Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock.

OBJECTIVE: Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS. METHODS: Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation. RESULTS: 105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = .054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = .027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007-4.774; p = .048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = .015), which, however, could not be confirmed in multivariable Cox regression. CONCLUSION: The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.

Predictors and Prognostic Impact of Early Acute Kidney Injury in Cardiogenic Shock: Results from a Monocentric, Prospective Registry.

INTRODUCTION: The presence of acute kidney injury (AKI) was shown to increase the risk of mortality following acute myocardial infarction; however, data regarding the prognostic impact of early AKI in patients with concomitant cardiogenic shock (CS) is limited. The study investigates predictors and the prognostic impact of AKI in patients with CS. METHODS: Consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. Predictors for AKI (defined as an increase of plasma creatinine >50% within 48 h referring to pre-admission or baseline creatinine on day 1 and/or the need for continuous veno-venous hemodiafiltration [CVVHDF]) and the prognostic impact of early AKI with regard to 30-day all-cause mortality were assessed. Statistical analyses included t test, Spearman's correlation, C-statistics, Kaplan-Meier, and Cox proportional regression analyses. RESULTS: A total of 219 CS patients were included with an incidence of early CS-related AKI of 52%. With an area under the curve of up to 0.689 (p = 0.001), creatine discriminated 30-day mortality in CS. Increasing lactate levels (OR = 1.194; 95% CI: 1.083-1.316; p = 0.001; per increase of 1 mmol/L) was associated with the occurrence of AKI. The presence of AKI was associated with an increased risk of 30-day all-cause mortality (63% vs. 36%; HR = 2.138; 95% CI: 1.441-3.171; p = 0.001), even after multivariable adjustment (HR = 1.861; 95% CI: 1.207-2.869; p = 0.005). Finally, highest risk of all-cause mortality was observed in patients with AKI requiring CVVHDF (75% vs. 44%; log rank p = 0.001; HR = 2.211; 95% CI: 1.315-3.718; p = 0.003). CONCLUSION: Early AKI affects more than half of patients with CS and is independently associated with 30-day all-cause mortality in CS, with highest risk of death among patients with AKI requiring CVVHDF.

Effect of Admission and Onset Time on the Prognosis of Patients With Cardiogenic Shock.

BACKGROUND: The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated. RESEARCH QUESTION: Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days? STUDY DESIGN AND METHODS: This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses. RESULTS: Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI. INTERPRETATION: Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT05575856; URL: www. CLINICALTRIALS: gov.

Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry.

OBJECTIVE: The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI). BACKGROUND: Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. METHODS: Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching. RESULTS: 273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528). CONCLUSION: AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Association of body mass index with 30-day all-cause mortality in cardiogenic shock.

BACKGROUND AND AIMS: This study investigates the prognostic impact of body mass index (BMI) on the risk of 30-day all-cause mortality in patients with cardiogenic shock (CS). Due to ongoing epidemiological developments, the characteristics of patients with cardiovascular disease are consistently changing. Especially increasing rates of obesity and associated comorbidities have been observed. However, data regarding the prognostic value of BMI in patients with CS remains inconclusive. METHODS AND RESULTS: Consecutive patients with CS were included from 2019 to 2021. The prognostic value of BMI (i.e., BMI 18.5-<25; 25-30 and >30 kg/m2) was analyzed using Kaplan-Meier and multivariable Cox proportional regression analyses regarding the primary endpoint of 30-day all-cause mortality. Additional risk stratification was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). 256 patients with a median BMI of 26.4 kg/m2 were included. The overall risk of 30-day all-cause mortality was 53.5%. Within the entire study cohort, BMI was not associated with the risk of 30-day all-cause mortality (log rank p ≥ 0.107). In contrast, BMI >30 kg/m2 was associated with higher risk of 30-day all-cause mortality when compared to BMI <25 kg/m2 in patients with AMI-CS (78% vs 47%; log rank p = 0.017), which was confirmed after multivariable adjustment (HR = 2.466; 95% CI 1.126-5.399; p = 0.024). However, BMI was not associated with mortality in patients with non-AMI-CS. CONCLUSION: BMI >30 kg/m2 was associated with increased risk of 30-day all-cause mortality in patients with AMI-CS, but not in non-AMI-CS.

