Out of hospital cardiac arrest - new insights and a call for a worldwide registry and guidelines.

INTRODUCTION: Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD: We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS: A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION: Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

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.

Immature Platelet Fraction and Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation.

INTRODUCTION: Immature platelets or reticulated platelets are newly released thrombocytes. They can be identified by their large size and high RNA cytoplasm concentration. Immature platelet fraction (IPF) represents the percentage of immature circulative platelets relative to the total number of platelets. The role of IPF in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. The aim of the current trial was to assess the levels of IPF in patients undergoing TAVI and correlation with clinical outcomes. MATERIAL AND METHODS: Immature platelet fraction levels were measured 3 times in all patients (preprocedure, 1-2 days post-procedure and 1-month post-procedure). Immature platelet fraction measurement was carried out using an autoanalyzer (Sysmex XE-2100). Patients were followed for 12 months. Primary outcomes were defined as complications during hospitalizations, rehospitalization, and mortality. RESULTS: Fifty-one patients were included in the study. Mean age was 79.8 (±9.6), and 28 (55%) were women. Twenty-one patients (41%) had complications: Of them, 6 of 21 (29%) occurred during hospitalizations (2-vascular complications; 2-sepsis, 2-implantation of a pacemaker), 9 of 21 (43%) patients were rehospitalized after the index admission, and 6 patients died during the follow-up period. Multivariate Cox regression analysis found that IPF < 7% in at least one of the 3 tests was associated with worse outcomes (hazard ratio 3.42; 95% CI 1.11-10.5, P = .032). CONCLUSION: Immature platelet fraction >7% in patients undergoing TAVI is associated with worse outcomes. Further studies are needed to better understand this phenomenon.

Acute coronary occlusion and percutaneous coronary intervention after out-of-hospital cardiac arrest.

OBJECTIVES: Early coronary angiography (CAG) has been recommended in selected patients following out-of-hospital-cardiac-arrest (OHCA). We aimed to identify clinical features associated with acute coronary occlusion (ACO) and evaluate the associations between ACO, successful percutaneous coronary intervention (PCI) and outcomes in this population. METHODS: We included comatose OHCA patients treated with targeted temperature management (TTM) between December 2005 and September 2016 who underwent early CAG within 24 hours. The co-primary outcomes were all-cause 30-day mortality and good neurological outcome (modified Rankin Score [mRS] ≤2) at hospital discharge. RESULTS: Among 155 patients (93% shockable arrest rhythm, 55% with ST elevation), 133 (86%) had coronary artery stenosis ≥50% and 65 (42%) had ACO. ST elevation (sensitivity 74%, specificity 59%, OR 4.0, 95% CI 2.0-8.1) and elevated first troponin (sensitivity 88%, specificity 26%, OR 2.5, 95% CI 1.1-6.1) had limited sensitivity and specificity for ACO. Unadjusted 30-day mortality did not differ significantly by coronary disease severity or ACO. Successful PCI was associated with a lower risk of 30-day mortality (adjusted HR 0.5, 95% CI 0.2-0.9, P=.03), especially among patients with ACO (adjusted HR 0.4, 95% CI 0.1-0.9, P=0.03). After adjustment, ACO and PCI were not associated with the probability of good neurological outcome. CONCLUSIONS: In this select cohort of resuscitated OHCA patients undergoing CAG, unstable coronary disease is highly prevalent and successful PCI was associated with a higher probability of 30-day survival, especially among those with ACO. Neither ACO nor successful PCI were independently associated with good neurological outcome.

Troponin level at presentation as a prognostic factor among patients presenting with non-ST-segment elevation myocardial infarction.

BACKGROUND: Timely reperfusion within 120 min is strongly recommended in patients presenting with non-ST-segment myocardial infarction (NSTEMI) with very high-risk features. Evidence regarding the use of high-sensitivity cardiac troponin (hs-cTn) concentration upon admission for the risk-stratification of patients presenting with NSTEMI to expedite percutaneous coronary intervention (PCI) and thus potentially improve outcomes is limited. METHODS: All patients admitted to a tertiary care center ICCU between July 2019 and July 2022 were included. Hs-cTnI levels on presentaion were recorded, dividing patients into quartiles based on baseline hs-cTnI. Association between initial hs-cTnI and all-cause mortality during up to 3 years of follow-up was studied. RESULTS: A total of 544 NSTEMI patients with a median age of 67 were included. Hs-cTnI levels in each quartile were: (a) ≤122, (b) 123-680, (c) 681-2877, and (d) ≥2878 ng/L. There was no difference between the initial hs-cTnI level groups regarding age and comorbidities. A higher mortality rate was observed in the highest hs-cTnI quartile as compared with the lowest hs-cTnI quartile (16.2% vs. 7.35%, p = .03) with hazard ratio (HR) for mortality of 2.6 (95% confidence interval [CI]: 1.23-5.4; p = .012) in the unadjusted model, and HR of 2.06 (95% CI: 1.01-4.79; p = .047) with adjustment for age, gender, serum creatinine, and significant comorbidities. CONCLUSIONS: Patients with NSTEMI and higher hs-cTnI levels upon admission faced elevated mortality risk. This underscores the need for further prospective investigations into early reperfusion strategies' impact on NSTEMI patients' mortality, based on admission troponin elevation.

Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit.

BACKGROUND: A high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients. METHODS: We included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7-0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables. RESULTS: We included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = -0.59) and LVOT VTI (r = -0.41), as were both systemic vascular resistance index (r = -0.43) and LVEF (r = -0.23). CONCLUSION: CICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.

Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study.

BACKGROUND: Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS: A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS: A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS: The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.

