The Prognostic Yield of Admission Shock Index in Patients with ST-Segment Elevation Myocardial Infarction: SEMI-CI Study

Background

Early identification of high-risk patients presenting with ST-segment elevation myocardial infarction (STEMI) helps prevent complications. The shock index (SI) is a bedside risk-stratification tool used in emergency departments. In this study, we aimed to assess the SI's predictive value for prognosticating in-hospital and one-year mortality, as well as one-year major cardiovascular events (MACEs). As secondary endpoints, we assessed the age SI's performance and the influence of prehospital transport factors on SI's predictive value.

Methods

This prospective cohort study is named SEMI-CI and enrolled patients with STEMI who were referred to a cardiology hospital in Isfahan. We analyzed data on 867 patients with STEMI. Systolic blood pressure (SBP) and heart rate (HR) upon admission were used to calculate SI. Patients were divided into two groups based on SI, and 277 patients had SI > 0.7.

Results

In-hospital death, one-year mortality, and MACE were more prevalent in those patients presenting with SI ≥ 0.7. However, after multivariate adjustment, SI was an independent predictor of in-hospital mortality and MACE, but it was not associated with one-year mortality. Furthermore, mortality rates increased from lower to higher age groups. Among patients transferred by emergency medical services to our hospital, SI showed prognostic implications for in-hospital mortality but not for one-year mortality.

Conclusions

The current study showed that a positive SI and age SI are valuable risk-stratification tools to identify high-risk patients presenting with STEMI.

Impact of shock index (SI), modified SI, and age-derivative indices on acute heart failure prognosis; A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) is still associated with quite considerable mortality rates and usage of simple tools for prognosis is pivotal. We aimed to evaluate the effect of shock index (SI) and its derivatives (age SI (ASI), modified SI (MSI), and age MSI (AMSI)) on acute HF (AHF) clinical outcomes.

METHODS

PubMed/Medline, Scopus and Web of science databases were screened with no time and language limitations till February 2024. We recruited relevant records assessed SI, ASI, MSI or AMSI with AHF clinical outcomes.

RESULTS

Eight records were selected (age: 69.44±15.05 years). Mean SI in those records reported mortality (either in-hospital or long-term death) was 0.67 (95% confidence interval (CI):0.63-0.72)). In-hospital and follow-up mortality rates in seven(n = 12955) and three(n = 5253) enrolled records were 6.18% and 10.14% with mean SI of 0.68(95%CI:0.63-0.73) and 0.72(95%CI:0.62-0.81), respectively. Deceased versus survived patients had higher SI difference (0.30, 95%CI:0.06-0.53, P = 0.012). Increased SI was associated with higher chances of in-hospital death (odds ratio (OR): 1.93, 95%CI:1.30-2.85, P = 0.001).The optimal SI cut-off point was found to be 0.79 (sensitivity: 57.6%, specificity: 62.1%). In-hospital mortality based on ASI was 6.12% (mean ASI: 47.49, 95%CI: 44.73-50.25) and significant difference was found between death and alive subgroups (0.48, 95%CI:0.39-0.57, P<0.001). Also, ASI was found to be independent in-hospital mortality predictor (OR: 2.54, 95%CI:2.04-3.16, P<0.001)). The optimal ASI cut-off point was found to be 49.6 (sensitivity: 66.3%, specificity: 58.6%). In terms of MSI (mean: 0.93, 95%CI:0.88-0.98)), significant difference was found specified by death/survival status (0.34, 95%CI:0.05-0.63, P = 0.021). AMSI data synthesis was not possible due to presence of a single record.

CONCLUSIONS

SI, ASI, and MSI are practical available tools for AHF prognosis assessment in clinical settings to prioritize high risk patients.

Age shock index as an early predictor of cardiovascular death in acute coronary syndrome patients

BACKGROUND

The shock index (SI), reflecting heart rate (HR) to SBP ratio, is established for predicting adverse outcomes in acute coronary syndrome (ACS) patients. Exploring the age shock index (ASI), obtained by multiplying SI with age, could offer further insights into ACS prognosis.

OBJECTIVES

Assess ASI's effectiveness in predicting in-hospital death in individuals with ACS.

METHODS

This study encompassed patients with acute myocardial infarction, drawn from a national registry spanning October 2010 to January 2022. The optimal ASI threshold was established using receiver operating characteristic (ROC) curve analysis. The primary outcome was in-hospital mortality.

RESULTS

A total of 27 312 patients were enrolled, exhibiting a mean age of 66 ± 13 years, with 72.3% being male and 47.5% having ST-elevation myocardial infarction. ROC analysis yielded an area under the curve (AUC) of 0.80, identifying the optimal ASI cutoff as 44. Multivariate regression analysis, adjusting for potential confounders, established ASI ≥ 44 as an independent predictor of in-hospital death [hazard ratio: 3.09, 95% confidence interval: 2.56-3.71, P  < 0.001]. Furthermore, ASI emerged as a notably superior predictor of in-hospital death compared to the SI (AUC ASI  = 0.80 vs. AUC SI  = 0.72, P  < 0.0001), though it did not outperform the Global Registry of Acute Coronary Events (GRACE) score (AUC ASI  = 0.80 vs. AUC GRACE  = 0.85, P  < 0.001) or thrombolysis in myocardial infarction (TIMI) risk index (AUC ASI  = 0.80 vs. AUC TIMI  = 0.84, P  < 0.001).

CONCLUSION

The ASI offers an expedient mean to promptly identify ACS patients at elevated risk of in-hospital death. Its simplicity and effectiveness could render it a valuable tool for early risk stratification in this population.

Retrospective evaluation of the utility of shock index to determine the presence of congestive heart failure in dogs with myxomatous mitral valve disease (2019-2021): 98 cases

OBJECTIVES

To calculate the shock index (SI) in dogs with myxomatous mitral valve disease (MMVD) and to evaluate its use to predict the presence of congestive heart failure (CHF).

DESIGN

Retrospective study.

SETTING

Small animal university veterinary teaching hospital.

ANIMALS

Ninety-eight dogs with MMVD and 20 healthy dogs as part of a control group.

