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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barsness GW, Chaudhry SP, Chonde MD, Cooper HA, Ginder C, Jentzer JC, Kontos MC, Miller PE, Newby LK, O'Brien CG, Park JG, Pierce MJ, Pisani BA, Potter BJ, Shah KS, Teuteberg JJ, Katz JN, van Diepen S, Morrow DA. Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2024; 17:e011736. [PMID: 38587438 DOI: 10.1161/circheartfailure.124.011736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). CONCLUSIONS Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | | | - Meshe D Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (H.A.C.)
| | - Curtis Ginder
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond (M.C.K.)
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (P.E.M.)
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco (C.G.O.B.)
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Matthew J Pierce
- Department of Cardiology, Northwell Health, Zucker School of Medicine, New Hyde Park, NY (M.J.P.)
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (B.A.P.)
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, Quebec, QC, Canada (B.J.P.)
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City (K.S.S.)
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (J.J.T.)
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York (J.N.K.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D.)
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
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Williams S, Kalakoutas A, Olusanya S, Schrage B, Tavazzi G, Carnicelli AP, Montero S, Vandenbriele C, Luk A, Lim HS, Bhagra S, Ott SC, Farrero M, Samsky MD, Kennedy JLW, Sen S, Agrawal R, Rampersad P, Coniglio A, Pappalardo F, Barnett C, Proudfoot AG. The management of heart failure cardiogenic shock: an international RAND appropriateness panel. Crit Care 2024; 28:105. [PMID: 38566212 PMCID: PMC10988801 DOI: 10.1186/s13054-024-04884-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF. METHODS A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1-3 as inappropriate, 4-6 as uncertain and as 7-9 appropriate). RESULTS Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS. CONCLUSION This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines.
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Affiliation(s)
- Stefan Williams
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Antonis Kalakoutas
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Segun Olusanya
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Benedict Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Hoong Sern Lim
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sai Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Sascha C Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | | | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jamie L W Kennedy
- Heart Failure / Transplant Program, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Richa Agrawal
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Amanda Coniglio
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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3
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Kanwar MK, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Baran DA. Heart failure related cardiogenic shock: An ISHLT consensus conference content summary. J Heart Lung Transplant 2024; 43:189-203. [PMID: 38069920 DOI: 10.1016/j.healun.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varinder Randhawa
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Cowger
- Department of Cardiology, Henry Ford Health Heart and Vascular Institute, Detroit, Michigan
| | - Christopher M Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Hoong S Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center, New York, New York
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Maria F Renedo
- Department of Heart Failure and Thoracic Transplantation, Fundacion Favaloro, Buenos Aires, Argentina
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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