Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Poor Mental Health Status as a Risk Factor and Prognosticator in SMuRF-Less Acute Myocardial Infarction

Background: The etiology of acute myocardial infarction (AMI) in patients without history of standard modifiable risk factors (SMuRFs) remains unclear. Simultaneously, evidence suggests that mental health status (MHS) contributes to the pathogenesis of AMI and worsens its outcomes. Methods: This analysis of the prospective "Beyond-SMuRFs" (NCT05535582) study included 650 consecutive patients with AMI who had available data on self-reported MHS before AMI, calculated by the SF36-Questionnaire mental component summary (MCS). Poor MHS was defined as MCS ≤ 50. Multivariable logistic-regression and Cox-regression analyses were implemented to investigate poor MHS as a potential predictor of SMuRF-less AMIs and compare all-cause mortality based on SMuRF-less and MH status, respectively. Results: Of 650 patients with AMI (mean age 62.6 ± 12.1 years), 288 (44.3%) had MCS ≤ 50 and 128 (19.7%) were SMuRF-less patients. Three out of four SMuRF-less patients reported an MCS ≤ 50 (n = 96, 75%), a significantly higher percentage than the corresponding percentage in patients with SMuRFs (n = 192, 36.8%; p < 0.01). The multivariable logistic regression model showed that MCS ≤ 50 was an independent predictor of SMuRF-less AMI [aOR = 0.95; 95% CI (0.94-0.96)]. Time-to-event analysis for all-cause mortality showed that patients with MCS > 50 had lower mortality rates than those with poor MHS (aHR, 3.61 [95% CI, 2.02 to 6.43], p < 0.01). Higher risk for all-cause mortality was also observed in SMuRF-less patients with poor MHS compared to patients with at least one SMuRF and good MHS [aHR, 4.52 (95% CI, 0.94-21.73)]. Conclusions: Poor MHS was an independent predictor of the occurrence of SMuRF-less AMI and predictive of higher mortality in patients with and without SMuRFs.

Influence of Right and Left Bundle Branch Block in Patients With Cardiogenic Shock and Cardiac Arrest

OBJECTIVES

The study investigates the prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in patients with cardiogenic shock (CS) compared with no bundle branch block (BBB). In patients with heart failure, existence of RBBB and LBBB has influence on prognosis.

DESIGN

Prospective registry-study.

SETTING

ICU of a tertiary academic hospital in Germany.

PATIENTS

Adult patients with CS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Consecutive patients with CS were included. The prognostic impact of RBBB and LBBB on 30-day all-cause mortality was tested within the entire cohort and in the subgroup of CS patients with cardiac arrest at admission. The final study cohort comprised 248 patients. Patients with RBBB showed the highest 30-day all-cause mortality followed by LBBB and no BBB (72.5% vs. 52.9% vs. 50.0%; log-rank p = 0.015). These findings were consistent even after solely including CS patients with cardiac arrest (90.0% vs. 73.3% vs. 62.2%; log-rank p = 0.008). After adjustment for lactate, norepinephrine, troponin I, Acute Physiology Score, Society of Cardiovascular Angiography & Interventions shock stage, and heart rate in a multivariable Cox regression analysis, RBBB still revealed a negative impact on 30-day all-cause mortality (hazard ratio [HR], 1.807; 95% CI, 1.107-2.947; p = 0.018), whereas LBBB was not associated with 30-day all-cause mortality. In this multivariable Cox regression model lactate (HR, 1.065; 95% CI, 1.018-1.115; p = 0.006), troponin I (HR, 1.003; 95% CI, 1.001-1.005; p = 0.001), and Acute Physiology Score (HR, 1.033; 95% CI, 1.001-1.066; p = 0.041) were as well associated with 30-day all-cause mortality. Finally, no association of RBBB was found with the incidence of liver or severe renal failure.

CONCLUSIONS

Besides the Acute Physiology Score, lactate, and troponin levels, RBBB was associated with an increased 30-day all-cause mortality in consecutive CS patients with and without cardiac arrest, whereas LBBB showed no prognostic impact.

Burden and predictors of mortality related to cardiogenic shock in the South Bronx Population

OBJECTIVES

Cardiogenic shock is a significant economic burden on healthcare facilities and patients. The prevalence and outcome of cardiogenic shock in the South Bronx are unknown. The aim of the study was to examine the burden of non-AMI CS in Hispanic and Black population in South Bronx and characterize their in-hospital outcomes.

METHODS

We reviewed patient charts between 1/1/2022 and 1/1/2023 to identify patients with a primary diagnosis of cardiogenic shock (ICD codes R57.0, R57, R57.8, R57.9) residing in the following zip codes: 10451-59 and 10463. Student's T-test was used to assess differences for continuous variables; chi-square statistic was used for categorical variables. A logistic regression analysis model was used to assess independent predictors of mortality. A P-value of < 0.05 was considered significant.

RESULTS

87 patients were admitted with cardiogenic shock (60% African American, 67% male, mean age =62±15 years) of which 54 patients (62%) died. Those who died were older, had > 1 pressor, out-of-hospital arrest, arrested within 24 hours of admission, and had higher SCAI class, lactate, and ALT levels than those who were discharged. The logistic regression analysis model showed that older age ((RR=3.4 [95% CI: 3.3-3.45]), > 1 pressor (RR=3.4 [95% CI: 2.6-4.2]) and higher SCAI class (2.1 [95% CI: 1.5-2.1], all P < 0.05)) were independent predictors of mortality in patients with cardiogenic shock. Additionally, most of the patients had either Medicare or Medicaid insurance in predominantly African American study population.

CONCLUSIONS

Cardiogenic shock carries a significant risk of death. Factors such as advanced age, the administration of more than one vasopressor, and a higher SCAI classification have been identified as independent predictors of mortality among inpatients with cardiogenic shock. Additionally, the progression and outcomes of the condition are influenced by variables like race (e.g., African American individuals in this study) and economic challenges, including the type of insurance coverage (e.g., Medicaid or Medicare). Further research is essential to explore strategies that could enhance survival rates in cardiogenic shock patients, with a particular focus on addressing economic and racial disparities.

Evaluating the prognostic value of systemic immune-inflammatory index in patients with acute decompensated heart failure

AIMS

The value of the systemic immune-inflammatory index (SII) in assessing adverse outcomes in various cardiovascular diseases has been extensively discussed. This study aims to evaluate the predictive value and risk stratification ability of SII for 30 day mortality in patients with acute decompensated heart failure (ADHF).

METHODS

This analysis included 1452 patients hospitalized for ADHF, all the participants being part of the China Jiangxi-acute decompensated heart failure1 project. The risk stratification capability of the SII in patients with ADHF, as well as its correlation with the 30 day mortality risk among ADHF patients, was evaluated utilizing Kaplan-Meier survival analysis and multivariable Cox regression models. A restricted cubic spline was employed to model the dose-response relationship between the two, and the receiver operating characteristic curve was utilized to assess the predictive ability of SII for 30 day mortality.

RESULTS

The Kaplan-Meier analysis revealed that the risk of mortality in the high SII group (SII ≥ 980 × 109/L) was significantly greater than that in the low SII group (SII < 980 × 109/L, log-rank P < 0.001). After adjusting for various confounding factors, a higher SII was associated with an increased risk of 30 day mortality in ADHF patients [hazard ratio (HR) = 2.03, 95% confidence interval (CI): 1.34-3.08]. Further restricted cubic spline analysis revealed a non-linear dose-response relationship between the two (P for non-linear = 0.006). Receiver operating characteristic analysis demonstrated that SII had a high accuracy in predicting 30 day mortality events in ADHF patients (AUC = 0.7479), and the optimal predictive threshold was calculated to be 980 × 109/L, a sensitivity of 0.7547 and a specificity of 0.7234.