Outcome of Patients With Cardiogenic Shock and Previous Right Ventricular Impairment Represented by Decreased Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio.

This study investigates the prognostic impact of known decreased ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) and TAPSE in patients with cardiogenic shock (CS). In patients with pulmonary artery hypertension and in critically ill patients, decreased TAPSE and TAPSE/PASP ratio are known to be negative predictors. However, studies regarding the prognostic impact in patients with CS are limited. Consecutive patients with CS from June 2019 to May 2021 treated at a single center were included. Medical history including echocardiographic parameters such as TAPSE and PASP was documented for each patient. The primary endpoint was all-cause mortality at 30 days. Statistical analyses included univariable t test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, and Cox proportional regression analyses. A total of 90 patients with CS and measurement of TAPSE and TAPSE/PASP ratio were included. TAPSE and TAPSE/PASP ratio measured several months before intensive care unit admission were both able to predict 30-day survival in CS patients, and were both lower in 30-day nonsurvivors. TAPSE/PASP ratio <0.4 mm/mmHg (log-rank p = 0.006) and TAPSE <18 mm (log-rank p = 0.004) were associated with increased risk of 30-day all-cause mortality. After multivariable adjustment, TAPSE/PASP ratio <0.4 mm/mmHg was not able to predict 30-day all-cause mortality, whereas TAPSE <18 mm was still significantly associated with the primary endpoint (hazard ratio 2.336, confidence interval 1.067 to 5.115, p = 0.034). In consecutive patients presenting with CS, compared to TAPSE alone, previously determined TAPSE/PASP ratio did not improve risk prediction for 30-day all-cause mortality.

D-Dimer Levels and the Risk of 30-Day All-Cause Mortality in Cardiogenic Shock Stratified by Etiology.

BACKGROUND: The study investigates the prognostic impact of D-dimer levels in patients with cardiogenic shock (CS). Although D-dimer levels were found to be associated with prognosis in various clinical settings such as heart failure or acute myocardial infarction (AMI), the prognostic role of D-dimer levels in CS patients has not yet been clarified. METHODS: Consecutive CS patients with and without concomitant AMI were prospectively included from 2019 to 2021. The prognostic impact of D-dimer levels was tested for 30-day all-cause mortality within the entire study cohort and stratified by the presence or absence of AMI. Statistical analyses included C-statistics, Kaplan-Meier, and multivariate Cox regression analyses. RESULTS: One hundred and twenty-three consecutive CS patients were included with an overall all-cause mortality at 30 days of 55%. The median D-dimer level on admission was 8.44 mg/L, whereas D-dimer levels were higher in 30-day non-survivors compared to survivors (median 13.0 vs. 5.2 mg/L; p = 0.011). D-dimer levels above the median were associated with an increased risk of 30-day all-cause mortality compared to patients with lower D-dimer levels (66% vs. 54%, log rank p = 0.050; HR = 1.594; 95% CI 0.979 - 2.594; p = 0.061), especially in patients with non-AMI-related CS (65% vs. 30%, log rank p = 0.010). The prognostic value of D-dimer levels was still demonstrated after multivariate adjustment (HR = 1.024; 95% CI 1.004 - 1.045; p = 0.020). CONCLUSIONS: D-dimer measurement may be a reliable biomarker to predict the risk of 30-day mortality in CS patients, especially in patients with non-AMI related CS.

Age-related outcomes in patients with cardiogenic shock stratified by etiology.

