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.

Asunto(s)

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 Años

RESUMEN

BACKGROUND: Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS. METHODS: In this individual patient data meta-analysis, randomised controlled trials of potential interest were identified, without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to Jan 26, 2024. All randomised trials with 6-month mortality data comparing early routine active MCS (directly in the catheterisation laboratory after randomisation) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295. FINDINGS: Nine reports of randomised controlled trials (n=1114 patients) were evaluated in detail. Overall, four randomised controlled trials (n=611 patients) compared VA-ECMO with a control treatment and five randomised controlled trials (n=503 patients) compared left ventricular unloading devices with a control treatment. Two randomised controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with a left ventricular unloading device]). The median patient age was 65 years (IQR 57-73); 845 (79·9%) of 1058 patients with data were male and 213 (20·1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR 0·87 [95% CI 0·74-1·03]; p=0·10). No significant differences were observed for left ventricular unloading devices versus control (0·80 [0·62-1·02]; p=0·075), and loading devices also had no effect on mortality (0·93 [0·75-1·17]; p=0·55). Patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality with MCS use (0·77 [0·61-0·97]; p=0·024). Major bleeding (odds ratio 2·64 [95% CI 1·91-3·65]) and vascular complications (4·43 [2·37-8·26]) were more frequent with MCS use than with control. INTERPRETATION: The use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications. However, patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality after MCS use. Therefore, the use of MCS should be restricted to certain patients only. FUNDING: The Heart Center Leipzig at Leipzig University and the Foundation Institut für Herzinfarktforschung.

Asunto(s)

Oxigenación por Membrana Extracorpórea , Corazón Auxiliar , Infarto del Miocardio , Ensayos Clínicos Controlados Aleatorios como Asunto , Choque Cardiogénico , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/etiología , Humanos , Infarto del Miocardio/mortalidad , Infarto del Miocardio/complicaciones , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Masculino , Persona de Mediana Edad , Estudios de Seguimiento , Anciano , Resultado del Tratamiento

RESUMEN

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/mortalidad

RESUMEN

PURPOSE: Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia. METHODS: In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92-96%) or to a liberal oxygen strategy (target SaO2 97-100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months. RESULTS: From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0-13.7] versus liberal: 0 days [IQR 0-13.7], median treatment effect: 0 days [95% confidence interval (CI) - 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001). CONCLUSIONS: In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.

Asunto(s)

Oxigenación por Membrana Extracorpórea , Humanos , Oxigenación por Membrana Extracorpórea/métodos , Oxigenación por Membrana Extracorpórea/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Adulto , Unidades de Cuidados Intensivos/estadística & datos numéricos , Saturación de Oxígeno/fisiología , Sistema de Registros/estadística & datos numéricos , Oxígeno , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Paro Cardíaco/terapia , Paro Cardíaco/mortalidad

RESUMEN

BACKGROUND: The prognostic implications of phenotypes along the preshock to cardiogenic shock (CS) continuum remain uncertain. OBJECTIVES: This study sought to better characterize pre- or early shock and normotensive CS phenotypes and examine outcomes compared to those with conventional CS. METHODS: The CCCTN (Critical Care Cardiology Trials Network) is a registry of contemporary cardiac intensive care units. Consecutive admissions (N = 28,703 across 47 sites) meeting specific criteria based on hemodynamic variables, perfusion parameters, and investigator-reported CS were classified into 1 of 4 groups or none: isolated low cardiac output (CO), heart failure with isolated hypotension, normotensive CS, or SCAI (Society of Cardiovascular Angiography and Intervention) stage C CS. Outcomes of interest were in-hospital mortality and incidence of subsequent hypoperfusion among pre- and early shock states. RESULTS: A total of 2,498 admissions were assigned to the 4 groups with the following distribution: 4.8% isolated low CO, 4.4% isolated hypotension, 12.1% normotensive CS, and 78.7% SCAI stage C CS. Overall in-hospital mortality was 21.3% (95% CI: 19.7%-23.0%), with a gradient across phenotypes (isolated low CO 3.6% [95% CI: 1.0%-9.0%]; isolated hypotension 11.0% [95% CI: 6.9%-16.6%]; normotensive CS 17.0% [95% CI 13.0%-21.8%]; SCAI stage C CS 24.0% [95% CI: 22.1%-26.0%]; global P < 0.001). Among those with an isolated low CO and isolated hypotension on admission, 47 (42.3%) and 56 (30.9%) subsequently developed hypoperfusion. CONCLUSIONS: In a large contemporary registry of cardiac critical illness, there exists a gradient of mortality for phenotypes along the preshock to CS continuum with risk for subsequent worsening of preshock states. These data may inform refinement of CS definitions and severity staging.