CONCLUSIONS

This study found a significant positive association between SII and 30 day all-cause mortality in ADHF patients. We determined the SII cut-off point for predicting 30 day all-cause mortality in patients with ADHF to be 980 × 109/L.

Blood Urea Nitrogen to Left Ventricular Ejection Ratio as a Predictor of Short-Term Outcome in Acute Myocardial Infarction Complicated by Cardiogenic Shock

INTRODUCTION

Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS).

METHODS

268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome.

RESULTS

The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125-5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456-2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05).

CONCLUSION

The admission BUNLVEFr provided important prognostic information for AMI-CS patients.

A study of the predictive role of multiple variables for the incidence of acute kidney injury and its outcomes in Indian patients with ST-elevation myocardial infarction and cardiogenic shock

BACKGROUND

Acute kidney injury (AKI) occurs frequently in ST-elevation myocardial infarction with cardiogenic shock (CS-STEMI) and is a strong independent prognostic marker for short and intermediate-term outcomes. Owing to the delayed presentation and limited facilities for primary percutaneous coronary intervention in low- and middle-income countries, the incidence, predictors, and outcome of AKI are likely to be different compared to the developed countries. We performed a post hoc analysis of patients presenting with CS-STEMI over 7 years (2016-2022) at a tertiary referral center in North India. The primary outcome assessed was AKI and the secondary outcome was in-hospital mortality.

RESULTS

Of the 426 patients, 194 (45.5%) patients developed AKI, as defined by the Kidney Disease Improving Global Outcomes criteria. Left ventricular (LV) pump failure with pulmonary edema [Odds ratio (OR) 1.67; 95% confidence interval (CI) 1.04-2.67], LV ejection fraction (OR 1.35 per 10% decrease in ejection fraction; CI 1.04-1.73), complete heart block (OR 2.06; CI 1.2-3.53), right ventricular infarction (OR 2.76; CI 1.39-5.49), mechanical complications (OR 3.89; CI 1.85-8.21), ventricular tachycardia (OR 2.80; CI 1.57-4.99), and non-revascularization (OR 2.2; CI 1.33-3.67) were independent predictors of AKI in multivariate logistic regression analysis. Additionally, AKI was a strong predictor of in-hospital mortality (univariate OR 30.61, CI 17.37-53.95).

CONCLUSIONS

There is a higher incidence of AKI in CS-STEMI in resource-limited settings and is associated with adverse short-term outcomes. Additional studies are needed to address the optimal strategies for the prevention and management of AKI in such settings.

Myocardial injury and clinical outcome in octogenarians after non-ST-elevation myocardial infarction

Introduction

The aim of this study was to analyze age-associated myocardial injury and clinical outcome after non-ST-elevation myocardial infarction (NSTEMI).

Methods

This prospective, multicenter study consists of 440 patients with NSTEMI enrolled at 7 centers. All patients were treated with primary percutaneous coronary intervention and underwent cardiac magnetic resonance (CMR) imaging 1-10 days after study inclusion. CMR parameters of myocardial injury and clinical outcome were evaluated by creating 2 subgroups: <80 years vs. ≥80 years. The clinical endpoint was the 1-year incidence of major adverse cardiac events (MACE) consisting of death, re-infarction and new congestive heart failure.

Results

Elderly patients ≥80 years accounted for 13.9% of the study population and showed a divergent cardiovascular risk profile compared to the subgroup of patients <80 years. CMR imaging did not reveal significant differences regarding infarct size, microvascular obstruction, left ventricular ejection fraction or multidimensional strain analysis between the study groups. At 1-year follow-up, MACE rate was significantly increased in patients ≥80 years compared to patients aged <80 years (19.7% vs. 9.6%; p = 0.019). In a multiple stepwise logistic regression model, the number of diseased vessels, aldosterone antagonist use and left ventricular global longitudinal strain were identified as independent predictors for MACE in all patients, while there was no independent predictive value of age regarding 1-year clinical outcome.

Conclusion

This prospective, multicenter analysis shows that structural and functional myocardial damage is similar in younger and older patients with NSTEMI. Furthermore, in this heterogeneous but also clinically representative cohort with reduced sample size, age was not independently associated with 1-year clinical outcome, despite an increased event rate in patients ≥80 years.

Activation of Cardiac δ2-Opioid Receptors Increases Heart Tolerance to Reperfusion

Coronary occlusion (45 min) and reperfusion (120 min) in male Wistar rats in vivo, as well as total ischemia (45 min) of an isolated rat heart followed by reperfusion (30 min) were reproduced. The selective δ2-opioid receptor agonist deltorphin II (0.12 mg/kg and 152 nmol/liter) was administered intravenously 5 min before reperfusion in vivo or added to the perfusion solution at the beginning of reperfusion of the isolated heart. The peripheral opioid receptor antagonist naloxone methiodide and δ2-opioid receptor antagonist naltriben were used in doses of 5 and 0.3 mg/kg, respectively. It was found that the infarct-limiting effect of deltorphin II is associated with the activation of δ2-opioid receptors. We have demonstrated that deltorphin II can improve the recovery of the contractility of the isolated heart after total ischemia.

The impact of chronic total occlusion in non-infarct related arteries on patient outcomes following percutaneous coronary intervention for STEMI superimposed with cardiogenic shock: A pilot systematic review and meta-analysis

INTRODUCTION

Chronic total occlusion (CTO) is defined as a near-total blockage of a coronary artery and often occurs in arteries that are not directly responsible for the event, known as non-infarct-related arteries (NIRA). Cardiogenic shock (CS) is a complication of ST-elevated myocardial infarction (STEMI) that carries significant mortality. We performed a meta-analysis to find an association between mortality in patients undergoing PCI for STEMI that have superimposed CS, with the presence of CTO in the NIRA.

MATERIALS AND METHODOLOGY

A comprehensive literature search was conducted using PubMed, EMBASE, Google Scholar and clinicaltrials.gov from inception till October 2023 to retrieve studies that compare the presence of CTO with the absence of CTO in NIRA in STEMI with CS patients undergoing PCI. The primary endpoint was 30-day mortality and the secondary endpoints were risk of all-cause mortality (ACM) and repeat myocardial infarction (MI). Forest plots were generated using the random effects model by pooling odds ratios (ORs) with a 95 % confidence interval. Statistical significance was set at p < 0.05.

RESULTS

5 observational studies with a total of 5186 patients (1031 with CTO in NIRA and 4155 with no CTO in NIRA) were included. The presence of CTO in NIRA was associated with higher odds of 30-day mortality [OR: 3.10; 95 % CI: 1.52, 6.32; p < 0.002], and ACM [OR: 2.37; 95 % CI: 1.83, 3.08; p < 0.00001]. The odds of repeat MI were comparable between the two groups [OR: 1.61, 95 % CI: 0.03, 74.36, p = 0.81].

CONCLUSIONS

The presence of CTO in the NIRA serves as an independent indicator of unfavorable clinical outcomes including increased risk of 30-day mortality and all-cause mortality. The risk of repeat MI was comparable between the two groups. Large-scale, multicenter trials are warranted to identify the most effective management approach for these patients.

Intra-aortic balloon pump versus percutaneous Impella© in emergency revascularisation for myocardial infarction and cardiogenic shock: systematic review

OBJECTIVES

Mortality rates in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) remain persistently high despite advances over the past decade in percutaneous mechanical circulatory support. This systematic review aims to analyse the existing literature to compare mortality outcomes in patients mechanically supported by intra-aortic balloon pump or percutaneous Impella 2.5/CP© for AMI-CS undergoing emergency revascularisation.

METHODS

The following MeSH terms were applied to the databases Ovid Medline, Ovid Embase, Cochrane and Web of Science: 'Intra-aortic balloon pump', 'Impella', 'Cardiogenic shock', 'Myocardial Infarction' and 'Mortality'. This yielded 2643 studies. Using predefined inclusion and exclusion criteria, the studies were initially screened by title and abstract before full text analysis.

