Comparative Prognostic Accuracy of Risk Prediction Models for Cardiogenic Shock.

OBJECTIVES: Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock. METHODS: Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality. CONCLUSIONS: In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods.

Contrast echocardiography in Canada: Canadian Cardiovascular Society/Canadian Society of Echocardiography position paper.

As an adjunct to transthoracic, transesophageal and stress echocardiography, contrast echocardiography (CE) improves the diagnostic accuracy of technically suboptimal studies when used in conjunction with harmonic imaging. Intravenous ultrasound contrast agents are indicated for left ventricular (LV) opacification and improvement of LV endocardial border delineation in patients with suboptimal acoustic windows. Demonstrated benefits of CE include improvement in the accuracy of LV measurements, regional wall motion assessment, evaluation of noncompaction cardiomyopathy, thrombus detection, Doppler signal enhancement and conjunctive use with stress echocardiography. Studies have shown the value of CE in the assessment and quantification of myocardial perfusion, and recent clinical trials have suggested a role for contrast perfusion imaging in the stratification of patients with suspected coronary artery disease. While it adds some time and cost to the echocardiographic study, CE frequently obviates the need for additional specialized, expensive and less accessible cardiac investigations, and allows for prompt and optimal subsequent patient management. Despite its proven advantages, CE is presently underused in Canada, and this situation will, unfortunately, not improve until several barriers to its use are overcome. Resolving these important hurdles is vital to the future of CE and to its eventual implementation into clinical practice of promising contrast-based diagnostic and therapeutic applications, including the assessment of perfusion by myocardial CE.

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient.

Out of hospital cardiac arrest (OHCA) is associated with a low rate of survival to hospital discharge and high rates of neurological morbidity among survivors. Programmatic efforts to institute and integrate OHCA best care practices from the bystander response through to the in-hospital phase have been associated with improved patient outcomes. This Canadian Cardiovascular Society position statement was developed to provide comprehensive yet practical recommendations to guide the in-hospital care of OHCA patients. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system recommendations have been generated. Recommendations on initial care delivery on the basis of presenting rhythm, appropriate use of targeted temperature management, postarrest angiography, and revascularization in the initial phase of care of the OHCA patient are detailed within this statement. In addition, further description of best practices on sedation, use of neuromuscular blockade, oxygenation targets, hemodynamic monitoring, and blood product transfusion triggers in the critical care environment are contained in this document. Last, discussion of optimal care systems for the OHCA patient is provided. These guidelines aim to serve as a practical guide to optimize the in-hospital care of survivors of cardiac arrest and encourage the adoption of "best practice" protocols and treatment pathways. Emphasis is placed on integrating these aspects of in-hospital care as part of a postarrest "care bundle." It is hoped that this position statement can assist all medical professionals who treat survivors of cardiac arrest.