Asunto(s)

Mortalidad Hospitalaria , Sistema de Registros , Choque Cardiogénico , Humanos , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Masculino , Femenino , Anciano , Persona de Mediana Edad , Cuidados Críticos , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Pronóstico , Fenotipo , Hipotensión/epidemiología , Unidades de Cuidados Coronarios/estadística & datos numéricos

RESUMEN

BACKGROUND: Cardiogenic shock (CS) is associated with significant morbidity and mortality. Sex differences in the outcomes and management of cardiogenic shock are not well established. The primary objective of this study is to investigate the differences inik cardiogenic shock outcomes between males and females. METHODS: A systematic review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Studies were searched via the MEDLINE/PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to December 2022. RESULTS: The analysis included 24 studies comprising 1,567,660 patients. Compared to females, males with CS had a significantly lower risk of in-hospital all-cause mortality (risk ratio [RR] 0.88, 95 % confidence interval [CI] 0.85-0.90, p < 0.001) and 1-year mortality (RR 0.90, 95 % CI 0.89-0.92, p < 0.001). Males were more likely to undergo percutaneous coronary intervention (RR 1.21, 95 % CI 1.13-1.31, p < 0.0001) and intra-aortic balloon pump placement (RR 1.21, 95 % CI 1.11-1.32, p < 0.0001), with no significant sex differences in the use of extracorporeal membrane oxygenation or Impella. During the index hospitalization, males were at higher risk of arrhythmias (RR 1.18, 95 % CI 1.05-1.34, p = 0.003) and less likely to develop acute kidney injury (RR 0.86, 95 % CI 0.79-0.94, p < 0.001). CONCLUSION: Men have a lower all-cause mortality risk in cardiogenic shock. Addressing disparities in management is crucial for improving CS outcomes, especially for women.

Asunto(s)

Choque Cardiogénico , Humanos , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Factores Sexuales , Femenino , Masculino , Mortalidad Hospitalaria/tendencias , Manejo de la Enfermedad , Contrapulsador Intraaórtico/métodos , Contrapulsador Intraaórtico/estadística & datos numéricos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Cardiogenic Shock (CS) complicating acute myocardial infarction (AMI) poses a significant mortality risk, suggesting the opportunity to implement effective mechanical circulatory support strategies. The comparative efficacy of Intra-Aortic Balloon Pump (IABP) and Impella in managing CS-AMI remains a subject of investigation. OBJECTIVE: This meta-analysis aims to evaluate the comparative effectiveness of Impella and IABP in managing CS-AMI, exploring mortality and adverse events. METHODS: A systematic search of major databases from inception to November 2023 identified eight studies, comprising 10,628 patients, comparing Impella and IABP in CS-AMI. Retrospective studies (preferably Propensity-matched) and Randomized Clinical Trials (RCTs) were included. RESULTS: Impella use exhibited significantly higher mortality (57% vs. 46%; OR: 1.44, 95% CI: 1.29-1.60; p < 0.001) and major bleeding (30% vs 15%; OR: 2.93, 95% CI: 1.67-5.13; p < 0.001). CONCLUSIONS: In unselected CS-AMI patients, Impella usage is associated with significantly higher mortality and major bleeding.