RESULTS

Fourteen studies met eligibility criteria: two randomised controlled trials (RCTs) and 12 observational studies. Data from a total of 21,006 patients were included across the studies. Notably, one study claimed reduced mortality with IABP versus control, and one study concluded that Impella© improved survival rates over the IABP. The average 30-day all-cause mortality in patients supported by IABP was 38.1%, 54.3% in Impella© groups and 39.4% in control groups.

CONCLUSION

AMI-CS presents an important cohort of patients in whom conducting RCTs is difficult. As a result, the literature is limited. Analysis of the available literature suggests that there is insufficient evidence to support superior survival in those supported by IABP or Impella© when compared to control despite suggestions that the Impella© offers superior haemodynamic support. Limitations of the studies have been discussed to outline suggestions for future research.

ST Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Systematic Review of Survival Predictors

Background

Cardiogenic shock complicating acute myocardial infarction is associated with reduced survival despite advancements in the treatment of acute coronary syndromes. Characterizing predictors of morbidity and mortality in this setting is crucial to improving risk stratification and management. Notwithstanding, the interplay of factors determining survival in this condition remains poorly studied.

Methods

Embase, MEDLINE, and CINAHL databases were searched for original studies evaluating predictors of short-term (30-day or in-hospital) survival in ST elevation myocardial infarction with cardiogenic shock (STEMI-CS). Included studies were analyzed by way of vote counting, identifying variables that predicted mortality or survival.

Results

Twenty-four studies, consisting of 14,735 patients (5649 nonsurvivors and 9086 survivors) were included. All studies were observational by design (17 retrospective and 7 prospective) with clinical and statistical heterogeneity. Unsuccessful revascularization, reduced left ventricular ejection fraction, renal impairment, and other variables were identified as key independent predictors of mortality.

Conclusion

Several key variables have been shown to independently increase mortality in STEMI-CS populations. Future prospective studies examining the prognostic role of multivariate scoring systems incorporating these domains are required.

PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study

BACKGROUND

The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model.

METHODS

A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve.

RESULTS

We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001.

CONCLUSIONS

Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.

The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality.

METHODS

STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE).

RESULTS

Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01).

CONCLUSIONS

CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.

δ-Opioid Receptor as a Molecular Target for Increasing Cardiac Resistance to Reperfusion in Drug Development

An analysis of published data and the results of our own studies reveal that the activation of a peripheral δ₂-opioid receptor (δ₂-OR) increases the cardiac tolerance to reperfusion. It has been found that this δ₂-OR is localized in cardiomyocytes. Endogenous opioids are not involved in the regulation of cardiac resistance to reperfusion. The infarct-limiting effect of the δ₂-OR agonist deltorphin II depends on the activation of several protein kinases, including PKCδ, ERK1/2, PI3K, and PKG. Hypothetical end-effectors of the cardioprotective effect of deltorphin II are the sarcolemmal K_ATP channels and the MPT pore.

Disparities in the management of non-ST-segment elevation myocardial infarction in the United States

Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189-0.279, and ≥ 80: OR 0.265, 95% CI 0.195-0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766-0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809-0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491-0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125-1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016.

Cardiogenic Shock Among Patients with Acute ST-Segment Elevation Myocardial Infarction in a Middle Eastern Country: A Single-Center Experience

Background

Cardiogenic Shock (CS) remains the most common cause of death in hospitalized acute ST-segment elevation myocardial infarction (STEMI) patients. Predictors of outcomes in those patients include clinical, laboratory, radiologic variables, and management strategies. The present study aimed to evaluate the incidence, characteristics, predictors of cardiogenic shock and mortality among acute ST-segment elevation myocardial infarction patients in our center.

Methods

This was a retrospective, single-center study conducted at KAMC, Makkah during 2015-2020. All acute ST-segment elevation myocardial infarction patients during this era were divided into two groups CS group and non-CS group.

Results

In this study total 3074 acute ST-segment elevation myocardial infarction patients of which 132(4.3%) patients had CS. CS group tended to have higher ages than non-CS group. Pilgrims were more complicated by CS than nonpilgrims. Subsequently, CS patients had a highly significant (p < 0.001 for all) increase in the incidence of in-hospital complications including pulmonary oedema, cardiac arrest and ventilation. There was a significant increase in hospital stay length and in-hospital mortality among CS patients. Renal impairment, peak troponin level, haemoglobin drop≥3 gm/dl, and Left ventricular ejection fraction (EF) were significant independent predictors of cardiogenic shock among our patients. However, STEMI type, left main disease, and EF was the independent predictors of CS among our patients with diabetes with EF cut-off value of 35% with a sensitivity of 74.6% and a specificity of 65.3%. Age was the only independent predictor of mortality among CS patients. Though age, female gender, and diabetes were found to be the independent predictors for in-hospital mortality among our patients.

Conclusion

High-income middle eastern countries have comparable outcomes to Europe and USA among patients with acute ST-segment elevation myocardial infarction patients with higher improvement of medical care in the last 2 to 3 decades. Renal impairment, peak troponin, severe bleeding and ejection fraction were significant independent predictors of CS in acute ST-segment elevation myocardial infarction patients. However, STEMI type, left main disease, and ejection fraction were the independent predictors of CS in acute ST-segment elevation myocardial infarction patients with diabetes. Age was the only independent predictor of mortality among CS patients.

Age as a predictor of clinical outcomes and determinant of therapeutic measures for emergency medical services treated cardiogenic shock

BACKGROUND

The impact of age on outcomes in cardiogenic shock (CS) is poorly described in the pre-hospital setting. We assessed the impact of age on outcomes of patients treated by emergency medical services (EMS).

METHODS

This population-based cohort study included consecutive adult patients with CS transported to hospital by EMS. Successfully linked patients were stratified into tertiles by age (18-63, 64-77, and > 77 years). Predictors of 30-day mortality were assessed through regression analyses. The primary outcome was 30-day all-cause mortality.

RESULTS

A total of 3523 patients with CS were successfully linked to state health records. The average age was 68 ± 16 years and 1398 (40%) were female. Older patients were more likely to have comorbidities including pre-existing coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, and cerebrovascular disease. The incidence of CS was significantly greater with increasing age (incidence rate per 100,000 person years 6.47 [95% CI: 6.1-6.8] in age 18-63 years, 34.34 [32.4-36.4] in age 64-77 years, 74.87 [70.6-79.3] in age > 77 years, P < 0.001). There was a step-wise increase in the rate of 30-day mortality with increasing age tertile. After adjustment, compared to the lowest age tertile, patients aged > 77 years had increased risk of 30-day mortality (adjusted hazard ratio = 2.26 [95% CI: 1.96-2.60]). Older patients were less likely to receive inpatient coronary angiography.

CONCLUSION

Older patients with EMS-treated CS have significantly higher rates of short-term mortality. The reduced rates of invasive interventions in older patients underscore the need for further development of systems of care to improve outcomes for this patient group.

Prognostic Factors of In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Among patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS), in-hospital mortality remains high. In the present study, we aimed to identify factors associated with clinical outcomes of acute MI patients with CS in a contemporary setting. A total of 1102 patients with acute MI undergoing primary percutaneous coronary intervention were included, among whom 196 (17.8%) were complicated by CS. The primary outcome was all-cause death during hospitalization, and factors associated with in-hospital mortality were explored in patients with acute MI and CS. Of the 196 patients with acute MI complicated by CS, 77 (39.3%) died during hospitalization. The rates of non-ST-segment elevation MI (NSTEMI) (33.8% vs. 19.3%, p = 0.02) and culprit lesion in the left main or left anterior descending coronary artery (68.8% vs. 47.9%, p = 0.004) were higher, while left ventricular ejection fraction (LVEF) was lower (24.4 ± 11.7% vs. 39.7 ± 13.8%, p < 0.001) in non-survivors than in survivors. Multivariable analysis identified NSTEMI presentation and lower LVEF as independent predictors of in-hospital death. In conclusion, NSTEMI and low LVEF were identified as factors associated with higher in-hospital mortality. The identification of even higher-risk subsets and targeted therapeutic strategies may be warranted to improve survival of patients with acute MI and CS.

