Gender Disparities in Cardiogenic Shock Treatment and Outcomes

Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia

OBJECTIVES

We aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock.

DESIGN

We conducted a population-based cohort study, where EMS-treated patients were individually linked to hospital-wide and state-wide administrative datasets. Direct healthcare costs (Australian dollars, AUD) were estimated for each element of care using a casemix funding method. The impact on productivity was assessed using a Markov state-transition model with a 3-year horizon.

SETTING

Patients older than 18 years of age with shock not related to trauma who received care by EMS (1 January 2015-30 June 2019) in Victoria, Australia were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome assessed was the total healthcare expenditure. Secondary outcomes included healthcare expenditure stratified by shock aetiology, years of life lived (YLL), productivity-adjusted life-years (PALYs) and productivity losses.

RESULTS

A total of 21 334 patients (mean age 65.9 (±19.1) years, and 9641 (45.2%) females were treated by EMS with non-traumatic shock with an average healthcare-related cost of $A11 031 per episode of care and total cost of $A280 million. Annual costs remained stable throughout the study period, but average costs per episode of care increased (Ptrend=0.05). Among patients who survived to hospital, the average cost per episode of care was stratified by aetiology with cardiogenic shock costing $A24 382, $A21 254 for septic shock, $A19 915 for hypovolaemic shock and $A28 057 for obstructive shock. Modelling demonstrated that over a 3-year horizon the cohort lost 24 355 YLLs and 5059 PALYs. Lost human capital due to premature mortality led to productivity-related losses of $A374 million. When extrapolated to the entire Australian population, productivity losses approached $A1.5 billion ($A326 million annually).

CONCLUSION

The direct healthcare costs and indirect loss of productivity among patients with non-traumatic shock are high. Targeted public health measures that seek to reduce the incidence of shock and improve systems of care are needed to reduce the financial burden of this syndrome.

Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting

AIMS

The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS).

METHODS AND RESULTS

This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile.

CONCLUSION

This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.

Impact of Acute Myocardial Infarction Type on Prognosis in Female Patients With Cardiogenic Shock

There are limited data about mid-term prognosis according to acute myocardial infarction (AMI) type in female patients with AMI complicated by cardiogenic shock (CS). In this study, we evaluated the impact of AMI type on prognosis in female patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by CS. A total of 184 female patients who underwent PCI for AMI complicated by CS were enrolled from 12 centers in the Republic of Korea. Patients were divided into 2 groups according to AMI type: the ST-segment elevation myocardial infarction (n = 114) and the non-ST-segment elevation myocardial infarction (n = 70) group. Primary outcome was a major adverse cardiac event (MACE) (defined as a composite of cardiac death, myocardial infarction, or repeat revascularization). Propensity-score matching analysis was performed to reduce selection bias and potential confounding factors. During 12-month follow-up, a total of 73 MACEs occurred (ST-segment elevation myocardial infarction group, 47 [41.2%] vs non-ST-segment elevation myocardial infarction group, 26 [37.1%], p = 0.643). Multivariate analysis revealed no significant difference in the incidence of MACE at 12 months between the 2 groups (adjusted hazard ratio 1.16, 95% confidence interval 0.70 to 2.37, p = 0.646). After propensity-score matching, the incidence of MACE at 12 months remained similar between the 2 groups (hazard ratio 1.31, 95% confidence interval 0.69 to 2.52, p = 0.413). The similarity in MACEs between the 2 groups was consistent across a variety of subgroups. In conclusion, after adjusting for baseline differences, AMI clinical type did not appear to increase the risk of MACEs at 12 months in female patients who underwent emergency PCI for AMI complicated by CS.

Addressing Barriers for Women with Advanced Heart Failure

PURPOSE OF REVIEW

Describe disparities in diagnosis and management between men and women with advanced heart failure (HF). Our goal is to identify barriers and suggest solutions.

RECENT FINDINGS

Women with advanced HF are less likely to undergo diagnostic testing and procedures (i.e., revascularization, implantable cardioverter defibrillators, cardiac resynchronization therapy, mechanical circulatory support, and orthotopic heart transplantation). Disparities related to gender create less favorable outcomes for women with advanced HF. The issues arise from access to care, paucity of knowledge, enrollment in clinical trials, and eligibility for advanced therapies. In this review, we propose a call to action to level the playing field in order to improve survival in women with advanced HF.

State of Shock: Contemporary Vasopressor and Inotrope Use in Cardiogenic Shock

Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.

Does sex affect the risk of 30-day all-cause mortality in cardiogenic shock?

BACKGROUND

Mortality rates following CS have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with cardiogenic shock (CS).

METHODS

Consecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were used for statistics.

RESULTS

From a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756-1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713-1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710-1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677-1.783; p = 0.704).

CONCLUSION

Sex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology. (clinicaltrials.gov identifier: NCT05575856).

HOSPITAL CHARACTERISTICS ARE ASSOCIATED WITH CLINICAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK

ABSTRACT

Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (<18 cases per year), hospitals in the highest volume quartile (>55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P < 0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.