Asunto(s)

Corazón Auxiliar , Contrapulsador Intraaórtico , Infarto del Miocardio , Choque Cardiogénico , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Choque Cardiogénico/etiología , Humanos , Contrapulsador Intraaórtico/métodos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Resultado del Tratamiento , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos

RESUMEN

BACKGROUND: Cardiogenic shock is a clinical syndrome caused by primary heart disease that results in decreased cardiac output and insufficient systemic perfusion. A study was conducted to determine what factors affect survival in patients with cardiogenic shock treated with extracorporeal membrane oxygenation (ECMO). METHODS: A systematic search was conducted across various databases, including CKNI, VIP, Wan Fang, CBM, Embase, PubMed, Cochrane Library, and Web of Science databases, to gather factors linked to the prognosis of patients with cardiogenic shock who underwent ECMO treatment. The search period for each database was set to conclude on April 30, 2024. RESULTS: The findings suggest that, in comparison to the death group, the lactic acid levels of the survival group after treatment were significantly lower (95% confidence interval [CI]: -0.79, -0.58). In addition, the creatinine levels of the survival group after treatment were also significantly lower than those of the death group (95% CI: -0.39, -0.14). Furthermore, the troponin levels in the survival group after treatment were lower than those in the death group (95% CI: -0.32, 0.04), and the total bilirubin levels in the survival group after treatment were also lower than those in the death group (95% CI: -0.62, -0.23). CONCLUSIONS: According to the study, total bilirubin, creatinine, and lactic acid levels were lower in the survival group than in the death group when ECMO was used to treat cardiogenic patients, suggesting a better prognosis for patients with cardiogenic shock. Therefore, total bilirubin, creatinine, and lactic acid could be influential factors in the prognosis of survival in patients with cardiogenic shock.

Asunto(s)

Oxigenación por Membrana Extracorpórea , Metaanálisis como Asunto , Choque Cardiogénico , Revisiones Sistemáticas como Asunto , Oxigenación por Membrana Extracorpórea/métodos , Choque Cardiogénico/terapia , Choque Cardiogénico/mortalidad , Humanos , Pronóstico , Ácido Láctico/sangre , Creatinina/sangre

RESUMEN

BACKGROUND: Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. METHODS: We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. RESULTS: In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. CONCLUSIONS: Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

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FUNDAMENTO: O choque cardiogênico (CC) refratário está associado com altas taxas de mortalidade, e o uso de oxigenação por membrana extracorpórea venoarterial (VA-ECMO, do inglês venoarterial extracorporeal membrane oxygenation) como uma opção terapêutica tem gerado discussões. Nesse sentido, sua custo-efetividade, principalmente em países de baixa e média renda como o Brasil, continua incerto.Objetivos: Conduzir uma análise de custo-efetividade na perspectiva do Sistema Único de Saúde (SUS) para avaliar a custo-efetividade de VA-ECMO combinado com o tratamento padrão em comparação ao tratamento padrão isolado em pacientes adultos com CC refratário. MÉTODOS: Acompanhamos uma coorte de pacientes com CC refratário tratados com VA-ECMO em centros de assistência terciária do sul brasileiro. Coletamos dados de desfechos e custos hospitalares. Realizamos uma revisão sistemática para complementar nossos dados e usamos o modelo de Markov para estimar a razão de custo-efetividade incremental (RCEI) por ano de vida ajustado pela qualidade (QALY) e por ano de vida ganho. RESULTADOS: Na análise do caso-base, a VA-ECMO gerou uma RCEI de Int$ 37 491 por QALY. Análises de sensibilidade identificaram o custo de internação, o risco relativo de sobrevida, e a sobrevida do grupo submetido à VA-ECMO como principais variáveis influenciando os resultados. A análise de sensibilidade probabilística mostrou um benefício do uso de VA-ECMO, com uma probabilidade de 78% de custo-efetividade no limiar recomendado de disposição a pagar. CONCLUSÕES: Nosso estudo sugere que, dentro do SUS, VA-ECMO pode ser uma terapia custo-efetiva para o CC refratário. Contudo, a escassez de dados sobre a eficácia e de ensaios clínicos recentes que abordem seus benefícios em subgrupos específicos de pacientes destaca a necessidade de mais pesquisas. Ensaios clínicos rigorosos, incluindo perfis diversos de pacientes, são essenciais para confirmar a custo-efetividade com uso de VA-ECMO e assegurar acesso igualitário a intervenções médicas avançadas dentro dos sistemas de saúde, especialmente em países com desigualdades socioeconômicas como o Brasil.