BACKGROUND: As a result of improved and novel treatment strategies, the spectrum of patients with cardiovascular disease is consistently changing. Overall, those patients are typically older and characterized by increased burden with comorbidities. Limited data on the prognostic impact of age in cardiogenic shock (CS) is available. Therefore, this study investigates the prognostic impact of age in patients with CS. METHODS: From 2019 to 2021, consecutive patients with CS of any cause were included. The prognostic value of age (i.e., 60-80 years and > 80 years) was investigated for 30-day all-cause mortality. Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses were performed for statistics. Subsequent risk assessment was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). RESULTS: 223 CS patients were included with a median age of 77 years (interquartile range: 69-82 years). No significant difference in 30-day all-cause mortality was observed for both age-groups (54.6% vs. 63.4%, log-rank P = 0.169; HR = 1.273, 95% CI: 0.886-1.831, P = 0.192). In contrast, when analyzing subgroups stratified by CS-etiology, AMI-related CS patients of the group > 80 years showed an increased risk of 30-day all-cause mortality (78.1% vs. 60.0%, log-rank P = 0.032; HR = 1.635, 95% CI: 1.000-2.673, P = 0.050), which was still evident after multivariable adjustment (HR = 2.072, 95% CI: 1.174-3.656, P = 0.012). CONCLUSIONS: Age was not associated with 30-day all-cause mortality in patients with CS of mixed etiology. However, increasing age was shown to be a significant predictor of increased mortality-risk in the subgroup of patients presenting with AMI-CS.

Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock.

This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.

Prognostic Value of the AST/ALT Ratio versus Bilirubin in Patients with Cardiogenic Shock.

This study investigates the prognostic value of the aspartate-to-alanine aminotransferase ratio (i.e., AST/ALT ratio) and bilirubin in patients with cardiogenic shock (CS). Despite ongoing improvements regarding the treatment of CS patients, invasive care unit (ICU) mortality in CS patients remains unacceptably high. Limited data regarding the prognostic value of the AST/ALT ratio and bilirubin in patients suffering from CS is available. The authors hypothesize the measurement of liver enzymes during the course of CS may be an easy and feasible method to assess right-heart dysfunction and prognosis in patients with CS. Consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from the day of disease onset (day 1), days 2, 3, 4 and 8. The prognostic value of the AST/ALT ratio and bilirubin was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses. A total of 157 CS patients were included, with an overall rate of all-cause mortality at 30 days of 51%. The median AST/ALT ratio on day 1 was 1.4, and the median bilirubin was 0.63 mg/dL. No association of the baseline AST/ALT ratio (HR = 1.005; 95% CI 0.649-1.558; p = 0.981) and bilirubin (HR = 1.320; 95% CI 0.834-2.090; p = 0.236) with the risk of 30-day all-cause mortality was found. In contrast, the AST/ALT ratio on day 4 was associated with the risk of 30-day all-cause mortality (HR = 2.826; 95% CI 1.227-6.510; p = 0.015), which was still evident after the multivariable adjustment (HR = 2.830; 95% CI 1.054-7.690; p = 0.039). The AST/ALT ratio during the course of ICU hospitalization from day 4-but not the baseline AST/ALT ratio and bilirubin-was associated with an increased risk of 30-day all-cause mortality in CS patients.

Does Atrial Fibrillation Deteriorate the Prognosis in Patients With Septic or Cardiogenic Shock?

Atrial fibrillation (AF) is associated with increased risk of mortality in various clinical conditions. However, the prognostic role of preexisting and new-onset AF in critically ill patients, such as patients with septic or cardiogenic shock remains unclear. This study investigates the prognostic impact of preexisting and new-onset AF on 30-day all-cause mortality in patients with septic or cardiogenic shock. Consecutive patients with sepsis, or septic or cardiogenic shock were enrolled in 2 prospective, monocentric registries from 2019 to 2021. Statistical analyses included Kaplan-Meier, multivariable logistic, and Cox proportional regression analyses. In total, 644 patients were included (cardiogenic shock: n = 273; sepsis/septic shock: n = 361). The prevalence of AF was 41% (29% with preexisting AF, 12% with new-onset AF). Within the entire study cohort, neither preexisting AF (log-rank p = 0.542; hazard ratio [HR] 1.075, 95% confidence interval [CI] 0.848 to 1.363, p = 0.551) nor new-onset AF (log-rank p = 0.782, HR = 0.957, 95% CI 0.683 to 1.340, p = 0.797) were associated with 30-day all-cause mortality compared with non-AF. In patients with AF, ventricular rates >120 beats/min compared with ≤120 beats/min were shown to increase the risk of reaching the primary end point in AF patients with cardiogenic shock (log-rank p = 0.006, HR 1.886, 95% CI 1.164 to 3.057, p = 0.010). Furthermore, logistic regression analyses suggested increased age was the only predictor of new-onset AF (odds ratio 1.042, 95% CI 1.018 to 1.066, p = 0.001). In conclusion, neither the presence of preexisting AF nor the occurrence of new-onset AF was associated with the risk of 30-day all-cause mortality in consecutive patients admitted with cardiogenic shock.