INTERVENTIONS

Heart rate (HR) and systolic blood pressure (SBP) were recorded, and SI was calculated by dividing HR by SBP for each dog.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) HR, SBP, and SI were 123/min (32.6), 147 mm Hg (21.5), and 0.86 (0.3), respectively, for dogs with MMVD and 98/min (20.9), 145 mm Hg (18.7), and 0.68 (0.13), respectively, for control dogs. Dogs with MMVD had a significantly higher HR compared with control dogs (P < 0.01), and an elevation in HR was seen as the severity of MMVD increased. Dogs in stage B2 and C/D MMVD had a significantly higher SI value compared with control dogs (P = 0.04 and P < 0.01, respectively). SI was significantly higher in dogs in stage C/D MMVD compared with dogs in stage B2 MMVD (P < 0.01). Ten of 98 (10%) dogs had an arrhythmia. HR, SBP, and SI were not significantly different between dogs with and without arrhythmias (P = 0.13, P = 0.57, and P = 0.07, respectively), but significantly more dogs with CHF had an arrhythmia (P = 0.01). SI (area under the curve [AUC]: 0.98) and HR (AUC: 0.95) were excellent indicators for the presence of CHF. An optimal SI cutoff value ≥1.1 had 92% sensitivity and 95% specificity for predicting the presence of CHF, and an optimal HR cutoff value of ≥157/min had 92% sensitivity and 93% specificity for the prediction of CHF.

CONCLUSIONS

When there are compatible clinical signs, SI values ≥1.1 may suggest the presence of CHF in dogs with MMVD.

Association between the shock index on admission and in-hospital mortality in the cardiac intensive care unit

BACKGROUND

An elevated shock index (SI) predicts worse outcomes in multiple clinical arenas. We aimed to determine whether the SI can aid in mortality risk stratification in unselected cardiac intensive care unit patients.

METHODS

We included admissions to the Mayo Clinic from 2007 to 2015 and stratified them based on admission SI. The primary outcome was in-hospital mortality, and predictors of in-hospital mortality were analyzed using multivariable logistic regression.

RESULTS

We included 9,939 unique cardiac intensive care unit patients with available data for SI. Patients were grouped by SI as follows: < 0.6, 3,973 (40%); 0.6-0.99, 4,810 (48%); and ≥ 1.0, 1,156 (12%). After multivariable adjustment, both heart rate (adjusted OR 1.06 per 10 beats per minute higher; CI 1.02-1.10; p-value 0.005) and systolic blood pressure (adjusted OR 0.94 per 10 mmHg higher; CI 0.90-0.97; p-value < 0.001) remained associated with higher in-hospital mortality. As SI increased there was an incremental increase in in-hospital mortality (adjusted OR 1.07 per 0.1 beats per minute/mmHg higher, CI 1.04-1.10, p-Value < 0.001). A higher SI was associated with increased mortality across all examined admission diagnoses.

CONCLUSION

The SI is a simple and universally available bedside marker that can be used at the time of admission to predict in-hospital mortality in cardiac intensive care unit patients.

Comparison of different scoring systems in predicting mortality and postoperative complications in acute care surgery patients at a Saudi Academic Centre

PURPOSE

Emergency surgery carries an increased risk of death and complications. Scoring systems can help identify patients at higher risk of mortality and complications. Scoring systems can also help benchmark acute care services. This study aims to compare different scoring systems in predicting outcomes among acute care surgery patients.

METHODS

Our study is a retrospective cohort study that included all adult emergency surgery admissions between 2017 and 2019. Data were obtained from patients' electronic health records. Same admission mortality and postoperative complications were collected. Data were recorded to calculate the American Society of Anesthesiologists Physical Status classification system (ASA-PS), Shock Index Score (SI), Age Shock Index Score (AgeSI), and the Emergency Surgery Score (ESS). The probability of death and complications was correlated with each scoring system and was assessed by calculating the c-statistic.

RESULTS

During the study period, 1606 patients fulfilled inclusion criteria. The mortality rate was 2.2%, complication rate was 18.7%. ESS predicted mortality with a c-statistic of 0.87 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.81, 0.74, and 0.57, respectively. ESS also predicted the occurrence of complications with a c-statistic of 0.83 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.72, 0.71, and 0.63, respectively.

CONCLUSION

ESS demonstrated a better prognostic accuracy for hospital mortality and postoperative complications than other prognostic scoring systems. Our findings suggest that a scoring system designed for the acute care surgical population may provide enhanced prognostic performance over other surgical prognostic scoring systems.

Shock index and modified shock index are predictors of long-term mortality not only in STEMI but also in NSTEMI patients

BACKGROUND

Shock index (SI) and modified shock index (mSI) are useful instruments for early risk stratification in acute myocardial infarction (AMI) patients. They are strong predictors for short-term mortality. Nevertheless, the association between SI or mSI and long-term mortality in AMI patients has not yet been sufficiently examined.

MATERIAL AND METHODS

For this study, a total of 10,174 patients with AMI was included. All cases were prospectively recorded by the population-based Augsburg Myocardial Infarction Registry from 2000 until 2017. Endpoint was all-cause mortality with a median observational time of 6.5 years [IQR: 3.5-7.4]. Using ROC analysis and calculating Youden-Index, the sample was dichotomized into a low and a high SI and mSI group, respectively. Moreover, multivariable adjusted COX regression models were calculated. All analyses were performed for the total sample as well as for STEMI and NSTEMI cases separately.

RESULTS

Optimal cut-off values were 0.580 for SI and 0.852 for mSI (total sample). AUC values were 0.6382 (95% CI: 0.6223-0.6549) for SI and 0.6552 (95% CI: 0.6397-0.6713) for mSI. Fully adjusted COX regression models revealed significantly higher long-term mortality for patients with high SI and high mSI compared to patients with low indices (high SI HR: 1.42 [1.32-1.52], high mSI HR: 1.46 [1.36-1.57]). Furthermore, the predictive ability was slightly better for mSI compared to SI and more reliable in NSTEMI cases compared to STEMI cases (for SI and mSI).

