 71 years, interquartile range 60-79; 65 (68%) males], of whom 49 patients (51%) presented CS secondary to acute myocardial infarction and 60 (63%) with a de novo presentation of CS. Dobutamine was the most frequently used inotrope and noradrenaline the most frequently used vasopressor (adopted in 56% and 82% of cases, respectively). Forty-five (47%) patients died during the hospitalization. Nonsurvivors were older and had a higher inflammatory burden at admission, elevated lactate levels, a greater increase in lactate levels, higher left ventricular filling pressures, and worse right ventricular function. C-reactive protein levels [odds ratio (OR) 1.03, 95% confidence interval (CI) (1.00-1.04), P = 0.027], lactate levels at admission (OR 3.49, 95% CI, 1.59-7.63, P = 0.02), and increase in lactate levels (OR 2.8, 95% CI, 1.37-5.75, P = 0.005) were independent predictors of in-hospital all-cause death. Our data contribute to the assessment of the regional variations in the management and outcomes of patients with CS. We observed a high mortality and complication rate. Lactate acidosis and C-reactive protein measured at admission may help in identifying patients at higher risk of adverse in-hospital outcomes.
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Mortalidad Hospitalaria , Hospitales de Alto Volumen , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/terapia , Choque Cardiogénico/fisiopatología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Italia/epidemiología , Resultado del Tratamiento , Factores de Riesgo , Unidades de Cuidados Coronarios , Factores de Tiempo , Biomarcadores/sangre , Medición de Riesgo , Cardiotónicos/uso terapéuticoRESUMEN
The overarching goal of cardiogenic shock (CS) therapy is ensuring long-term survival. In recent years, increasing emphasis has been placed on analyzing mechanisms to improve outcomes in CS. This includes averting in-hospital mortality, modifying the disease process by promoting heart recovery while avoiding multiorgan failure, and circumventing complications related to both CS and treatment strategies deployed to treat CS. Heart replacement therapies represent a viable strategy for long-term survival but are restricted to a small, select percentage of patients. In this review we focus on pathophysiology of the shock state, with an emphasis on addressing reversible etiologies contributing to the decompensated state, optimizing physiological factors for recovery, and identifying therapeutic targets to promote recovery. We also review the known predictors of myocardial recovery, regardless of the etiology of CS. Lastly, we highlight the current gaps in knowledge in this field and support additional high-quality studies focusing on myocardial recovery in CS.
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Recuperación de la Función , Choque Cardiogénico , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/mortalidad , Choque Cardiogénico/etiología , Humanos , Resultado del Tratamiento , Factores de Riesgo , Función Ventricular Izquierda , Factores de Tiempo , AnimalesRESUMEN
BACKGROUND: ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (STEMI-CS) is associated with high mortality rates. Patients admitted during off-hours, specifically on weekends and at night, show higher mortality rates, which is called the "off-hours effect". The off-hours effect in patients with STEMI-CS treated with mechanical circulatory support, especially Impella, has not been fully evaluated. AIMS: We aimed to investigate whether off-hours admissions were associated with higher mortality rates in this population. METHODS: We used large-scale Japanese registry data for consecutive patients treated with Impella between February 2020 and December 2021 and compared on- and off-hours admissions. On- and off-hours were defined as the time between 8:00 and 19:59 on weekdays and the remaining time, respectively. The Cox proportional hazards model was used to calculate the adjusted hazard ratios (aHRs) for 30-day mortality. RESULTS: Of the 1,207 STEMI patients, 566 (46.9%) patients (mean age: 69 years; 107 females) with STEMI-CS treated with Impella were included. Of these, 300 (53.0%) were admitted during on-hours. During the follow-up period (median 22 days [interquartile range 13-38 days]), 112 (42.1%) and 91 (30.3%) deaths were observed among patients admitted during off- and on-hours, respectively. Off-hours admissions were independently associated with a higher risk of 30-day mortality than on-hours admissions (aHR 1.60, 95% confidence interval: 1.07-2.39; p=0.02). CONCLUSIONS: Our findings indicated the persistence of the "off-hours effect" in STEMI-CS patients treated with Impella. Healthcare professionals should continue to address the disparities in cardiovascular care by improving the timely provision of evidence-based treatments and enhancing off-hours medical services.