LINC00452 overexpression reverses oxLDL-induced injury of human umbilical vein endothelial cells (HUVECs) via regulating miR-194-5p/IGF1R axis

It has been reported that atherosclerosis (AS) is the basis of the development of coronary artery disease (CAD). In addition, a previous study demonstrated that long non-coding RNA LINC00452 was notably downregulated in the whole blood of patients with CAD. However, the role of LINC00452 in the progression of AS remains unclear. Therefore, to mimic AS in vitro, HUVECs were treated with 100 μg/ml oxLDL for 24 h. Reverse transcription-quantitative PCR was performed to detect the expression levels of LINC00452 and IGF1R in HUVECs. Additionally, the cell angiogenetic ability was assessed by tube formation assay, while dual-luciferase reporter assay was carried out to explore the association among LINC00452, miR-194-5p, and IGF1R. The results showed that LINC00452 was downregulated in oxLDL-treated HUVECs. In addition, HUVEC treatment with oxLDL significantly inhibited cell viability, proliferation, and angiogenesis. However, the above effects were all reversed by LINC00452 overexpression. Furthermore, LINC00452 overexpression in HUVECs remarkably inhibited oxLDL-induced cell apoptosis and endothelial to mesenchymal transition. In addition, LINC00452 overexpression could markedly reverse oxLDL-induced inhibition of angiogenesis in HUVEC. The results of dual-luciferase reporter assay indicated that LINC00452 could bind with miR-194-5p. In addition, IGF1R was identified as a downstream target of miR-194-5p. And LINC00452 was able to regulate the miR-194-5p/IGF1R axis in HUVECs. Moreover, LINC00452 overexpression obviously reversed oxLDL-mediated growth inhibition of HUVEC via regulating the miR-194-5p/IGF1R axis. Overall, the current study demonstrated that LINC00452 overexpression reversed oxLDL-induced growth inhibition of HUVECs via regulating the miR-194-5p/IGF1R axis, thus providing a potential beneficial targets for AS.

Early Prediction of Cardiogenic Shock Using Machine Learning

Cardiogenic shock (CS) is a severe condition with in-hospital mortality of up to 50%. Patients who develop CS may have previous cardiac history, but that may not always be the case, adding to the challenges in optimally identifying and managing these patients. Patients may present to a medical facility with CS or develop CS while in the emergency department (ED), in a general inpatient ward (WARD) or in the critical care unit (CC). While different clinical pathways for management exist once CS is recognized, there are challenges in identifying the patients in a timely manner, in all settings, in a timeframe that will allow proper management. We therefore developed and evaluated retrospectively a machine learning model based on the XGBoost (XGB) algorithm which runs automatically on patient data from the electronic health record (EHR). The algorithm was trained on 8 years of de-identified data (from 2010 to 2017) collected from a large regional healthcare system. The input variables include demographics, vital signs, laboratory values, some orders, and specific pre-existing diagnoses. The model was designed to make predictions 2 h prior to the need of first CS intervention (inotrope, vasopressor, or mechanical circulatory support). The algorithm achieves an overall area under curve (AUC) of 0.87 (0.81 in CC, 0.84 in ED, 0.97 in WARD), which is considered useful for clinical use. The algorithm can be refined based on specific elements defining patient subpopulations, for example presence of acute myocardial infarction (AMI) or congestive heart failure (CHF), further increasing its precision when a patient has these conditions. The top-contributing risk factors learned by the model are consistent with existing clinical findings. Our conclusion is that a useful machine learning model can be used to predict the development of CS. This manuscript describes the main steps of the development process and our results.

Laboratory Predictors of Prognosis in Cardiogenic Shock Complicating Acute Myocardial Infarction

Cardiogenic shock is a state of reduced cardiac output leading to hypotension, pulmonary congestion, and hypoperfusion of tissues and vital organs. Despite the advances in intensive care over the last years, the morbidity and mortality of patients remain high. The available studies of patients with cardiogenic shock suggest a connection between clinical variables, the level of biomarkers, the results of imaging investigations, strategies of management and the outcome of this group of patients. The management of patients with cardiogenic shock initially complicating acute myocardial infarction is challenging, and the number of studies in this area is growing fast. The purpose of this review is to summarize the currently available evidence on cardiogenic shock initially complicating acute myocardial infarction with particular attention to predictors of prognosis, focusing on laboratory variables (established and new), and to discuss the practical implementation. Currently available scoring systems developed during the past few decades predict the clinical outcome of this group of patients using some of the established biomarkers among other variables. With the new laboratory biomarkers that have shown their predictive value in cardiogenic shock outcomes, a new design of scoring systems would be of interest. Identifying high-risk patients offers the opportunity for early decision-making.

Association between admission ECG changes and long-term mortality in patients with an incidental myocardial infarction: Results from the KORA myocardial infarction registry

BACKGROUND

The aim of this study was to examine the predictive value of specific changes in admission ECG on long-term outcome in acute myocardial infarction (AMI).

METHODS

From 2000 until 2017 all AMI cases (n = 9,689) in the study area of Augsburg, Germany, were prospectively recorded. For this study, all patients with a first-time AMI, who survived the first 28 days, were considered. Median observational time was 6.7 years (IQR: 3.6-10.9). Each case was assigned to one of the following groups according to the admission ECG: 'ST-segment elevation', 'ST-segment depression', 'T-wave inversion', 'unspecific changes', 'normal ECG' and 'bundle branch block' (BBB). Multivariable adjusted COX regression models were calculated to compare long-term all-cause mortality.

RESULTS

The final regression model revealed a significantly higher mortality among patients with BBB (HR: 1.52 [1.34-1.73], p-value: < 0.001) and 'ST-segment depression' (HR: 1.16 [1.03-1.29], p-value: 0.01252) compared to the STEMI group (reference group). The 'normal ECG' group (HR: 0.76 [0.66-0.87], p-value: < 0.001) on the other hand was associated with significantly lower long-term mortality. The 'T-wave inversion' group (HR: 1.08 [0.96-1.21]) and the 'unspecific changes' group (HR: 1.05 [0.94-1.17]) did not differ significantly from the STEMI group.

CONCLUSION

ST-segment depressions and BBB admission ECGs go along with higher long-term mortality in AMI patients compared to STEMI cases. This should be taken into account by physicians when treating patients with NSTEMIs. Only the complete absence of AMI-related ECG changes predicts a more favorable outcome.

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BACKGROUND

Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.

METHODS

We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.

RESULTS

Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality.

CONCLUSIONS

In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

BACKGROUND

Prior studies have shown worse outcomes in patients with cardiogenic shock (CS) who have reduced left ventricular ejection fraction (LVEF), but the association between other transthoracic echocardiogram (TTE) findings and mortality in CS patients remains uncertain. We hypothesized that Doppler TTE measurements would outperform LVEF for risk stratification.

METHODS

Retrospective analysis of cardiac intensive care unit patients with an admission diagnosis of CS and a TTE within 1 day of admission. Hospital survivors and inpatient deaths were compared, and multivariable logistic regression was used to analyze the associations between TTE variables and hospital mortality.