Asunto(s)

Análisis Costo-Beneficio , Oxigenación por Membrana Extracorpórea , Años de Vida Ajustados por Calidad de Vida , Choque Cardiogénico , Humanos , Brasil , Oxigenación por Membrana Extracorpórea/economía , Cadenas de Markov , Choque Cardiogénico/terapia , Choque Cardiogénico/economía , Choque Cardiogénico/mortalidad , Resultado del Tratamiento

RESUMEN

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.

Asunto(s)

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 terapéutico

RESUMEN

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.

Asunto(s)

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 , Animales

RESUMEN

Optimal timing of revascularization for patients who presented with non-ST segment elevation myocardial infarction (NSTEMI) and severe left ventricular (LV) dysfunction is unclear. A total of 386 NSTEMI patients with severe LV dysfunction from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction Registry V (KAMIR-V) were enrolled. Severe LV dysfunction was defined as LV ejection fraction ≤ 35%. Patients with cardiogenic shock were excluded. Patients were stratified into two groups: PCI within 24 hours (early invasive group) and PCI over 24 hours (selective invasive group). Primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, non-fatal MI, repeat revascularization, and stroke at 12 months after index procedure. Early invasive group showed higher incidence of in-hospital death (9.4% vs 3.3%, P = .036) and cardiogenic shock (11.5% vs 4.6%, P = .030) after PCI. Early invasive group also showed higher maximum troponin I level during admission (27.7 ±â€…44.8 ng/mL vs 14.9 ±â€…24.6 ng/mL, P = .001), compared with the selective invasive group. Early invasive group had an increased risk of 12-month MACCE, compared with selective invasive group (25.6% vs 17.1%; adjusted HR = 2.10, 95% CI 1.17-3.77, P = .006). Among NSTEMI patients with severe LV dysfunction, the early invasive strategy did not improve the clinical outcomes. This data supports that an individualized approach may benefit high-risk NSTEMI patients rather than a routine invasive approach.

Asunto(s)

Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Sistema de Registros , Disfunción Ventricular Izquierda , Humanos , Disfunción Ventricular Izquierda/fisiopatología , Masculino , Femenino , Infarto del Miocardio sin Elevación del ST/cirugía , Infarto del Miocardio sin Elevación del ST/mortalidad , Persona de Mediana Edad , Anciano , Intervención Coronaria Percutánea/métodos , República de Corea/epidemiología , Estudios Prospectivos , Tiempo de Tratamiento/estadística & datos numéricos , Mortalidad Hospitalaria , Revascularización Miocárdica/métodos , Factores de Tiempo , Choque Cardiogénico/mortalidad , Choque Cardiogénico/etiología

RESUMEN

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.

Asunto(s)