CONCLUSION

High SI and mSI are useful tools for early risk stratification including long-term outcome especially in NSTEMI cases, which can help physicians to make decision on therapy. NSTEMI patients with high SI and mSI might especially benefit from immediate invasive therapy.Key messagesShock index and modified shock index are predictors of long-term mortality after acute myocardial infarction.Both indices predict long-term mortality not only for STEMI cases, but even more so for NSTEMI cases.

Multifactorial Shock: A Neglected Situation in Polytrauma Patients

Background: Shock after traumatic injury is likely to be hypovolemic, but different types of shock (distributive shock, obstructive shock, or cardiogenic shock) can occur in combination, known as multifactorial shock. Multifactorial shock is a neglected area of study, and is only reported sporadically. Little is known about the incidence, characteristics, and outcomes of multifactorial shock after polytrauma. Methods: A retrospective, observational, multicenter study was conducted in four Level I trauma centers involving 1051 polytrauma patients from June 2020 to April 2022. Results: The mean Injury Severity Score (ISS) was 31.1, indicating a severely injured population. The most common type of shock in the early phase after polytrauma (≤48 h) is hypovolemic shock (83.2%), followed by distributive shock (14.4%), obstructive shock (8.7%), and cardiogenic shock (3.8%). In the middle phase after polytrauma (>48 h or ≤14 days), the most common type of shock is distributive shock (70.7%), followed by hypovolemic shock (27.2%), obstructive shock (9.9%), and cardiogenic shock (7.2%). Multifactorial shock accounted for 9.7% of the entire shock population in the early phase and 15.2% in the middle phase. In total, seven combinations of multifactorial shock were described. Patients with multifactorial shock have a significantly higher complication rate and mortality than those with single-factor shock. Conclusions: This study characterizes the incidence of various types of shock in different phases after polytrauma and emphasizes that different types of shock can occur simultaneously or sequentially in polytrauma patients. Multifactorial shock has a relatively high incidence and mortality in polytrauma patients, and trauma specialists should be alert to the possibility of their occurrence.

Clinical Validation of the Shock Index, Modified Shock Index, Delta Shock Index, and Shock Index-C for Emergency Department ST-Segment Elevation Myocardial Infarction

Background: ST-segment elevation myocardial infarction (STEMI) is a leading cause of death worldwide. A shock index (SI), modified SI (MSI), delta-SI, and shock index-C (SIC) are known predictors of STEMI. This retrospective cohort study was designed to compare the predictive value of the SI, MSI, delta-SI, and SIC with thrombolysis in myocardial infarction (TIMI) risk scales. Method: Patients > 20 years old with STEMI who underwent percutaneous coronary intervention (PCI) were included. Receiver operating characteristic (ROC) curve analysis with the Youden index was performed to calculate the optimal cutoff values for these predictors. Results: Overall, 1552 adult STEMI cases were analyzed. The thresholds for the emergency department (ED) SI, MSI, SIC, and TIMI risk scales for in-hospital mortality were 0.75, 0.97, 21.00, and 5.5, respectively. Accordingly, ED SIC had better predictive power than the ED SI and ED MSI. The predictive power was relatively higher than TIMI risk scales, but the difference did not achieve statistical significance. After adjusting for confounding factors, the ED SI > 0.75, MSI > 0.97, SIC > 21.0, and TIMI risk scales > 5.5 were statistically and significantly associated with in-hospital mortality of STEMI. Compared with the ED SI and MSI, SIC (>21.0) had better sensitivity (67.2%, 95% CI, 58.6−75.9%), specificity (83.5%, 95% CI, 81.6−85.4%), PPV (24.8%, 95% CI, 20.2−29.6%), and NPV (96.9%, 95% CI, 96.0−97.9%) for in-hospital mortality of STEMI. Conclusions: SIC had better discrimination ability than the SI, MSI, and delta-SI. Compared with the TIMI risk scales, the ACU value of SIC was still higher. Therefore, SIC might be a convenient and rapid tool for predicting the outcome of STEMI.

The relationship between age shock index, and severity of stroke and in-hospital mortality in patients with acute ischemic stroke

BACKGROUND

Shock index (SI) has been reported to help us predict adverse prognosis in patients with acute ischemic stroke (AIS). However, the prognostic value of age SI and age modified shock index (MSI) in acute ischemic stroke is unknown. In our study, we aimed to examine the association between the severity of the stroke and in-hospital mortality, age SI and age MSI in patients with AIS.

METHODS

A total of 256 patients were enrolled in this study. The National Institutes of Health Stroke Scale (NIHSS) was used to determine the severity of stroke. Patients were divided into two groups according to the NIHSS score calculated during hospitalization (NIHSS>14: severe disability group, NIHSS<15: moderate and mild disability group). Shock indexes were calculated using the blood pressure and heart rate values measured as a result of the cardiovascular examinations of the patients. We looked for correlations between increased NIHSS and in-hospital mortality with age shock index and age modified shock index.

RESULTS

Age SI and age MSI values were higher in the severe disability group than those without severe disability, and the results were statistically significant (p<0.001, p<0.001, respectively). Also, a positive correlation was determined between the height of NIHSS and the age SI and the age MSI (p=0.002, r=0.197, p=0.001, r=0.215, respectively). Thirty-two (12.5%) of 256 patients included in the study died during hospitalization. Patients who died were older (77.1±11.0 vs. 67.5±13.5, respectively; p<0.001). According to Point-Biserial correlation analysis, there was a positive correlation between mortality and age SI, and age MSI (p<0.001, r=0.258 ve p<0.001, r=0.274, respectively).

CONCLUSIONS

As a result of our study, the relationship between stroke severity and increasing age SI and age MSI was significant and there was a positive correlation. In addition, there was a significant and positive relationship between in-hospital mortality and age SI and age MSI.

Prognostic utility of shock index and modified shock index on long-term mortality in acute decompensated heart failure; Persian Registry of cardioVascular diseasE/Heart Failure (PROVE/HF) study

BACKGROUND

Shock index (SI) and modified SI (MSI) are used for prognosis in patients with cardiovascular diseases (CVDs), especially myocardial infarction. However, the utility of these indices in heart failure(HF) is less frequently investigated. We aimed to evaluate the long-term prognostic capability of SI and MSI among Iranian HF patients.