RESULTS

We included 1,085 patients, with a median age of 69.5 (59.6, 77.5) years; 37% were females and 62% had an acute coronary syndrome. Most patients (66%) had moderate or severe left ventricular (LV) systolic dysfunction, and 48% had moderate or severe right ventricular (RV) systolic dysfunction. Hospital mortality occurred in 31%, and inpatient deaths had a lower median LVEF (29% vs. 35%, P < 0.001). Patients with mild or no LV or RV dysfunction were at lower risk of adjusted hospital mortality (P < 0.01). The LV outflow tract (LVOT) velocity-time integral (VTI) was the single best predictor of hospital mortality. After multivariable adjustment, both the LVEF and LVOT VTI remained strongly associated with hospital mortality (P < 0.001).

CONCLUSIONS

Early comprehensive Doppler TTE can provide important prognostic insights in CS patients, highlighting its potential utility in clinical practice. The LVOT VTI, reflecting forward flow, is an important measurement to obtain on bedside TTE.

Blood Urea Nitrogen for Short-Term Prognosis in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction

PURPOSE

Cardiogenic shock (CS) is the leading cause of death in patients with acute myocardial infarction (AMI). Our study aimed to evaluate the short-term prognostic value of admission blood urea nitrogen (BUN) in patients with CS complicating AMI.

MATERIALS AND METHODS

218 consecutive patients with CS after AMI were enrolled. The primary endpoint was 30-day mortality. The association of admission BUN and 30-day mortality and major adverse cardiovascular event (MACE) was investigated by Cox regression. The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) further examined the predictive value of BUN.

RESULTS

During a period of 30-day follow-up, 105 deaths occurred. Compared to survivors, nonsurvivors had significantly higher admission BUN (p < 0.001), creatinine (p < 0.001), BUN/creatinine (p = 0.03), and a lower glomerular filtration rate (p < 0.001). The area under the curve (AUC) of the 4 indices for predicting 30-day mortality was 0.781, 0.734, 0.588, and 0.773, respectively. When compared to traditional markers associated with CS, the AUC for predicting 30-day mortality of BUN, lactate, and left ventricular ejection fraction were 0.781, 0.776, and 0.701, respectively. The optimal cut-off value of BUN for predicting 30-day mortality was 8.95 mmol/L with Youden-Index analysis. Multivariate Cox analysis indicated BUN >8.95 mmol/L was an important independent predictor for 30-day mortality (HR 2.08, 95%CI 1.28-3.36, p = 0.003) and 30-day MACE (HR 1.85, 95%CI 1.29-2.66, p = 0.001). IDI (0.053, p = 0.005) and NRI (0.135, p = 0.010) showed an improvement in the accuracy for mortality prediction of the new model when BUN was included compared with the standard model of predictors in previous scores.

CONCLUSION

An admission BUN >8.95 mmol/L was robustly associated with increased short-term mortality and MACE in patients with CS after AMI. The prognostic value of BUN was superior to other renal markers and comparable to traditional markers. This easily accessible index might be promising for early risk stratification in CS patients following AMI.

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research

Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.

Risk Prediction in Cardiogenic Shock: Current State of Knowledge, Challenges and Opportunities

Cardiogenic shock (CS) is a condition associated with high mortality rates in which prognostication is uncertain for a variety of reasons, including its myriad causes, its rapidly evolving clinical course and the plethora of established and emerging therapies for the condition. A number of validated risk scores are available for CS prognostication; however, many of these are tedious to use, are designed for application in a variety of populations and fail to incorporate contemporary hemodynamic parameters and contemporary mechanical circulatory support interventions that can affect outcomes. It is important to separate patients with CS who may recover with conservative pharmacological therapies from those in who may require advanced therapies to survive; it is equally important to identify quickly those who will succumb despite any therapy. An ideal risk-prediction model would balance incorporation of key hemodynamic parameters while still allowing dynamic use in multiple scenarios, from aiding with early decision making to device weaning. Herein, we discuss currently available CS risk scores, perform a detailed analysis of the variables in each of these scores that are most predictive of CS outcomes and explore a framework for the development of novel risk scores that consider emerging therapies and paradigms for this challenging clinical entity.

Biventricular Function and Shock Severity Predict Mortality in Cardiac ICU Patients

BACKGROUND

Ventricular function, including left ventricular systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and biventricular dysfunction (BVD), contribute to shock in cardiac ICU (CICU) patients, but the prognostic usefulness remains unclear.

RESEARCH QUESTION

Do patients with ventricular dysfunction have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage?

STUDY DESIGN AND METHODS

We identified patients in the CICU admitted with available echocardiography data. LVSD was defined as left ventricular ejection fraction < 40%, RVSD as moderate or greater systolic dysfunction by semiquantitative measurement, and BVD as the presence of both. Multivariate logistic regression determined the relationship between ventricular dysfunction and adjusted in-hospital mortality as a function of SCAI stage.

RESULTS

The study population included 3,158 patients with a mean ± SD age of 68.2 ± 14.6 years, of which 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and BVD in 16.4%. After adjustment for SCAI shock stage, no difference in in-hospital mortality was found between patients with LVSD or RVSD and those without ventricular dysfunction (P > .05), but BVD was associated independently with higher in-hospital mortality (adjusted hazard ratio, 1.815; 95% CI, 1.237-2.663; P = .0023). The addition of ventricular dysfunction to the SCAI staging criteria increased discrimination for hospital mortality (area under the receiver operating characteristic curve, 0.784 vs 0.766; P < .001).

INTERPRETATION

Among patients admitted to the CICU, only BVD was associated independently with higher hospital mortality. The addition of echocardiography assessment to the SCAI shock criteria may facilitate improved clinical risk stratification.

Impact of COVID-19 Pandemic on Presentation and Outcome of Consecutive Patients Admitted to Hospital Due to ST-Elevation Myocardial Infarction

Impact of COVID-19 pandemic and pandemic-related social restrictions on clinical course of patients treated for acute ST-elevation myocardial infarction (STEMI) is unclear. In the present study presentation and outcome of patients with STEMI in the year 2020 were compared with the years before in a German registry that includes all patients hospitalized for acute STEMI in a region with approximately 1 million inhabitants. In the year 2020 726 patients with STEMI were registered compared with 10.226 patients in the years 2006 to 2019 (730 ± 57 patients per year). No significant differences were observed between the groups regarding age, gender and medical history of patients. However, in the year 2020 a significantly higher rate of patients admitted with cardiogenic shock (21.9% vs 14.2%, p <0.01) and out-of-hospital cardiac arrest (OHCA) (14.3% vs 11.1%, p <0.01) was observed. The rate of patients with subacute myocardial infarction (14.3% vs 11.6%, p <0.05) was elevated in 2020. Hospital mortality increased by 52% from the years 2006 to 2019 (8.4%) to the year 2020 (12.8%, p <0.01). Only 4 patients (0.6%) with STEMI in the year 2020 had SARS-CoV-2 infection, none of those died in-hospital. In conclusion, in the year 2020 a highly significant increase of STEMI-patients admitted to hospital with advanced infarction and poor prognosis was observed. As the structure of the emergency network to treat patients with STEMI was unchanged during the study period, the most obvious reason for these changes was COVID-19 pandemic-related lockdown and the fear of many people to contact medical staff during the pandemic.

Cardiogenic Shock Complicating Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention Supported by Impella: Implications of Advanced Age and Refractory Shock on Outcomes

Supplemental Digital Content is available in the text.

OBJECTIVES:

With percutaneous left ventricular mechanical circulatory support devices becoming increasingly available for patients with cardiogenic shock due to acute myocardial infarction and the lack of a clear mortality benefit to date, identifying optimal candidates for this technology is crucial. We studied the effectiveness of Impella Cardiac Pow (Abiomed, Danvers, MA) in various stages of cardiogenic shock and elderly cohorts.

DESIGN:

Retrospective review.

SETTING:

Data were collected for patients at a single community hospital between January 1, 2018, and December 31, 2019.