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Corazón Auxiliar , Sistema de Registros , Infarto del Miocardio con Elevación del ST , Choque Cardiogénico , Humanos , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/complicaciones , Masculino , Femenino , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Anciano , Persona de Mediana Edad , Corazón Auxiliar/estadística & datos numéricos , Atención Posterior/estadística & datos numéricos , Anciano de 80 o más Años , Japón/epidemiología , Resultado del Tratamiento , Factores de Tiempo , Admisión del Paciente/estadística & datos numéricos , Mortalidad Hospitalaria , Factores de RiesgoRESUMEN
Whipple disease is a rare systemic illness associated with weight loss, diarrhea, and arthralgia. Asymptomatic carriage is common, but the disease can be complicated by cardiac involvement and may result in culture-negative endocarditis. Cardiac manifestations of the disease can lead to death. This report presents the case of a 66-year-old man with Whipple disease and biventricular heart failure with cardiogenic shock. Medical therapy followed by successful replacement of the aortic and mitral valves resulted in substantial improvement.
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Endocarditis Bacteriana , Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Tropheryma , Enfermedad de Whipple , Humanos , Masculino , Anciano , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/complicaciones , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/microbiología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/etiología , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/terapia , Tropheryma/aislamiento & purificación , Resultado del Tratamiento , Antibacterianos/uso terapéutico , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/microbiología , Válvula Mitral/cirugía , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/microbiología , Válvula Aórtica/microbiología , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/microbiología , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/complicacionesRESUMEN
Objectives. Temporary mechanical circulatory support (TMCS) has become a component in the therapeutic strategy for treatment of cardiogenic shock as a bridge-to-decision. TMCS can facilitate recovery of cardiopulmonary function, end-organ function, and potentially reduce the surgical risk of left ventricular assist device (LVAD) implantation. Despite the improvements of hemodynamics and end-organ function, post-LVAD operative morbidity might be increased in these high-risk patients. The aim of the study was to compare outcomes after Heartmate 3 (HM3) implantation in patients with and without TMCS prior to HM3 implant. Methods. In this retrospective cohort study of all HM3 patients in the period between November 2015 and October 2021, patients with and without prior TMCS were compared. Patients' demographics, baseline clinical characteristics, laboratory tests, intraoperative variables, postoperative outcomes, and adverse events were collected from patient records. Results. The TMCS group showed an improvement in hemodynamics prior to LVAD implantation. Median TMCS duration was 19.5 (14-26) days. However, the TMCS group were more coagulopathic, had more wound infections, neurological complications, and more patients were on dialysis compared with patient without TMCS prior to HM3 implantation. Survival four years after HM3 implantation was 80 and 82% in the TMCS (N = 22) and non-TMCS group (N = 41), respectively. Conclusion. Patients on TMCS had an acceptable short and long-term survival and comparable to patients receiving HM3 without prior TMCS. However, they had a more complicated postoperative course.
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Insuficiencia Cardíaca , Corazón Auxiliar , Hemodinámica , Recuperación de la Función , Choque Cardiogénico , Función Ventricular Izquierda , Humanos , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Factores de Tiempo , Resultado del Tratamiento , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Choque Cardiogénico/diagnóstico , Factores de Riesgo , Adulto , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/diagnóstico , Anciano , Implantación de Prótesis/instrumentación , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/mortalidad , Medición de Riesgo , Diseño de PrótesisAsunto(s)
Corazón Auxiliar , Choque Cardiogénico , Humanos , Choque Cardiogénico/terapia , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/diagnóstico , Resultado del Tratamiento , Masculino , Contrapulsador Intraaórtico/instrumentación , Contrapulsador Intraaórtico/efectos adversos , Recuperación de la FunciónRESUMEN
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been presented as a potential therapeutic option for patients with cardiogenic shock complicating myocardial infarction (CS-MI). We aimed to investigate the efficacy and safety of ECMO in CS-MI. METHODS: A systematic review and meta-analysis synthesizing evidence from randomized controlled trials obtained from PubMed, Embase, Cochrane, Scopus, and Web of Science until September 2023. We used the random-effects model to report dichotomous outcomes using risk ratio and continuous outcomes using mean difference with a 95% confidence interval. Finally, we implemented a trial sequential analysis to evaluate the reliability of our results. RESULTS: We included four trials with 611 patients. No significant difference was observed between ECMO and standard care groups in 30-day mortality with pooled RR of 0.96 (95% CI: 0.81-1.13, p = 0.60), acute kidney injury (RR: 0.65, 95% CI: 0.41-1.03, p = 0.07), stroke (RR: 1.16, 95% CI: 0.38-3.57, p = 0.80), sepsis (RR: 1.06, 95% CI: 0.77-1.47, p = 0.71), pneumonia (RR: 0.99, 95% CI: 0.58-1.68, p = 0.96), and 30-day reinfarction (RR: 0.95, 95% CI: 0.25-3.60, p = 0.94). However, the ECMO group had higher bleeding events (RR: 2.07, 95% CI: 1.44-2.97, p < 0.0001). CONCLUSION: ECMO did not improve clinical outcomes compared to the standard of care in patients with CS-MI but increased the bleeding risk.