METHODS

This retrospective cohort study was implemented in the context of the Persian Registry Of cardioVascular diseasE/HF (PROVE/HF). A total of 3896 acute decompensated HF (ADHF) patients were enrolled from March 2016 to March 2020. SI and MSI were assessed at admission. Receiver operating characteristic (ROC) and Kaplan-Meier curves were used to define optimum SI and MSI cut-off points and depict mortality during follow-up, respectively. The association of CVD death according to different SI and MSI cut-off points and quartiles was assessed through univariate and multivariate regression hazard models.

RESULTS

Mean age of participants was 70.22 ± 12.65 years (males: 62.1%). We found 0.66 (sensitivity:62%, specificity: 51%) and 0.87 (sensitivity: 61%, specificity: 51%) as optimised cut-off points for SI and MSI, respectively. Mean follow-up was 10.26 ± 7.5 months and 1110 (28.5%) deaths occurred during this time. Multivariate adjusted models revealed patients had SI ≥ 0.66 or within the third and fourth quartiles had higher likelihood of mortality compared to reference group (hazard ratio(HR): 1.58, 95%CI: 1.39-1.80, p < 0.001, HR: 1.38,95%CI:1.14-1.66, p = 0.001 and HR:2.00,95%CI:1.68-2.38, p < 0.001, respectively). MSI outcomes were similar (MSI ≥ 0.87: HR: 1.52,95%CI: 1.34-1.72, p < 0.001, third quartile (0.89 ≤ MSI < 1.00):HR:1.23,95%CI:1.009-1.50, p = 0.041, fourth quartile (MSI ≥ 1.00): HR: 1.80,95%CI: 1.53-2.13, p < 0.001). Kaplan-Meier curves showed patients with higher SI and MSI cut-off values and quartiles had lower survival rates.

CONCLUSION

Higher SI and MSI values were associated with increased mortality risk, and these two bedside indices could be appropriately considered for long-term prognosis in ADHF patients.

Coronary blood flow in heart failure: cause, consequence and bystander

Heart failure is a clinical syndrome where cardiac output is not sufficient to sustain adequate perfusion and normal bodily functions, initially during exercise and in more severe forms also at rest. The two most frequent forms are heart failure of ischemic origin and of non-ischemic origin. In heart failure of ischemic origin, reduced coronary blood flow is causal to cardiac contractile dysfunction, and this is true for stunned and hibernating myocardium, coronary microembolization, myocardial infarction and post-infarct remodeling, possibly also for the takotsubo syndrome. The most frequent form of non-ischemic heart failure is dilated cardiomyopathy, caused by genetic mutations, myocarditis, toxic agents or sustained tachyarrhythmias, where alterations in coronary blood flow result from and contribute to cardiac contractile dysfunction. Hypertrophic cardiomyopathy is caused by genetic mutations but can also result from increased pressure and volume overload (hypertension, valve disease). Heart failure with preserved ejection fraction is characterized by pronounced coronary microvascular dysfunction, the causal contribution of which is however not clear. The present review characterizes the alterations of coronary blood flow which are causes or consequences of heart failure in its different manifestations. Apart from any potentially accompanying coronary atherosclerosis, all heart failure entities share common features of impaired coronary blood flow, but to a different extent: enhanced extravascular compression, impaired nitric oxide-mediated, endothelium-dependent vasodilation and enhanced vasoconstriction to mediators of neurohumoral activation. Impaired coronary blood flow contributes to the progression of heart failure and is thus a valid target for established and novel treatment regimens.

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.

Early detection of hospitalized patients with COVID-19 at high risk of clinical deterioration: Utility of emergency department shock index

BACKGROUND

The COVID-19 outbreak has put an unprecedented strain on Emergency Departments (EDs) and other critical care resources. Early detection of patients that are at high risk of clinical deterioration and require intensive monitoring, is key in ED evaluation and disposition. A rapid and easy risk-stratification tool could aid clinicians in early decision making. The Shock Index (SI: heart rate/systolic blood pressure) proved useful in detecting hemodynamic instability in sepsis and myocardial infarction patients. In this study we aim to determine whether SI is discriminative for ICU admission and in-hospital mortality in COVID-19 patients.

METHODS

Retrospective, observational, single-center study. All patients ≥18 years old who were hospitalized with COVID-19 (defined as: positive result on reverse transcription polymerase chain reaction (PCR) test) between March 1, 2020 and December 31, 2020 were included for analysis. Data were collected from electronic medical patient records and stored in a protected database. ED shock index was calculated and analyzed for its discriminative value on in-hospital mortality and ICU admission by a ROC curve analysis.

RESULTS

In total, 411 patients were included. Of all patients 249 (61%) were male. ICU admission was observed in 92 patients (22%). Of these, 37 patients (40%) died in the ICU. Total in-hospital mortality was 28% (114 patients). For in-hospital mortality the optimal cut-off SI ≥ 0.86 was not discriminative (AUC 0.49 (95% CI: 0.43-0.56)), with a sensitivity of 12.3% and specificity of 93.6%. For ICU admission the optimal cut-off SI ≥ 0.57 was also not discriminative (AUC 0.56 (95% CI: 0.49-0.62)), with a sensitivity of 78.3% and a specificity of 34.2%.

CONCLUSION

In this cohort of patients hospitalized with COVID-19, SI measured at ED presentation was not discriminative for ICU admission and was not useful for early identification of patients at risk of clinical deterioration.

Prognostic value of shock index in patients admitted with non-ST-segment elevation myocardial infarction: the ARIC study community surveillance

AIMS

Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and predictive of mortality in patients with ST-segment elevation myocardial infarction. However, large-scale evaluations of SI in patients with non-ST-segment elevation myocardial infarction (NSTEMI) are lacking.