Effect of Hemoglobin Levels in Patients with Cardiogenic Shock of Any Cause: Insights from a Single-Centre, Prospective Registry.

BACKGROUND: Data regarding the short-term prognostic impact of hemoglobin levels in cardiogenic shock (CS) patients is limited. The study examines the prognostic impact of hemoglobin levels in patients with CS. METHODS: Consecutive patients with CS of any etiology from 2019 to 2021 were included at one institution. Hemoglobin levels were retrieved from the day of admission (i.e., day 1), and on days 2, 3, 4, and 8 of intensive care unit (ICU) treatment thereafter. The primary endpoint was 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman´s correlations, C-statistics, Kaplan-Meier analyses as well as multivariable logistic and Cox regression analyses. RESULTS: From a total of 250 consecutive patients admitted with CS, 54% died within 30 days. Hemoglobin levels on day 4 and on day 8 were associated with moderate discrimination for 30-day all-cause mortality (area under the curve (AUC) 0.598 - 0.666), whereas hemoglobin level on day 1 was not predictive for 30-day all-cause mortality (AUC = 0.504). There was no association with 30-day all-cause mortality when stratified by the presence of anemia (defined as hemoglobin level < 12 g/dL) on day 1 (54% vs. 55%; log rank p = 0.906; HR = 0.981; 95% CI 0.698 - 1.378; p = 0.910). However, a decrease of hemoglobin by > 2 g/dL from day 1 to day 3 of ICU treatment was associated with an increased risk of 30-day all-cause mortality (56% vs. 41%; log rank p = 0.014; HR = 1.831; 95% CI 1.108 - 3.026; p = 0.018). CONCLUSIONS: Hemoglobin levels on day 1 were not associated with prognosis in CS. However, an early decrease of hemoglobin levels from day 1 to day 3 indicated impaired short-term prognosis in CS patients.

Effect of Cardiovascular Risk Factors on 30-Day All-Cause Mortality in Cardiogenic Shock.

Although previous studies investigated the influence of cardiovascular risk (CVR) factors in patients with acute coronary syndrome, data concerning the effect of CVR factors on the prognosis of patients with cardiogenic shock (CS) is scarce. Consecutive patients with CS were prospectively included from 2019 to 2021. The prognosis of patients with "low CVR" (i.e., 0-1 CVR factors) was compared to patients with "high CVR" (i.e., 2-4 CVR factors) according to presence or absence of arterial hypertension, diabetes mellitus, hyperlipidaemia or smoking. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier and Cox proportional regression analyses. 273 consecutive patients with CS were included. 28% presented with low CVR and 72% with high CVR. Within the entire study cohort, the risk of 30-day all-cause mortality did not differ between patients with high and low CVR (55% vs. 57%; log rank p = 0.727; HR = 0.942; 95% CI 0.663-1.338; p = 0.738). Even after multivariable adjustment, high CVR was not associated with an elevated risk of 30-day all-cause mortality (HR = 1.039; 95% CI 0.648-1.667; p = 0.873). The presence of arterial hypertension (55% vs. 58%; log rank p = 0.564; HR = 0.906; 95% CI 0.638-1.287; p = 0.582), diabetes mellitus (60% vs. 52%; log rank p = 0.215; HR = 1.213; 95% CI 0.881-1.671; p = 0.237) and a history of smoking (56% vs. 56%; log rank p = 0.725; HR = 0.945; 95% CI 0.679-1.315; p = 0.737) did not significantly influence short-term prognosis.. Only the absence of hyperlipidaemia significantly decreased the risk of all-cause mortality (65% vs. 51%; log rank p = 0.038; HR = 0.718; 95% CI 0.516-0.998; p = 0.049), which was no longer observed after multivariable adjustment (HR = 0.801; 95% CI 0.536-1.195; p = 0.277). In conclusion, neither the overall CVR nor individual CVR factors were associated with the risk of 30-day all-cause mortality in patients with CS.