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 Riesgo

RESUMEN

BACKGROUND AND OBJECTIVES: The relevance of the use of intra-aortic balloon pump (IABP) in cardiogenic shock (CS) has been discussed over the past years. The aim of this study is to describe a single-centre 10-year experience with IABP and analyse the risk factors for 30-day mortality. METHODS: The data for this single-centre, observational, retrospective study were drawn from records dated from January 2012 to May 2022 pertaining to patients presenting with CS, treated with IABP and hospitalised at the Department of Acute Cardiology, Institute for Clinical and Experimental Medicine, Prague. RESULTS: Among the patients included in the study, 87% patients presented with newly developed heart failure. The leading cause of CS was acute myocardial infarction accounting for 86% of cases. Hospital mortality was recorded at 39% and the 30-day mortality reached 43%. Upon multi-variable analysis, only the vasoactive inotropic score on day 5 emerged as a statistically significant predictor for 30-day mortality (p=0.0055). Cox regression analysis revealed that the presence of mechanical complications was the only variable identified as yielding a statistically significant impact on the 30-day survival (Log-rank p=0.014, HR 2.19, 95% CI: 1.15‒4.15). There was no statistically significant difference in the 30-day mortality across the SCAI classes. CONCLUSION: The main cause of CS was a newly developed acute heart failure secondary to acute myocardial infarction. Despite the implementation of mechanical circulatory support, both in-hospital and 30-day mortality rates remained high. Increased vasoactive inotropic score and presence of mechanical complications were identified as significant predictors the 30-day survival (Tab. 6, Fig. 1, Ref. 36). Text in PDF www.elis.sk Keywords: cardiogenic shock, IABP, risk factors, mortality, Czech Republic, AMICS.

Asunto(s)

Mortalidad Hospitalaria , Contrapulsador Intraaórtico , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Choque Cardiogénico/etiología , Masculino , Femenino , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Factores de Riesgo , República Checa/epidemiología , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/complicaciones , Anciano de 80 o más Años

RESUMEN

PURPOSE: Cardiac surgery, post-cardiotomy cardiogenic shock (PCCS), and temporary mechanical circulatory support (tMCS) provoke substantial inflammation. We therefore investigated whether a selenium-based, anti-inflammatory strategy would benefit PCCS patients treated with tMCS in a post-hoc analysis of the sustain CSX trial. METHODS: Post-hoc analysis of patients receiving tMCS for PCCS in the Sustain CSX trial, which investigated the effects of high-dose selenium on postoperative organ dysfunction in cardiac surgery patients. PRIMARY OUTCOME: duration of tMCS therapy. SECONDARY OUTCOMES: postoperative organ dysfunction and 30-day mortality. RESULTS: Thirty-nine patients were treated with tMCS for PCCS. There was no difference in the median duration of tMCS between the selenium and the placebo group (3 days [IQR: 1-6] vs. 2 days [IQR: 1-7], p = 0.52). Median dialysis duration was longer in the selenium group (1.5 days [0-21.8] vs. 0 days [0-1.8], p = 0.048). There was no difference in 30-day mortality (53% vs. 41%, OR 1.44, 95% CI 0.32-6.47, p = 0.62). CONCLUSION: In this explorative study, a perioperative high-dose selenium-supplementation did not show beneficial effects on organ dysfunctions and mortality rates in patients with PCCS receiving tMCS.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias , Selenio , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Masculino , Femenino , Selenio/administración & dosificación , Selenio/uso terapéutico , Persona de Mediana Edad , Anciano , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/prevención & control , Corazón Auxiliar , Insuficiencia Multiorgánica/mortalidad , Insuficiencia Multiorgánica/prevención & control , Insuficiencia Multiorgánica/etiología

RESUMEN

OBJECTIVES: Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT. DESIGN: Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022. SETTING: Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn. PATIENTS AND INTERVENTIONS: In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated. MEASUREMENTS AND MAIN RESULTS: In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485). CONCLUSIONS: HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.

Asunto(s)

Anticoagulantes , Heparina , Choque Cardiogénico , Trombocitopenia , Humanos , Heparina/efectos adversos , Trombocitopenia/inducido químicamente , Trombocitopenia/epidemiología , Trombocitopenia/diagnóstico , Trombocitopenia/mortalidad , Estudios Retrospectivos , Choque Cardiogénico/inducido químicamente , Choque Cardiogénico/epidemiología , Choque Cardiogénico/mortalidad , Femenino , Masculino , Anciano , Persona de Mediana Edad , Anticoagulantes/efectos adversos , Prevalencia , Alemania/epidemiología

RESUMEN

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.