METHODS AND RESULTS

Hospitalizations for acute myocardial infarction were sampled from four US areas by the Atherosclerosis Risk in Communities (ARIC) study and classified by physician review. Shock index was derived from the HR and SBP at first presentation and considered high when ≥0.7. From 2000 to 2014, 18 301 weighted hospitalizations for NSTEMI were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs. 39%) and had more prevalent chronic kidney disease (40% vs. 32%). TIMI (Thrombolysis in Myocardial Infarction) risk scores were similar between the groups (4.3 vs. 4.2), but GRACE (Global Registry of Acute Coronary Syndrome) score was higher with high SI (140 vs. 118). Angiography, revascularization, and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was higher (13% vs. 5%). Prediction of 28-day mortality by SI as a continuous measurement [area under the curve (AUC): 0.68] was intermediate to that of the GRACE score (AUC: 0.87) and the TIMI score (AUC: 0.54). After adjustments, patients with high SI had twice the odds of 28-day mortality (odds ratio = 2.02; 95% confidence interval: 1.46-2.80).

CONCLUSION

The SI is easily obtainable, performs moderately well as a predictor of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.

Hemodynamic monitoring and management of pediatric septic shock

Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.

Usefulness of a Novel Risk Score to Predict In-Hospital Mortality in Patients ≥ 60 Years of Age with ST Elevation Myocardial Infarction

Numerous algorithms are available to predict short-term mortality in ST elevation myocardial infarction (STEMI) but none are focused on elderly patients or include invasive hemodynamics. A simplified risk score (LASH score) including left ventricular end diastolic pressure > 20 mm Hg, age > 75 years, systolic blood pressure < 100 mm Hg and heart rate > 100 bpm was tested in a retrospective, single-center study of 346 patients ≥ 60 years old who underwent primary percutaneous coronary intervention (PPCI). The median age was 70 years [IQR: 64, 79], 60.1% were men, and 77.8% identified as White. In-hospital all-cause mortality was 10.1%. Patients with a LASH score ≥ 3 (n = 34) had an in-hospital mortality rate of 44.1% compared to 6.4% for LASH score ≤ 2 (p < 0.0001). The odds ratio for in-hospital mortality for patients with LASH score ≥ 3 was 13.2 (95% CI 5.3-33.1) compared to patients with a LASH score ≤ 2 when adjusted for sex, cardiac arrest, heart failure, and prior cerebrovascular event. The LASH score had an area under the ROC curve for predicting in-hospital mortality of 0.795 [CI 0.716-0.872], as compared to TIMI-STEMI (0.881, CI 0.829-0.931; p = 0.01), GRACE (0.849, CI 0.778-0.920; p = 0.19), shock index (0.769, CI 0.667-0.871; p = 0.51) and modified shock index (0.765, CI 0.716-0.873; p = 0.48). In summary, a simplified, easy to calculate risk score that incorporates age and invasive hemodynamics predicts in-hospital mortality in patients ≥ 60 years old undergoing PPCI for STEMI.

Ability of a novel shock index that incorporates invasive hemodynamics to predict mortality in patients with ST-elevation myocardial infarction

OBJECTIVE

To determine whether the use of invasively measured hemodynamics improves the prognostic ability of a shock index (SI).

BACKGROUND

SI such as Admission-SI, Age-SI, Modified SI (MSI), and Age-MSI predict short-term mortality in ST-elevation myocardial infarction (STEMI).

METHODS

Single-center study of 510 patients who underwent primary percutaneous coronary intervention. STEMI SI was defined as age × heart rate (HR) divided by coronary perfusion pressure (CPP).

RESULTS

The mean age was 62 ± 14 years, 66% were males with hypertension (69%), tobacco use (38%), diabetes (28%) and chronic kidney disease (6%). The mean HR, systolic blood pressure (SBP), and CPP were 81 ± 18 bpm, 124 ± 28 mmHg, and 52.8 ± 16.3 mmHg, respectively. Patients with STEMI SI ≥182 (n = 51) were more likely to experience a cardiac arrest in the catheterization laboratory (9.8% vs. 2.0%; p = .001), require mechanical circulatory support (47.1% vs. 8.5%; p < .0001) and be treated with vasopressors (56.9% vs. 10.7%; p < .0001) compared to STEMI SI < 182 (n = 459). After multivariate adjustment, patients with STEMI SI ≥182 were 10, 10.1 and 4.8 times more likely to die during hospitalization, at 30 days and at 5 years, respectively. The C statistic of STEMI SI was 0.870, similar to GRACE score (AUC = 0.902; p = .29) and TIMI STEMI score (AUC = 0.895; p = .36).

CONCLUSION

STEMI SI is an easy to calculate risk score that identifies STEMI patients at high risk of in-hospital death.

Comparison of shock index-based risk indices for predicting in-hospital outcomes in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

Objective

We aimed to determine whether the prognostic value of the shock index (SI) and its derivatives is better than that of the Thrombolysis In Myocardial Infarction risk index (TRI) for predicting adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 257 patients with STEMI undergoing primary PCI from January 2018 to June 2019 were analyzed in a retrospective cohort study. The SI, modified shock index (MSI), age SI (age × the SI), age MSI (age × the MSI), and TRI at admission were calculated. Clinical endpoints were in-hospital complications, including all-cause mortality, acute heart failure, cardiac shock, mechanical complications, re-infarction, and life-threatening arrhythmia.

Results

Multivariate analyses showed that a high SI, MSI, age SI, age MSI, and TRI at admission were associated with a significantly higher rate of in-hospital complications. The predictive value of the age SI and age MSI was comparable with that of the TRI (area under the receiver operating characteristic curve: z = 1.313 and z = 0.882, respectively) for predicting in-hospital complications.

Conclusions

The age SI and age MSI appear to be similar to the TRI for predicting in-hospital complications in patients with STEMI undergoing primary PCI.

Association of the age shock index with coronary plaque characteristics in ST-segment elevation myocardial infarction: A 3-vessel optical coherence tomography study

OBJECTIVES

We investigated whether the age shock index (SI) was associated with coronary plaque characteristics in patients with ST-segment elevation myocardial infarction (STEMI) using optical coherence tomography (OCT).

BACKGROUND

The age SI is a simple clinical parameter that effectively predicts poor clinical outcomes among patients with STEMI.

METHODS

This retrospective study evaluated 408 STEMI patients who underwent 3-vessel OCT during emergency percutaneous coronary interventions at a single center between January 2017 and October 2018. Patients were divided into groups with low or high age SI values (<41 vs. ≥41). Plaque characteristics were compared between the two groups for both culprit lesions (n = 408) and non-culprit lesions (n = 1,077).