SUBJECTS:

Thirty-one consecutive adult patients with cardiogenic shock due to acute myocardial infarction who received Impella Cardiac Pow support. Shock stages were defined by the Society for Cardiovascular Angiography and Intervention (Stages A–E).

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was in-hospital death across Society for Cardiovascular Angiography and Intervention cardiogenic shock stages and in patients greater than or equal to 80 and less than 80 years old. Secondary outcomes were Valve Academic Research Consortium-2 vascular and bleeding complications, stroke, and renal failure requiring dialysis. The median age of the study population was 64 years, with seven patients (23%) being greater than or equal to 80 years old. No patients were in Society for Cardiovascular Angiography and Intervention Stage A, whereas there were seven in B, eight in C, six in D, and 10 (32%) in E. Overall in-hospital mortality occurred in 61% of patients. All 10 patients in Stage E died before hospital discharge. Mortality occurred in 54% of patients (13/24) age less than 80 years compared with 86% of those 80 years or older (6/7). A total of 38.7% of patients (12/31) and 32.3% of patients (10/31) experienced Valve Academic Research Consortium-2 bleeding and vascular events, which were evenly distributed across Society for Cardiovascular Angiography and Intervention cardiogenic shock Stages.

CONCLUSIONS:

In conclusion, patients with shock in extremis and those 80 years old and older may have a prohibitively high mortality despite Impella use. These findings merit further prospective investigation in a larger number of patients to evaluate the effectiveness of Impella (and other left ventricular mechanical circulatory devices) and the inherent resource utilization in advanced cardiogenic shock and the elderly.

Long-Term Clinical Impact of Cardiogenic Shock and Heart Failure on Admission for Acute Myocardial Infarction

Long-term clinical outcomes among patients with cardiogenic shock (CS) and heart failure (HF) who survive the early phase of acute myocardial infarction (AMI) remain uncertain. We investigated 3283 consecutive patients with AMI, selected from a prospective, nation-wide multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014. The 3263 eligible patients were divided into the following three groups: CS-/HF- group (n = 2467, 75.6%); CS-/HF+ group (n = 479, 14.7%); and CS+ group (n = 317, 9.7%). The thirty-day mortality rate in CS+ patients was 32.8%, significantly higher than in CS- patients. Among CS+ patients, multivariate logistic regression analysis identified statin use before admission (Odds ratio (OR) 0.32, 95% confidence interval (CI) 0.14-0.66, P = 0.002), renal deficiency (OR 8.72, 95%CI 2.81-38.67, P < 0.0001) and final thrombolysis in myocardial infarction flow grade (OR 0.42, 95%CI 0.18-0.99, P = 0.046) were associated with 30-day mortality. Landmark Kaplan-Meier analysis showed that mortality rates after 30 days were comparable between CS+ and CS-/HF+ groups but were lower in the CS-/HF- group. Multivariate Cox hazard analysis also showed that hazard risk of mortality after 30 days was comparable between the CS+ and CS-/HF+ groups (Hazard ratio (HR) 1.03, 95%CI 0.63-1.68, P = 0.90), and significantly lower in the CS-/HF- group (HR 0.44, 95%CI 0.32-059, P < 0.0001). In conclusion, AMI patients with CS who survived 30 days experienced worse long-term outcomes compared with those without CS up to 3 years. Attention is required for patients who show HF on admission without CS to improve long-term AMI outcomes.

Predictive Value of Sirtuins in Acute Myocardial Infarction - Bridging the Bench to the Clinical Practice

Acute myocardial infarction (AMI) is a non-transmissible condition with high prevalence, morbidity, and mortality. Different strategies for the management of AMI are employed worldwide, but its early diagnosis remains a major challenge. Many molecules have been proposed in recent years as predictive agents in the early detection of AMI, including troponin (C, T, and I), creatine kinase MB isoenzyme, myoglobin, heart-type fatty acid-binding protein, and a family of histone deacetylases with enzymatic activities named sirtuins. Sirtuins may be used as predictive or complementary treatment strategies and the results of recent preclinical studies are promising. However, human clinical trials and data are scarce, and many issues have been raised regarding the predictive values of sirtuins. The present review summarizes research on the predictive value of sirtuins in AMI. We also briefly summarize relevant clinical trials and discuss future perspectives and possible clinical applications.

SCD leads to the development and progression of acute myocardial infarction through the AMPK signaling pathway

Background

Acute myocardial infarction (AMI) is myocardial necrosis caused by acute coronary ischemia and hypoxia. It can be complicated by arrhythmia, shock, heart failure and other symptoms that can be life-threatening. A multi-regulator driven dysfunction module for AMI was constructed. It is intended to explore the pathogenesis and functional pathways regulation of acute myocardial infarction.

Methods

Combining differential expression analysis, co-expression analysis, and the functional enrichment analysis, a set of expression disorder modules related to AMI was obtained. Hypergeometric test was performed to calculate the potential regulatory effects of multiple factors on the module, identifying a range of non-coding RNA and transcription factors.

Results

A total of 4551 differentially expressed genes for AMI and seven co-expression modules were obtained. These modules are primarily involved in the metabolic processes of prostaglandin transport processes, regulating DNA recombination and AMPK signal transduction. Based on this set of functional modules, 3 of 24 transcription factors (TFs) including NFKB1, MECP2 and SIRT1, and 3 of 782 non-coding RNA including miR-519D-3P, TUG1 and miR-93-5p were obtained. These core regulators are thought to be involved in the progression of AMI disease. Through the AMPK signal transduction, the critical gene stearoyl-CoA desaturase (SCD) can lead to the occurrence and development of AMI.

Conclusions

In this study, a dysfunction module was used to explore the pathogenesis of multifactorial mediated AMI and provided new methods and ideas for subsequent research. It helps researchers to have a deeper understanding of its potential pathogenesis. The conclusion provides a theoretical basis for biologists to design further experiments related to AMI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02011-8.

Admission ECG changes predict short term-mortality after acute myocardial infarction less reliable in patients with diabetes

Prior studies examined association between short-term mortality and certain changes in the admission ECG in acute myocardial infarction (AMI). Nevertheless, little is known about possible differences between patients with diabetes and without diabetes in this regard. So the aim of the study was to investigate the association between 28-day case fatality according to certain ECG changes comparing AMI cases with and without diabetes from the general population. From 2000 until 2017 a total of 9756 AMI cases was prospectively recorded in the study Area of Augsburg, Germany. Each case was assigned to one of the following groups according to admission ECG: ‘ST-elevation’, ‘ST-depression’, ‘only T-negativity’, ‘predominantly bundle branch block’, ‘unspecific changes’ and ‘normal ECG’ (the last two were put together for regression analyses). Multivariable adjusted logistic regression models were calculated to compare 28-day case-fatality between the ECG groups for the total sample and separately for diabetes and non-diabetes cases. For the non-diabetes group, the parsimonious logistic regression model revealed significantly better 28-day-outcome for the ‘normal ECG / unspecific changes’ group (OR: 0.47 [0.29–0.76]) compared to the reference group (STEMI). Contrary, in AMI cases with diabetes the category ‘normal ECG / unspecific changes’ was not significantly associated with lower short-term mortality (OR: 0.87 [0.49–1.54]). Neither of the other ECG groups was significantly associated with 28-day-mortality in the parsimonious logistic regression models. Consequently, the absence of AMI-typical changes in the admission ECG predicts favorable short-term mortality only in non-diabetic cases, but not so in patients with diabetes.

Prognostic role of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock

OBJECTIVE

Cardiogenic shock accounts for the majority of deaths amongst patients with ST-elevation myocardial infarction. Procalcitonin is elevated in acute myocardial infarction, especially when complicated by left heart failure, cardiogenic shock, resuscitated cardiac arrest, and bacterial infections. However, the prognostic utility of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock has not been systematically evaluated.