The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock.

OBJECTIVE: The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock. BACKGROUND: Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available. METHODS: All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses. RESULTS: Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P  = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P  = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P  = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P  = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P  = 0.019). CONCLUSION: Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.

Does Albumin Predict the Risk of Mortality in Patients with Cardiogenic Shock?

This study investigates the prognostic impact of albumin levels in patients with cardiogenic shock (CS). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Limited data regarding the prognostic value of albumin in patients with CS is available. All consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from the day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. The prognostic impact of albumin was tested for 30-day all-cause mortality. Moreover, the prognostic performance of albumin decline during ICU treatment was examined. Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, multivariable mixed analysis of variance (ANOVA), C-Statistics, and Cox proportional regression analyses. In total, 230 CS patients were included, with an overall all-cause mortality at 30 days of 54%. The median albumin on day 1 was 30.0 g/L. Albumin on day 1 was able to discriminate between 30-day survivors and non-survivors (area under the curve (AUC) 0.607; 0.535-0.680; p = 0.005). CS patients with albumin < 30.0 g/L were associated with an increased risk of 30-day all-cause mortality (63% vs. 46%; log-rank p = 0.016; HR = 1.517; 95% CI 1.063-2.164; p = 0.021), which was demonstrated even after multivariable adjustment. Moreover, a decrease of albumin levels by ≥20% from day 1 to day 3 was accompanied by a higher risk of 30-days all-cause mortality (56% vs. 39%; log-rank p = 0.036; HR = 1.645; 95% CI 1.014-2.669; p = 0.044). Especially when combined with lactate, creatinine, and cardiac troponin I, reliable discrimination of 30-day all-cause mortality was observed, including albumin in CS risk stratification models (AUC = 0.745; 95% CI 0.677-0.814; p = 0.001). In conclusion, low baseline albumin levels as well as a decay of albumin levels during the course of ICU treatment, deteriorate prognostic outcomes in CS patients. The additional assessment of albumin levels may further improve risk stratification in CS patients.

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

BACKGROUND: Mortality rates following cardiogenic shock (CS) have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with CS. METHODS: Consecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were applied for statistics. RESULTS: From a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756-1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713-1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710-1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677-1.783; p = 0.704). CONCLUSION: Sex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology. (clinicaltrials.gov identifier: NCT05575856).

Differences in Outcome of Patients with Cardiogenic Shock Associated with In-Hospital or Out-of-Hospital Cardiac Arrest.

Cardiogenic Shock (CS) complicated by in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) has a poor outcome. However, studies regarding the prognostic differences between IHCA and OHCA in CS are limited. In this prospective, observational study, consecutive patients with CS were included in a monocentric registry from June 2019 to May 2021. The prognostic impact of IHCA and OHCA on 30-day all-cause mortality was tested within the entire group and in the subgroups of patients with acute myocardial infarction (AMI) and coronary artery disease (CAD). Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as uni- and multivariable Cox regression analyses. A total of 151 patients with CS and cardiac arrest were included. IHCA on ICU admission was associated with higher 30-day all-cause mortality compared to OHCA in univariable COX regression and Kaplan-Meier analyses. However, this association was solely driven by patients with AMI (77% vs. 63%; log rank p = 0.023), whereas IHCA was not associated with 30-day all-cause mortality in non-AMI patients (65% vs. 66%; log rank p = 0.780). This finding was confirmed in multivariable COX regression, in which IHCA was solely associated with higher 30-day all-cause mortality in patients with AMI (HR = 2.477; 95% CI 1.258-4.879; p = 0.009), whereas no significant association could be seen in the non-AMI group and in the subgroups of patients with and CAD. CS patients with IHCA showed significantly higher all-cause mortality at 30 days compared to patients with OHCA. This finding was primarily driven by a significant increase in all-cause mortality at 30 days in CS patients with AMI and IHCA, whereas no difference could be seen when differentiated by CAD.