RESULTS

In culprit lesions, patients with a high age SI (≥41) were more likely to have plaque rupture (61.0% vs. 56.8%, p = .002) and thinner fibrous caps (fibrous cap thickness [FCT]: 40.0 [33.0-53.0] μm vs. 46.0 [36.0-63.8] μm, p = .021). In non-culprit lesions, patients with a high age SI were more likely to have high-risk plaques (29.9% vs. 17.8%, p = .018; simultaneous presence of a minimal lumen area of <3.5 mm² , maximum lipid arc of >180°, FCT of <75 μm, and macrophage accumulation). Plaque-based analyses revealed that patients with a high age SI had larger lipid cores and lesser FCT.

CONCLUSIONS

Patients with STEMI and a high age SI had increased risks of culprit plaque rupture and high-risk non-culprit plaques, and vulnerable plaque features at the culprit and non-culprit lesions. Therefore, a high age SI in patients with STEMI may indicate greater pancoronary vulnerability.

Social stress is lethal in the mdx model of Duchenne muscular dystrophy

Background

Duchenne muscular dystrophy (DMD) is caused by the loss of dystrophin. Severe and ultimately lethal, DMD progresses relatively slowly in that patients become wheelchair bound only around age twelve with a survival expectancy reaching the third decade of life.

Methods

The mildly-affected mdx mouse model of DMD, and transgenic DysΔMTB-mdx and Fiona-mdx mice expressing dystrophin or utrophin, respectively, were exposed to either mild (scruffing) or severe (subordination stress) stress paradigms and profiled for their behavioral and physiological responses. A subgroup of mdx mice exposed to subordination stress were pretreated with the beta-blocker metoprolol.

Findings

Subordination stress caused lethality in ∼30% of mdx mice within 24 h and ∼70% lethality within 48 h, which was not rescued by metoprolol. Lethality was associated with heart damage, waddling gait and hypo-locomotion, as well as marked up-regulation of the hypothalamus-pituitary-adrenocortical axis. A novel cardiovascular phenotype emerged in mdx mice, in that scruffing caused a transient drop in arterial pressure, while subordination stress caused severe and sustained hypotension with concurrent tachycardia. Transgenic expression of dystrophin or utrophin in skeletal muscle protected mdx mice from scruffing and social stress-induced responses including mortality.

Interpretation

We have identified a robust new stress phenotype in the otherwise mildly affected mdx mouse that suggests relatively benign handling may impact the outcome of behavioural experiments, but which should also expedite the knowledge-based therapy development for DMD.

Funding

Greg Marzolf Jr. Foundation, Summer's Wish Fund, NIAMS, Muscular Dystrophy Association, University of Minnesota and John and Cheri Gunvalson Trust.

Utility of shock index in 24,636 patients presenting with acute coronary syndrome

BACKGROUND

Shock index is a bedside reflection of integrated response of the cardiovascular and nervous systems. We aimed to evaluate the utility of shock index (heart rate/systolic blood pressure) in patients presenting with acute coronary syndrome (ACS).

METHODS

We analyzed pooled data from seven Arabian Gulf registries; these ACS registries were carried out in seven countries (Qatar, Bahrain, Kuwait, UAE, Saudi Arabia, Oman and Yemen) between 2005 and 2017. A standard uniform coding strategy was used to recode each database using each registry protocol and clinical research form. Patients were categorized into two groups based on their initial shock index (low vs. high shock index). Optimal shock index cutoff was determined according to the receiver operating characteristic curve (ROC). Primary outcome was hospital mortality.

RESULTS

A total of 24,636 ACS patients met the inclusion criteria with a mean age 57±13 years. Based on ROC analysis, the optimal shock index was 0.80 (83.5% had shock index <0.80 and 16.5% had shock index ≥0.80). In patients with high shock index, 55% had ST-elevation myocardial infarction and 45% had non-ST-elevation myocardial infarction. Patients with high shock index were more likely to have diabetes mellitus, late presentation, door to electrocardiogram >10 min, symptom to Emergency Department > 3 h, anterior myocardial infarction, impaired left ventricular function, no reperfusion post-therapy, recurrent ischemia/myocardial infarction, tachyarrhythmia and stroke. However, high shock index was associated significantly with less chest pain, less thrombolytic therapy and less primary percutaneous coronary intervention. Shock index correlated significantly with pulse pressure (r= -0.52), mean arterial pressure (r= -0.48), Global Registry of Acute Coronary Events score (r =0.41) and Thrombolysis In Myocardial Infarction simple risk index (r= -0.59). Shock index ≥0.80 predicted mortality in ACS with 49% sensitivity, 85% specificity, 97.6% negative predictive value and 0.6 negative likelihood ratio. Multivariate regression analysis showed that shock index was an independent predictor for in-hospital mortality (adjusted odds ratio (aOR) 3.40, p<0.001), heart failure (aOR 1.67, p<0.001) and cardiogenic shock (aOR 3.70, p<0.001).

CONCLUSIONS

Although shock index is the least accurate of the ones tested, its simplicity may argue in favor of its use for early risk stratification in patients with ACS. The utility of shock index is equally good for ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. High shock index identifies patients at increased risk of in-hospital mortality and urges physicians in the Emergency Department to use aggressive management.

Association of shock index with short-term and long-term prognosis after ST-segment elevation myocardial infarction

BACKGROUND

The association of shock index with long-term mortality after ST-segment elevation myocardial infarction (STEMI) remains poorly investigated. We aimed to assess the association between shock index and eight-year mortality after STEMI.

METHODS

The study included 1369 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). Patients were categorized into three groups: a group with shock index in the first tertile (shock index, 0.21 to 0.52; n = 458), a group with shock index in the second tertile (shock index > 0.52 to 0.67; n = 457) and a group with shock index in the third tertile (shock index > 0.67 to 2.80; n = 454). The primary outcome was eight-year mortality.