Asunto(s)

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 Prótesis

RESUMEN

PURPOSE OF REVIEW: To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing perioperative low cardiac output syndrome (P-LCOS). RECENT FINDINGS: P-LCOS is a significant predictor of mortality in cardiac surgery patients. Preoperative risk factors, such as cardiogenic shock and elevated lactate levels, can help identify those at higher risk. Proactive use of MCS, rather than reactive implementation after P-LCOS develops, may lead to improved outcomes by preventing severe organ hypoperfusion. The emerging concept of "protected cardiac surgery" emphasizes early identification of these high-risk patients and planned MCS utilization. Additionally, specific MCS strategies are being developed and refined for various cardiac conditions, including AMI-CS, valvular surgeries, and pulmonary thromboendarterectomy. SUMMARY: This paper explores the shifting demographics and complexities in cardiac surgery patients. It emphasizes the importance of proactive, multidisciplinary approaches to identify high-risk patients and implement early MCS to prevent P-LCOS and improve outcomes. The concept of protected cardiac surgery, involving planned MCS use and shared decision-making, is highlighted. The paper also discusses MCS strategies tailored to specific cardiac procedures and the ethical considerations surrounding MCS implementation.

Asunto(s)

Gasto Cardíaco Bajo , Procedimientos Quirúrgicos Cardíacos , Humanos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Gasto Cardíaco Bajo/prevención & control , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/mortalidad , Corazón Auxiliar , Choque Cardiogénico/mortalidad , Oxigenación por Membrana Extracorpórea , Factores de Riesgo , Medición de Riesgo

RESUMEN

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.

Asunto(s)

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 Tiempo

RESUMEN

BACKGROUND: Patients presenting with cardiogenic shock (CS) are at risk of developing mixed shock (MS), characterized by distributive-inflammatory phenotype. However, no objective definition exists for this clinical entity. METHODS: We assessed the frequency, predictors, and prognostic relevance of MS complicating CS, based on a newly proposed objective definition. MS complicating CS was defined as an objective shock state secondary to both an ongoing cardiogenic cause and a distributive-inflammatory phenotype arising at least 12 hours after the initial CS diagnosis, as substantiated by predefined longitudinal changes in hemodynamics, clinical, and laboratory parameters. RESULTS: Among 213 consecutive patients admitted at 2 cardiac intensive care units with CS, 13 with inflammatory-distributive features at initial presentation were excluded, leading to a cohort of 200 patients hospitalized with pure CS (67±13 years, 96% Society of Cardiovascular Angiography and Interventions CS stage class C or higher). MS complicating CS occurred in 24.5% after 120 (29-216) hours from CS diagnosis. Lower systolic arterial pressure (P=0.043), hepatic injury (P=0.049), and suspected/definite infection (P=0.013) at CS diagnosis were independent predictors of MS development. In-hospital mortality (53.1% versus 27.8%; P=0.002) and hospital stay (21 [13-48] versus 17 [9-27] days; P=0.018) were higher in the MS cohort. At logistic multivariable analysis, MS diagnosis (odds ratio [OR], 3.00 [95% CI, 1.39-6.63]; Padj=0.006), age (OR, 1.06 [95% CI, 1.03-1.10] years; Padj<0.001), admission systolic arterial pressure <100 mm Hg (OR, 2.41 [95% CI, 1.19-4.98]; Padj=0.016), and admission serum creatinine (OR, 1.61 [95% CI, 1.19-2.26]; Padj=0.003) conferred higher odds of in-hospital death, while early temporary mechanical circulatory support was associated with lower in-hospital death (OR, 0.36 [95% CI, 0.17-0.75]; Padj=0.008). CONCLUSIONS: MS complicating CS, objectively defined leveraging on longitudinal changes in distributive and inflammatory features, occurs in one-fourth of patients with CS, is predicted by markers of CS severity and inflammation at CS diagnosis, and portends higher hospital mortality.

Asunto(s)

Mortalidad Hospitalaria , Choque Cardiogénico , Humanos , Choque Cardiogénico/etiología , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Choque Cardiogénico/fisiopatología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Anciano de 80 o más Años , Hemodinámica , Factores de Tiempo