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Oxigenación por Membrana Extracorpórea , Infarto del Miocardio , Ensayos Clínicos Controlados Aleatorios como Asunto , Choque Cardiogénico , Humanos , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/mortalidad , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Infarto del Miocardio/diagnóstico , Resultado del Tratamiento , Factores de Riesgo , Masculino , Femenino , Persona de Mediana Edad , Medición de Riesgo , Anciano , Factores de TiempoRESUMEN
BACKGROUND: Early prognosis evaluation is crucial for decision-making in cardiogenic shock (CS) patients. Dynamic lactate assessment, for example, normalized lactate load, has been a better prognosis predictor than single lactate value in septic shock. Our objective was to investigate the correlation between normalized lactate load and in-hospital mortality in patients with CS. METHODS: Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The calculation of lactate load involved the determination of the cumulative area under the lactate curve, while normalized lactate load was computed by dividing the lactate load by the corresponding period. Receiver Operating Characteristic (ROC) curves were constructed, and the evaluation of areas under the curves (AUC) for various parameters was performed using the DeLong test. RESULTS: Our study involved a cohort of 1932 CS patients, with 687 individuals (36.1%) experiencing mortality during their hospitalization. The AUC for normalized lactate load demonstrated significant superiority compared to the first lactate (0.675 vs. 0.646, P < 0.001), maximum lactate (0.675 vs. 0.651, P < 0.001), and mean lactate (0.675 vs. 0.669, P = 0.003). Notably, the AUC for normalized lactate load showed comparability to that of the Sequential Organ Failure Assessment (SOFA) score (0.675 vs. 0.695, P = 0.175). CONCLUSION: The normalized lactate load was an independently associated with the in-hospital mortality among CS patients.
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Biomarcadores , Mortalidad Hospitalaria , Ácido Láctico , Valor Predictivo de las Pruebas , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/sangre , Masculino , Femenino , Anciano , Ácido Láctico/sangre , Biomarcadores/sangre , Persona de Mediana Edad , Pronóstico , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Bases de Datos Factuales , Estudios Retrospectivos , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Sex disparities exist in the management and outcomes of various cardiovascular diseases. However, little is known about sex differences in cardiogenic shock (CS). We sought to assess sex-related differences in the characteristics, resource utilization, and outcomes of patients with CS. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of advanced cardiac intensive care units (CICUs) in North America. Between 2018 and 2022, each center (N=35) contributed annual 2-month snapshots of consecutive CICU admissions. Patients with CS were stratified as either CS after acute myocardial infarction or heart failure-related CS (HF-CS). Multivariable logistic regression was used for analyses. RESULTS: Of the 22â 869 admissions in the overall population, 4505 (20%) had CS. Among 3923 patients with CS due to ventricular failure (32% female), 1235 (31%) had CS after acute myocardial infarction and 2688 (69%) had HF-CS. Median sequential organ failure assessment scores did not differ by sex. Women with HF-CS had shorter CICU lengths of stay (4.5 versus 5.4 days; P<0.0001) and shorter overall lengths of hospital stay (10.9 versus 12.8 days; P<0.0001) than men. Women with HF-CS were less likely to receive pulmonary artery catheters (50% versus 55%; P<0.01) and mechanical circulatory support (26% versus 34%; P<0.0001) compared with men. Women with HF-CS had higher in-hospital mortality than men, even after adjusting for age, illness severity, and comorbidities (34% versus 23%; odds ratio, 1.76 [95% CI, 1.42-2.17]). In contrast, there were no significant sex differences in utilization of advanced CICU monitoring and interventions, or mortality, among patients with CS after acute myocardial infarction. CONCLUSIONS: Women with HF-CS had lower use of pulmonary artery catheters and mechanical circulatory support, shorter CICU lengths of stay, and higher in-hospital mortality than men, even after accounting for age, illness severity, and comorbidities. These data highlight the need to identify underlying reasons driving the differences in treatment decisions, so outcomes gaps in HF-CS can be understood and eliminated.