C-Reactive Protein and White Blood Cell Count in Cardiogenic Shock.

This study examines the prognostic impact of C-reactive protein (CRP) and white blood cell (WBC) counts in patients with cardiogenic shock (CS). Data regarding the prognostic impact of inflammatory biomarkers in CS are scarce. All consecutive patients with CS from 2019 to 2021 admitted to a cardiac intensive care unit (ICU) were included at one institution. Laboratory measurements were retrieved from the day of admission (i.e., day 1), as well as days 2, 3, 4, and 8. The primary endpoint was 30-day all-cause mortality. Statistical analyses included univariate t-tests, Spearman's correlations, C-statistics, Kaplan-Meier, and Cox regression analyses. From a total of 240 consecutive patients admitted with CS, 55% died within 30 days. CRP levels on days 3 to 8 were associated with reliable discrimination for 30-day all-cause mortality (area under the curve (AUC): 0.623-0.754), whereas CRP on day 1 was not (AUC = 0.514). In line, CRP > 100 mg/L on day 3 (56% vs. 37%; log-rank p = 0.023; HR = 1.702; 95% CI 1.060-2.735; p = 0.028) and especially a CRP increase of at least 200% from days 1 to day 3 (51% vs. 35%; log-rank p = 0.040; HR = 1.720; 95% CI 1.006-2.943; p = 0.048) were associated with an increased risk of all-cause mortality. Furthermore, WBC on day 1 discriminated 30-day all-cause mortality (AUC = 0.605; p = 0.005) with an increased risk of all-cause mortality in patients admitted with WBC > 10 × 106/mL (59% vs. 40%; log-rank p = 0.036; HR = 1.643; 95% CI 1.010-2.671; p = 0.045). In conclusion, WBC count on admission as well as CRP levels during the course of ICU treatment were associated with 30-day all-cause mortality. Specifically, an increase of CRP levels by at least 200% from day 1 to day 3 during the course of ICU treatment was associated with an increased risk of 30-day all-cause mortality. The present study is one of the first to describe the prognostic value of inflammatory biomarkers in consecutive all-comer CS patients treated at a cardiac ICU.

Impact of Lactate on 30-Day All-Cause Mortality in Patients with and without Out-of-Hospital Cardiac Arrest Due to Cardiogenic Shock.

In patients with cardiogenic shock (CS) due to myocardial infarction, elevated lactate levels are known to be negative predictors. Studies regarding the prognostic impact in patients with CS complicated by out-of-hospital cardiac arrest (OHCA) are limited. Two hundred and sixty-three consecutive patients with CS were included. The prognostic value of lactate on days 1, 2, 3, 4 and 8 was tested stratified by OHCA and non-OHCA. Statistical analyses included the univariable t-test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, as well as multivariable mixed analysis of variance (ANOVA) and Cox proportional regression analyses. The primary endpoint of all-cause mortality occurred in 49.4% of the non-OHCA group and in 63.4% of the OHCA group. Multivariable regression models showed an association of lactate values with 30-day all-cause mortality in the non-OHCA (p = 0.024) and OHCA groups (p = 0.001). In Kaplan-Meier analyses, patients with lactate levels ≥ 4 mmol/L (log-rank p = 0.001) showed the highest risk for 30-day all-cause mortality in the non-OHCA as well as in the OHCA group. However, in C-statistics lactate on days 1 and 8 had a better discrimination for 30-day all-cause mortality in the OHCA group compared to the non-OHCA group. In conclusion, patients presenting with CS lactate levels showed a good prognostic performance, with and without OHCA. Especially, lactate levels on days 1 and 8 were more accurate in the discrimination for all-cause mortality in CS-patients with OHCA.