METHODS

We performed a retrospective registry review of 125 patients with ST-elevation myocardial infarction and cardiogenic shock over 2 years at a tertiary referral hospital to examine the prognostic value of serum procalcitonin measurement at 24 hours after the onset of infarction for in-hospital mortality.

RESULTS

The mean age of the study population was 57.75 ± 11.1 years, and the median delay from onset to hospital admission was 15 hours. The in-hospital mortality was 28.8%. Receiver operating characteristic analysis revealed a strong relationship between elevated procalcitonin and in-hospital mortality (area under the curve = 0.676; p = 0.002). Although procalcitonin was found to be higher in non-survivors in univariate analysis, it was not an independent predictor of mortality in multivariate regression analysis. Acute kidney injury, left ventricular ejection fraction, and non-revascularization were independently associated with mortality after adjusting for covariates.

CONCLUSION

Although procalcitonin was higher in non-survivors, static procalcitonin measurement at 24 hours after the onset of ST-elevation myocardial infarction complicated by cardiogenic shock was not an independent predictor of in-hospital mortality. Additional prospective studies are required to assess the role of serial procalcitonin monitoring in ST-elevation myocardial infarction complicated by cardiogenic shock.

Validity of TIMI Score for Predicting 14-Day Mortality of Non-ST Elevation Myocardial Infarction Patients

Background

Accurate management of non-ST elevation myocardial infarction (NSTEMI) patients can be achieved by stratifying risks as early as possible on hospital admission. Previously, the Thrombolysis in Myocardial Infarction (TIMI) risk score has been validated and used on patients presenting with NSTEMI or unstable angina (UA) in developed countries. The aim of this study was to assess the validity of the TIMI risk score in patients presenting with NSTEMI in Pakistan.

Methods

This cross-sectional study was undertaken on 300 patients who were diagnosed with NSTEMI. Data were collected from medical records, the TIMI score was calculated, and 14-day outcome was recorded. The receiver operating characteristic (ROC) curve analysis was performed, and area under the curve (AUC) along with 95% confidence interval (CI) was reported. Univariate and multivariate logistic regression analysis was performed and odds ratio (OR) along with 95% CI was reported.

Results

This cross-sectional study was undertaken on 300 patients who were diagnosed with NSTEMI. Data were collected from medical records, the TIMI score was calculated, and 14-day outcome was recorded. Validity of TIMI score in predicting hospital mortality 14 days after the diagnosis of NSTEMI in a population in Pakistan was assessed by ROC curve and logistic regression analysis. The AUC of the TIMI score for predicting 14-day outcome was 0.788 [95% CI: 0.689-0.887], with optimal cutoff of ≥4 with sensitivity of 77.78%. On multivariate analysis, cardiac arrest at presentation and the TIMI risk score were found to be independent predictors of 14-day mortality with adjusted ORs of 136.49 [10.23-1821.27] and 2.67 [1.09-6.57], respectively.

Conclusions

The TIMI risk score is a useful and simple score for the stratification of patients with high risk of 14-day mortality with reasonably acceptable discriminating ability in patients with NSTEMI acute coronary syndrome.

Influence of age and shock severity on short-term survival in patients with cardiogenic shock

AIMS

Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS.

METHODS AND RESULTS

Patients with a diagnosis of CS from Mayo Clinic (2007-15) and University Clinic Hamburg (2009-17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years.

CONCLUSION

Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.

Risk Assessment of Patients After ST-Segment Elevation Myocardial Infarction by Killip Classification: An Institutional Experience

Introduction The Killip classification system was introduced for clinical assessment of patients with acute myocardial infarction (MI). It stratifies individuals according to the severity of their post-MI heart failure. This system provides effective stratification of long-term and short-term outcomes in patients with acute MI and influences the treatment strategies. Revalidation of Killip class in our local population is mandatory. We planned this study to increase cardiologist's readiness to tackle the risks associated with increased mortality in each class post ST-segment elevation MI (STEMI). Objectives were to determine the frequency of Killip classes I, II, III, and IV and in-hospital mortality in each Killip class in patients with left ventricular failure secondary to STEMI. Methods A retrospective cross-sectional study was conducted in the Department of Cardiology, Jinnah Hospital, Lahore, over a period of three years. Patients with STEMI were stratified using Killip classification, and validation was performed by determining the within 15 days in-hospital mortality in each Killip class. Results The frequency (percentage) of patients with STEMI in each Killip class from I to IV was 395 (81.4%), 46 (9.5%), 27 (5.6%), and 17 (3.5%), respectively, while the in-hospital mortality in each Killip class came out to be 39 (9.9%), 4 (8.7%), 25 (92.6%) and 17 (100%), respectively. The presence of diabetes, history of smoking, and body mass index (BMI) of more than 30 kg/m2 were significant contributors to mortality, along with higher Killip class and age of presentation. Conclusions It is concluded that the Killip classification system is a valid tool for risk stratification for patients after STEMI, especially in resource-limited countries.

Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: A Post Hoc Analysis of a Randomized Clinical Trial

Importance

Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes.

Objective

To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock.

Design, Setting, and Participants

Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017.

Interventions

Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group.

Main Outcomes and Measures

End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year.

Results

The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02).

Conclusions and Relevance

In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding.

Trial Registration

ClinicalTrials.gov Identifier: NCT01927549.

Noninvasive Echocardiographic Left Ventricular Stroke Work Index Predicts Mortality in Cardiac Intensive Care Unit Patients

BACKGROUND

Reduced left ventricular stroke work index (LVSWI) has been associated with adverse outcomes in several populations of patients with chronic heart disease, but no prior studies have examined this metric in cardiac intensive care unit (CICU) patients. We sought to determine whether a low LVSWI, as measured noninvasively using transthoracic echocardiography, is associated with higher mortality in CICU patients.

METHODS

Using a database of unique Mayo Clinic CICU admissions from 2007 to 2018, we identified patients with LVSWI measured by transthoracic echocardiography within 1 day of CICU admission. Hospital mortality was analyzed using multivariable logistic regression, and 1-year mortality was analyzed using multivariable Cox proportional-hazards analysis, adjusted for left ventricular ejection fraction and known predictors of hospital mortality.

RESULTS

We included 4536 patients with a mean age of 68±14 years (36% women). Admission diagnoses (not mutually exclusive) included acute coronary syndrome in 62%, heart failure in 46%, and cardiogenic shock in 11%. The mean LVSWI was 38±14 g×min/m², and in-hospital mortality occurred in 6% of patients. LVSWI had better discrimination for hospital mortality than left ventricular ejection fraction (P<0.001 by De Long test). Higher LVSWI was associated with lower in-hospital mortality (adjusted odds ratio, 0.72 per 10 g×min/m² higher [95% CI, 0.61-0.84]; P<0.001) and lower 1-year mortality (adjusted hazard ratio, 0.812 per 1 g×min/m² higher [95% CI, 0.759-0.868]; P<0.001). Stepwise decreases in hospital and 1-year mortality were observed with higher LVSWI.

CONCLUSIONS

Low LVSWI, reflecting poor left ventricular systolic and diastolic performance, is associated with increased short-term and long-term mortality among CICU patients. This emphasizes the importance of Doppler transthoracic echocardiography as a predictor of outcomes among critically ill patients. Further study is required to determine whether early interventions to optimize LVSWI can improve outcomes in the CICU setting.

Comparison of mechanical circulatory support with venoarterial extracorporeal membrane oxygenation or Impella for patients with cardiogenic shock: a propensity-matched analysis

BACKGROUND

Percutaneous mechanical circulatory devices are increasingly used in patients with cardiogenic shock (CS). As evidence from randomized studies comparing these devices are lacking, optimal choice of the device type is unclear. Here we aim to compare outcomes of patients with CS supported with either Impella or vaECMO.