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Disparidades en el Estado de Salud , Disparidades en Atención de Salud , Sistema de Registros , Choque Cardiogénico , Humanos , Femenino , Masculino , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/epidemiología , Anciano , Factores Sexuales , Persona de Mediana Edad , Disparidades en Atención de Salud/tendencias , Factores de Riesgo , América del Norte/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Mortalidad Hospitalaria , Medición de Riesgo , Recursos en Salud , Anciano de 80 o más Años , Tiempo de Internación , Unidades de Cuidados Coronarios , Estados Unidos/epidemiología , Resultados de Cuidados CríticosRESUMEN
BACKGROUND: Intensive cardiac care units (ICCUs) were created to manage ventricular arrhythmias after acute coronary syndromes, but have diversified to include a more heterogeneous population, the characteristics of which are not well depicted by conventional methods. AIMS: To identify ICCU patient subgroups by phenotypic unsupervised clustering integrating clinical, biological, and echocardiographic data to reveal pathophysiological differences. METHODS: During 7-22 April 2021, we recruited all consecutive patients admitted to ICCUs in 39 centers. The primary outcome was in-hospital major adverse events (MAEs; death, resuscitated cardiac arrest or cardiogenic shock). A cluster analysis was performed using a Kamila algorithm. RESULTS: Of 1499 patients admitted to the ICCU (69.6% male, mean age 63.3±14.9 years), 67 (4.5%) experienced MAEs. Four phenogroups were identified: PG1 (n=535), typically patients with non-ST-segment elevation myocardial infarction; PG2 (n=444), younger smokers with ST-segment elevation myocardial infarction; PG3 (n=273), elderly patients with heart failure with preserved ejection fraction and conduction disturbances; PG4 (n=247), patients with acute heart failure with reduced ejection fraction. Compared to PG1, multivariable analysis revealed a higher risk of MAEs in PG2 (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.16-10.0) and PG3 (OR 3.16, 95% CI 1.02-10.8), with the highest risk in PG4 (OR 20.5, 95% CI 8.7-60.8) (all P<0.05). CONCLUSIONS: Cluster analysis of clinical, biological, and echocardiographic variables identified four phenogroups of patients admitted to the ICCU that were associated with distinct prognostic profiles. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05063097.
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Unidades de Cuidados Coronarios , Fenotipo , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Factores de Riesgo , Análisis por Conglomerados , Medición de Riesgo , Mortalidad Hospitalaria , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio sin Elevación del ST/fisiopatología , Infarto del Miocardio sin Elevación del ST/mortalidad , Infarto del Miocardio sin Elevación del ST/diagnóstico por imagen , Infarto del Miocardio sin Elevación del ST/diagnóstico , Pronóstico , Factores de Tiempo , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/diagnóstico , Estudios Prospectivos , Paro Cardíaco/terapia , Paro Cardíaco/fisiopatología , Paro Cardíaco/diagnóstico , Paro Cardíaco/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/mortalidad , Anciano de 80 o más Años , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidadRESUMEN
PURPOSE OF REVIEW: Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods. RECENT FINDINGS: Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure. SUMMARY: Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.
Asunto(s)
Choque Cardiogénico , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Choque Cardiogénico/etiología , Humanos , Hemodinámica/fisiología , Paro Cardíaco/terapia , Paro Cardíaco/diagnósticoRESUMEN
BACKGROUND: Cardiogenic shock is a morbid complication of heart disease that claims the lives of more than 1 in 3 patients presenting with this syndrome. Supporting a unique collaboration across clinical specialties, federal regulators, payors, and industry, the American Heart Association volunteers and staff have launched a quality improvement registry to better understand the clinical manifestations of shock phenotypes, and to benchmark the management patterns, and outcomes of patients presenting with cardiogenic shock to hospitals across the United States. METHODS: Participating hospitals will enroll consecutive hospitalized patients with cardiogenic shock, regardless of etiology or severity. Data are collected through individual reviews of medical records of sequential adult patients with cardiogenic shock. The electronic case record form was collaboratively designed with a core minimum data structure and aligned with Shock Academic Research Consortium definitions. This registry will allow participating health systems to evaluate patient-level data including diagnostic approaches, therapeutics, use of advanced monitoring and circulatory support, processes of care, complications, and in-hospital survival. Participating sites can leverage these data for onsite monitoring of outcomes and benchmarking versus other institutions. The registry was concomitantly designed to provide a high-quality longitudinal research infrastructure for pragmatic randomized trials as well as translational, clinical, and implementation research. An aggregate deidentified data set will be made available to the research community on the American Heart Association's Precision Medicine Platform. On March 31, 2022, the American Heart Association Cardiogenic Shock Registry received its first clinical records. At the time of this submission, 100 centers are participating. CONCLUSIONS: The American Heart Association Cardiogenic Shock Registry will serve as a resource using consistent data structure and definitions for the medical and research community to accelerate scientific advancement through shared learning and research resulting in improved quality of care and outcomes of shock patients.