RESULTS

In patients with shock index in the first to third tertiles, inhospital cardiogenic shock (n = 153) occurred in 3.5, 3.9 and 26.2% of patients, respectively [adjusted odds ratio = 1.54, 95% confidence interval (CI) 1.40 to 1.69, P < 0.001]; 30-day deaths (n = 122) occurred in 2.8, 5.5 and 18.5% of patients, respectively [adjusted hazard ratio = 1.06 (1.01-1.12); P = 0.024]; eight-year deaths (n = 300) occurred in 22.9, 21.6 and 36.1% of patients, respectively [adjusted hazard ratio = 1.06 (1.02-1.11); P = 0.007] with all risk estimates calculated per 0.1 unit increment in shock index values. From 30 days to 8 years, deaths (n = 178) occurred in 20.7, 17.0 and 21.5% of patients in the first to third shock index tertiles, respectively (the difference was nonsignificant for all intertertile comparisons).

CONCLUSIONS

In patients with STEMI, elevated shock index is associated with the risk of inhospital cardiogenic shock and mortality up to 8 years after PPCI. The long-term adverse prognosis was almost entirely driven by events within the first 30 days.

Shock Index in Patients Presenting With Acute Heart Failure: A Multicenter Multinational Observational Study

Shock index (SI) has a prognostic role in coronary heart disease; however, data on acute heart failure (AHF) are lacking. We evaluated the predictive values of SI in patients with AHF. Data were retrospectively analyzed from the Gulf Acute Heart Failure Registry. Patients were categorized into low SI versus high SI based on the receiver operating characteristic curves. Primary outcomes included cardiogenic shock (CS) and mortality. Among 4818 patients with AHF, 1143 had an SI ≥0.9. Compared with SI <0.9, patients with high SI were more likely males, younger, and having advanced New York Heart Association class, fewer cardiovascular risk factors and less prehospital β-blockers and angiotensin-converting enzyme inhibitor use. Shock index had significant negative correlations with age, pulse pressure, mean arterial pressure, and left ventricle ejection fraction and had positive correlation with hospital length of stay. Shock index ≥0.9 was significantly associated with higher composite end points, in-hospital, and 3-month mortality. Shock index ≥0.9 had 96% negative predictive value (NPV) and 3.5 relative risk for mortality. Multivariate regression analysis showed that SI was independent predictor of mortality and CS. With a high NPV, SI is a simple reliable bedside tool for risk stratification of patients with AHF. However, this conclusion needs further support.

Skullcapflavone I protects cardiomyocytes from hypoxia-caused injury through up-regulation of lincRNA-ROR

Myocardial infarction (MI) is a serious heart disease in which cardiomyocytes are damaged, caused by hypoxia. This study explored the possible protective activity of Skullcapflavone I (SF I), a flavonoid isolated from the root of Scutellaria baicalensis Georgi, on hypoxia-stimulated cardiomyocytes cell injury in vitro. Viability and apoptosis of H9c2 cells and primary cardiomyocytes were tested using cell counting kit–8 (CCK-8) assay and Guava Nexin Reagent, respectively. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used to measure the long non-coding RNA regulator of reprogramming (lincRNA-ROR) expression. si-ROR was transfected to knockdown lincRNA-ROR. Western blotting was conducted to assess the protein levels of key molecules related to cell proliferation, apoptosis, and mitogen-activated protein kinase/extracellular signal–regulated kinase (MEK/ERK) pathway. We discovered that hypoxia stimulation obviously reduced H9c2 cell and primary cardiomyocytes’ viability and proliferation, but promoted cell apoptosis. SF I treatment mitigated the cell viability and proliferation inhibition, as well as cell apoptosis caused by hypoxia. Moreover, SF I promoted the hypoxia-caused up-regulation of lincRNA-ROR in H9c2 cells and primary cardiomyocytes. Knockdown of lincRNA-ROR reversed the influence of SF I on hypoxia-stimulated H9c2 cells and primary cardiomyocytes. Besides, SF I activated MEK/ERK pathway in H9c2 cells and primary cardiomyocytes via up-regulating lincRNA-ROR. To sum up, our research verified the beneficial activity of SF I on hypoxia-caused cardiomyocytes injury. SF I protected cardiomyocytes from hypoxia-caused injury through up-regulation of lincRNA-ROR and activation of MEK/ERK pathway.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments

STUDY OBJECTIVES

The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant.

RESULTS

A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively).

CONCLUSIONS

In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

Shock Index-A Useful Noninvasive Marker Associated With Age-Specific Early Mortality in Children With Severe Sepsis and Septic Shock: Age-Specific Shock Index Cut-Offs

BACKGROUND

Aim of the study was to analyze the association of shock index (SI) from 0 to 6 hours with early mortality in severe sepsis/septic shock and to explore its age-specific cut-off values. To investigate association of change in SI over first 6 hours with early mortality.

METHODS

A prospective cohort study of children (<14 years) admitted in emergency department, tertiary care hospital with severe sepsis or septic shock, divided into 3 groups: group 1: 1 month to <1 year; group 2: 1 to <6 years; group 3: 6 to 12 years. Shock index (SI = heart rate/systolic blood pressure) measured at admission (X0) and hourly till 6 hours (X1-6). Primary outcome was death within 48 hours of admission. Area under receiver operating characteristic curves were constructed for SI (0-6). Optimal cut-offs of SI 0 and SI 6, maximizing both sensitivity and specificity were determined and positive and negative predictive values (PPV, NPV) were calculated.

RESULTS

From 2015 to 2016, 120 children were recruited. Septic shock was present at admission in 56.7% children. Early mortality was 50%. All hourly shock indices (SI 0-6) were higher among nonsurvivors in group 2 (P ≤ .03) and group 3 (P < .001). In group 1, SI after 2 hours was higher in nonsurvivors (P 2-6: ≤ .02). Area under receiver operating characteristic curves (95% CI) for SI at 0 hour was 0.72 (0.5-0.9), 0.66 (0.5-0.8), and 0.77 (0.6-0.9) and at 6 hours was 0.8 (0.6-1), 0.75 (0.6-0.9), and 0.8 (0.7-1) in 3 groups. The cut-off values of SI 0 (sensitivity; specificity; PPV; NPV) in 3 groups: 1.98 (77; 75; 67; 83), 1.50 (65; 65; 68; 63), and 1.25 (90; 67; 77; 83) and SI6: 1.66 (85; 80; 73; 89), 1.36 (73; 70; 73; 70), and 1.30 (74; 73; 78; 69). Improvement of SI over 6 hours was associated with better outcome. Children with higher SI at both time points had higher mortality than those with SI score below the cut-offs (P = .001).