METHODS

Retrospective single-center analysis of patients with CS, from September 2014 to September 2019. Patients were assisted with either Impella 2.5/CP or vaECMO. Patients supported ultimately with both devices were analyzed according to the first device implanted. Primary outcomes were hospital and 6-month survival. Secondary endpoints were complications. Survival outcomes were compared using propensity-matched analysis to account for differences in baseline characteristics between both groups.

RESULTS

A total of 423 patients were included (Impella, n = 300 and vaECMO, n = 123). Survival rates were similar in both groups (hospital survival: Impella 47.7% and vaECMO 37.3%, p = 0.07; 6-month survival Impella 45.7% and vaECMO 35.8%, p = 0.07). There was no significant difference in survival rates, even after adjustment for baseline differences (hospital survival: Impella 50.6% and vaECMO 38.6%, p = 0.16; 6-month survival Impella 45.8% and vaECMO 38.6%, p = 0.43). Access-site bleeding and leg ischemia occurred more frequently in patients with vaECMO (17% versus 7.3%, p = 0.004; 17% versus 7.7%, p = 0.008).

CONCLUSIONS

In this retrospective analysis of patients with CS, treatment with Impella 2.5/CP or vaECMO was associated with similar hospital and 6-month survival rates. Device-related access-site vascular complications occurred more frequently in the vaECMO group. A randomized trial is warranted to examine the effects of these devices on outcomes and to determine the optimal device choice in patients with CS.

Inotropic Agents and Vasopressors in the Treatment of Cardiogenic Shock

BACKGROUND

Worldwide, cardiogenic shock (CS) is the leading cause of death in patients admitted with an acute myocardial infarction (AMI). CS is characterised by reduced cardiac output secondary to systolic dysfunction which can lead to multi-organ failure. The mainstay of medical treatment in CS are inotropes and vasopressors to improve cardiac output. However, current clinical guidelines do not direct clinicians as to which agents to use and in what combinations. This article aims to review the current evidence on the management of CS with a major focus on the use of inotropes and vasopressors.

METHOD

A literature review was conducted analysing published literature from the following databases: PubMed, MedLine, Cochrane Library and Embase, as well as a manual search of articles that were deemed relevant. Relevant articles were identified by using keywords such as "cardiogenic shock".

RESULTS

Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias. Conversely, noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS. Compared to other inotropes, levosimendan appears to have a better safety profile and is associated with decreased mortality in CS, particularly when combined with a vasopressor. Our literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS.

Positive association between systemic immune-inflammatory index and mortality of cardiogenic shock

BACKGROUND

Cardiogenic shock (CGS) is not only a state of hypoperfusion, but also related to inflammation. The prognostic value of systemic immune-inflammatory index (SII), an innovate biomarker of inflammation, in CGS patients has not been assessed. This study aims to explore the associations between SII and mortality in patients with CGS.

METHODS

Data on patients diagnosed with CGS were extracted from MIMIC-III database version 1.4. The follow-up started on the patients' first admission to ICU. The primary outcome was 30-day mortality. 90-day and 365-day mortality were the secondary outcomes. Cox proportional hazards models were used to investigate the associations between SII and mortality of CGS patients.

RESULTS

707 patients with CGS were included in our study (59.8% male, 67.5% the white, 70.27 ± 14.56 years). For 30-day mortality, the HR (95% CI) value of high-SII group was 2.17 (1.60, 2.93) compared with the reference of low-SII group (P < 0.0001). The HR value of mid-SII group, however, showed none statistical significance (HR: 1.03, 95% CI: 0.74-1.43, P = 0.8516). When adjusted for age, gender and ethnicity in Model I, the adjusted HR (95% CI) value of high-SII group was 2.28 (1.69, 3.09). When further adjusted for heart rate, SBP, serum potassium, PTT, INR and ECI in Model II, the adjusted HR value of high-SII group was still statistically significant (HR: 2.08, 95% CI: 1.52-2.86, P < 0.0001). Similar results were also shown in the secondary outcomes of 90-day and 365-day mortality.

CONCLUSIONS

High level of SII is associated with increased short- and long-term mortality of patients with CGS. SII, a readily available biomarker, can independently predict the prognosis of CGS patients.

Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure

AIMS

Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF.

METHODS AND RESULTS

We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007-2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2-1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage.

CONCLUSIONS

Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Noninvasive Hemodynamic Assessment of Shock Severity and Mortality Risk Prediction in the Cardiac Intensive Care Unit

OBJECTIVES

This study sought to define the 2-dimensional and Doppler echocardiographic hemodynamics associated with each Society for Cardiovascular Angiography and Interventions (SCAI) stage, and to determine their association with mortality.

BACKGROUND

The SCAI shock stages classification stratifies mortality risk in cardiac intensive care unit (CICU) patients, but the echocardiographic and hemodynamic parameters that define these SCAI shock stages are unknown.

METHODS

Unique CICU patients admitted from 2007 to 2015 who had a transthoracic echocardiogram within 1 day of CICU admission were included. Echocardiographic variables were evaluated as a function of SCAI shock stage. Multivariable logistic regression determined the association between echocardiographic parameters with adjusted hospital mortality.

RESULTS

We included 5,453 patients with a median age of 69.3 years (interquartile range: 58.2 to 79.0 years) (37% women), and a median left ventricular ejection fraction (LVEF) of 50% (interquartile range: 35% to 61%). Higher SCAI shock stages were associated with lower LVEF and worse systemic hemodynamics. Hospital mortality was higher in patients with LVEF <40%, cardiac index <1.8 l/min/m², stroke volume index <35 ml/m², cardiac power output <0.6 W, or medial early mitral valve inflow velocity to early diastolic annular velocity (E/e') ratio >15 (particularly in SCAI shock Stages A to C). After multivariable adjustment, only stroke volume index <35 ml/m² (adjusted odds ratio: 2.0; 95% confidence interval: 1.4 to 3.0; p < 0.001) and E/e' ratio >15 (adjusted odds ratio: 1.52; 95% confidence interval: 1.04 to 2.23; p = 0.03) remained associated with higher hospital mortality.

CONCLUSIONS

Noninvasive 2-dimensional and Doppler echocardiographic parameters correlate with the SCAI shock stages and improve risk stratification for hospital mortality in CICU patients. Low stroke volume index and high E/e' ratio demonstrated the strongest association with hospital mortality.

Role of N-terminal pro-B-type natriuretic peptide in the prediction of outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock

Although measurements of natriuretic peptides have a role in chronic heart failure and acute coronary syndrome, their role has not been studied in ST-elevation myocardial infarction complicated by cardiogenic shock (CS-STEMI). Sixty-four patients with CS-STEMI were prospectively recruited to assess the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement after 24 h of the onset of angina or anginal equivalent. Patients who died within 24 h were excluded. The mean age was 56.9 ± 10.6 years and the median time to presentation was 22 h (Interquartile range 7–48 h). Thrombolysis was done in 51% and PCI in 31% of cases. The in-hospital mortality was 26.5%. The ROC analysis showed a strong relationship between elevated NT-proBNP and in-hospital mortality (AUC = 0.748; p = 0.003). An NT-proBNP value > 8582 pg/mL showed 76.5% sensitivity, 68% specificity, 46.4% positive predictive value, and 89% negative predictive value for in-hospital mortality. Acute kidney injury [Odds ratio (OR) 7.30; 95% confidence interval (CI) 1.42–37.37] and NT-proBNP (OR 1.12 per 1000 pg/mL; CI 1.012–1.25) were independent predictors of mortality in multivariate regression analysis. Although we found plasma NT-proBNP at 24 h to be an independent predictor of in-hospital mortality in CS-STEMI, additional studies with a larger sample are required to ascertain these findings and validate the appropriate cut-off values.