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American Heart Association , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Sistema de Registros , Choque Cardiogénico , Humanos , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/etiología , Estados Unidos , Resultado del Tratamiento , Benchmarking , Proyectos de Investigación , Factores de Tiempo , Registros Electrónicos de Salud , Desarrollo de Programa , Mortalidad HospitalariaRESUMEN
The large spectrum of etiologies, severities, and histologic appearances of eosinophilic myocarditis (EoM) poses challenges to its diagnosis and management. Endomyocardial biopsy is the current gold standard for diagnosis. However, cardiovascular magnetic resonance imaging is becoming more frequently used to diagnose acute myocarditis because of enhanced sensitivity when compared to histopathologic examination, and its less invasive nature. We report a complicated case of EoM in a male in his mid-thirties that led to fulminant cardiogenic shock that required immunosuppressive therapy on day 5 of admission and implantation of a left ventricular assist device (LVAD) on day 30. EoM was diagnosed on histopathologic examination of the resected fragment of the left ventricular myocardium. Nine months after the initial presentation, the patient ultimately required heart transplantation. The explanted heart showed minimal residual interstitial inflammation with evidence of mildly active intimal arteritis and patchy areas of interstitial fibrosis. In this report, we describe our patient's clinical features and correlate them with imaging and histopathologic findings to illustrate the difficulty in diagnosing EoM, particularly in this complicated patient that ultimately required heart transplantation. The diagnosis can be challenging due to the variable histopathologic features, clinical presentation, and utilization of therapeutic medications and devices.
Asunto(s)
Eosinofilia , Insuficiencia Cardíaca , Trasplante de Corazón , Corazón Auxiliar , Miocarditis , Miocardio , Humanos , Masculino , Miocarditis/patología , Insuficiencia Cardíaca/etiología , Eosinofilia/patología , Eosinofilia/complicaciones , Adulto , Miocardio/patología , Biopsia , Inmunosupresores/uso terapéutico , Resultado del Tratamiento , Choque Cardiogénico/etiología , Choque Cardiogénico/patología , Choque Cardiogénico/terapia , Choque Cardiogénico/diagnósticoRESUMEN
AIMS: We sought to characterize circulating protein biomarkers associated with cardiogenic shock (CS) using highly multiplex proteomic profiling. METHODS AND RESULTS: This analysis employed a cross-sectional case-control study design using a biorepository of patients admitted to a cardiac intensive care unit between 2017 and 2020. Cases were patients adjudicated to have CS, and controls were those presenting for cardiac critical care without shock, including subsets of patients with isolated hypotension or heart failure (HF). The Olink platform was used to analyse 359 biomarkers with Bonferroni correction. The analysis included 239 patients presenting for cardiac critical care (69 cases with CS, 170 non-shock controls). A total of 63 biomarkers (17.7%) were significantly associated with CS after Bonferroni correction compared with all controls. Of these, nine biomarkers remained significantly associated with CS when separately cross-validated in subsets of controls presenting with isolated hypotension and HF: cathepsin D, fibroblast growth factor (FGF)-21 and -23, growth differentiation factor (GDF)-15, insulin-like growth factor-binding protein-1, N-terminal pro-B-type natriuretic peptide, osteopontin, oncostatin-M-specific receptor subunit beta (OSMR), and soluble ST2 protein (sST2). Four biomarkers were identified as providing complementary information for CS diagnosis with development of a multi-marker model: sST2, FGF-23, CTSD, and GDF-15. CONCLUSION: In this pilot study of targeted proteomic profiling in CS, we identified nine biomarkers significantly associated with CS when cross-validated against non-shock controls including those with HF or isolated hypotension, illustrating the potential application of a targeted proteomic approach to identify novel candidates that may support the diagnosis of CS.