CONCLUSIONS

Age-specific SI cut-off values may identify children at high risk of early mortality in severe sepsis/septic shock and allow for better targeted management.

Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock

Trauma resuscitation is a complex and dynamic process that requires a high-performing team to optimize patient outcomes. More than 30 years ago, Advanced Trauma Life Support was developed to formalize and standardize trauma care; however, the sequential nature of the algorithm that is used can lead to ineffective prioritization. An improved understanding of shock mandates an updated approach to trauma resuscitation. This article proposes a resequenced approach that (1) addresses immediate threats to life and (2) targets strategies for the diagnosis and management of shock causes. This updated approach emphasizes evidence-based resuscitation principles that align with physiologic priorities.

Derivation and Validation of Shock Index as a parameter for Predicting Long-term Prognosis in Patients with Acute Coronary Syndrome

The objective of this study was to examine whether shock index (SI), defined by ratio of heart rate and systolic blood pressure, can predict long-term prognosis of acute coronary syndrome (ACS) in patients undergoing percutaneous coronary intervention (PCI) and to compare prognostic accuracy of SI with the Global Registry of Acute Coronary Events (GRACE) risk score. This study included individuals from 2 independent cohorts: derivation cohort (n = 2631) and validation cohort (n = 963). In the derivation cohort, we derived that higher admission SI was associated with a greater risk of long-term all-cause mortality [HR = 4.104, 95% CI 1.553 to 10.845, p = 0.004] after adjusting for covariates. We validated this finding in the validation cohort [HR = 10.091, 95% CI 2.205 to 46.187, p = 0.003]. Moreover, admission SI had similar performance to the GRACE score in determining all-cause mortality risk in both cohorts (derivation cohort, admission SI vs. GRACE, z = 1.919, p = 0.055; validation cohort, admission SI vs. GRACE, z = 1.039, p = 0.299). In conclusion, admission SI is an independent predictor of adverse outcome in ACS patients undergoing PCI, and can identify patients at high risk of death. SI and the GRACE score showed similar performance in predicting all-cause mortality, and SI is more readily obtained than the GRACE score.

The prognostic value of shock index for the outcomes of acute myocardial infarction patients: A systematic review and meta-analysis

BACKGROUND

Several studies have revealed that high shock index (SI) is a risk factor for acute myocardial infarction (AMI) patients. These studies do not give a systematic review in this issue. Therefore, we conducted a systematic review and meta-analysis to determine the effect of high SI on the prognosis of AMI patients.

METHODS

We did a systematic search of PubMed, Embase, and the Cochrane Library, using various combinations of keywords such as "shock index," "shock-index," "acute myocardial infarction," "ST elevation myocardial infarction," "non-ST segment elevation myocardial infarction," "STEMI," "NSTEMI," "AMI," and "MI" for eligible studies published up to December 23, 2016. The 3 primary outcomes for this analysis were all-cause in-hospital mortality, short-term adverse outcomes, and long-term adverse outcomes.

RESULTS

Database searches retrieved 226 citations. Finally, 8 studies enrolling 20,404 patients were eventually included in the analysis. High SI was associated with an increased in-hospital mortality (pooled RR = 10.96, 95% CI: 2.00-59.94, P = .01). Adverse outcomes were significantly higher in the high SI group compared to the low SI group (pooled RR = 1.93, 95% CI: 1.10-3.39, P = .02; I = 95%). Individuals with high SI had an increased risk of long-term adverse outcomes (pooled RR = 2.31, 95% CI: 1.90-2.81, P < .001) compared to low SI.

CONCLUSION

High SI may increase the in-hospital mortality, short-term, and long-term adverse outcomes in AMI patients.

Ratio of systolic blood pressure to left ventricular end-diastolic pressure at the time of primary percutaneous coronary intervention predicts in-hospital mortality in patients with ST-elevation myocardial infarction

OBJECTIVE

To determine the ability of simple hemodynamic parameters obtained at the time of cardiac catheterization to predict in-hospital mortality following ST-elevation myocardial infarction (STEMI).

BACKGROUND

Hemodynamic parameters measured at the time of primary percutaneous coronary intervention (PPCI) could potentially identify high-risk patients who would benefit from aggressive hemodynamic support in the Cardiac Catheterization laboratory.

METHODS

This is a retrospective single-center study of 219 consecutive patients with STEMI. Left ventricular end-diastolic pressure (LVEDP), systolic blood pressure (SBP), and aortic diastolic blood pressure were obtained after successful revascularization. The prognostic ability of LVEDP, pulse pressure, and SBP/LVEDP ratio were compared to major mortality risk scores.

RESULTS

Patients had a mean age of 60 ±14 years, were predominantly white (73%), male (64%), with anterior wall infarcts in 39%. Comorbidities included diabetes mellitus (27%), heart failure (9%), and chronic kidney disease (7%). In-hospital mortality was 9%. Patients with SBP/LVEDP ≤ 4 had increased risk of in-hospital death (32% vs. 5.3%, P < 0.0001), intra-aortic balloon pump (IABP) usage (51.6% vs. 9.6%, P < 0.0001) and combined endpoint of death or IABP usage (58.1% vs. 13.3%, P < 0.0001) compared to patients with SBP/LVEDP > 4. The area under curve (AUC) for SBP/LVEDP ratio for in-hospital mortality (0.69) was more predictive than LVEDP (0.61, P = 0.04) or pulse pressure (0.55, P = 0.02) but similar to Shock Index (ratio of heart rate to SBP) and Modified Shock Index (ratio of HR to mean arterial pressure).

CONCLUSION

An SBP/LVEDP ratio ≤ 4 identified a group of STEMI patients at high risk of in-hospital death. © 2017 Wiley Periodicals, Inc.