Clinical and Echocardiographic Predictors of Recovery of Moderate-to-severe Sepsis-associated Acute Kidney Injury in Critically Ill Patients.

Background: Acute kidney injury (AKI) is associated with significant short- and long-term morbidity and mortality. In critically ill patients with sepsis, AKI tends to be more severe, more likely to require kidney replacement therapy (KRT), with less chance of recovery. Consequently, critically ill patients with sepsis-associated AKI (SA-AKI) have extended intensive care unit (ICU) stays and higher mortality rates. This study evaluated the predictive value of clinical and transthoracic echocardiographic (TTE) parameters for recovery from moderate-to-severe SA-AKI in critically ill patients. Methods: This single-center historical cohort study was conducted at a tertiary academic medical center. We analyzed the data of all adults (age ≥18 years) admitted to the ICU at Mayo Clinic, Rochester, MN, from June 1, 2018, to December 31, 2020. We included all patients who developed sepsis within the initial 24 h of their ICU stay. Results: We identified 2919 eligible septic patients with available TTE, among which 1431 patients (49%) had moderate-to-severe SA-AKI. The mean age of the patients was 68 ± 15 years, and the male-to-female ratio was 1.3:1. The most common comorbidities were diabetes mellitus and chronic lung and kidney diseases. Clinical predictors associated with SA-AKI non-recovery were the presence of stage III AKI (HR 1.5, 95% CI 1.0-2.1, p = 0.03) and utilization of kidney replacement therapy (KRT) (HR 6.8, 95% CI 3.6-12.4, p = 0.01). On the other hand, higher TAPSE was the only TTE variable associated with SA-AKI recovery (HR 1.1; 95% CI 1.08-1.15; p = 0.01). Conclusion: Our data from a single-center provide new information on the clinical (AKI stage, utilization of KRT, BMI, and peak serum creatinine) and echocardiographic features (TAPSE) associated with improved recovery in SA-AKI. There is a definite knowledge gap in the current literature regarding optimizing recovery in moderate-to-severe SA-AKI. Larger, multi-center studies are required to confirm these findings.

Echocardiographic findings in cardiogenic shock due to acute myocardial infarction versus heart failure.

BACKGROUND: Acute myocardial infarction (AMI) is the prototypical cause of cardiogenic shock (CS), yet CS due to heart failure (HF-CS) is increasingly common. Little is known regarding cardiac function in AMI-CS versus HF-CS. We compared transthoracic echocardiography (TTE) findings in AMI-CS versus HF-CS and identified predictors of mortality in AMI-CS patients. METHODS: We performed a single-center, retrospective analysis of CS admissions between 2007 and 2018. We compared baseline demographic and TTE parameters in patients with AMI-CS and HF-CS as well as ST elevation myocardial infarction (STEMI)-CS versus non-ST elevation myocardial infarction (NSTEMI)-CS. RESULTS: We included 893 unique patients, including 581 (65%) with AMI-CS. AMI-CS patients were older but had lower illness severity and non-cardiac comorbidity burden. AMI-CS patients had better left ventricular function (LVEF 35% versus 28%), lower biventricular filling pressures, and higher stroke volume versus those with HF-CS. Among TTE measurements, myocardial contraction fraction had the highest discrimination for mortality in AMI-CS (AUC: 0.64); AUC values for LVEF and SOFA score were 0.61 and 0.65, respectively. Differences in TTE findings between STEMI-CS versus NSTEMI-CS were modest. There were no significant differences in unadjusted or adjusted in-hospital mortality between AMI-CS and HF-CS (31% versus 35%) or STEMI-CS and NSTEMI-CS (31% versus 30%) groups (all p > 0.05). CONCLUSIONS: Patients with HF-CS and AMI-CS differ in terms of clinical and TTE variables yet have similar prognoses. TTE is useful in determining prognosis of patients admitted with AMI-CS and may allow for early triage and directed therapy.

Nonagenarians admission and prognosis in a tertiary center intensive coronary care unit - a prospective study.

BACKGROUND: With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). METHODS: We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 - July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. RESULTS: A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). CONCLUSION: With increasing life expectancy, the prevalence of nonagenarians in ICCU's is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit.

BACKGROUND: Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. METHODS: Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. OUTCOMES: A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p < 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p < 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47-3.62)] as compared with the NBT-group, p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760-0.852)]. CONCLUSIONS: BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted.

Urine Output and Mortality in Patients Resuscitated from out of Hospital Cardiac Arrest.

BACKGROUND: Limited data exist regarding urine output (UO) as a prognostic marker in out-of-hospital-cardiac-arrest (OHCA) survivors undergoing targeted temperature management (TTM). METHODS: We included 247 comatose adult patients who underwent TTM after OHCA between 2007 and 2017, excluding patients with end-stage renal disease. Three groups were defined based on mean hourly UO during the first 24 h: Group 1 (<0.5 mL/kg/h, n = 73), Group 2 (0.5-1 mL/kg/h, n = 81) and Group 3 (>1 mL/kg/h, n = 93). Serum creatinine was used to classify acute kidney injury (AKI). The primary and secondary outcomes respectively were in-hospital mortality and favorable neurological outcome at hospital discharge (modified Rankin Scale [mRS]<3). RESULTS: In-hospital mortality decreased incrementally as UO increased (adjusted OR 0.9 per 0.1 mL/kg/h higher; p = 0.002). UO < 0.5 mL/kg/h was strongly associated with higher in-hospital mortality (adjusted OR 4.2 [1.6-10.8], p = 0.003) and less favorable neurological outcomes (adjusted OR 0.4 [0.2-0.8], p = 0.007). Even among patients without AKI, lower UO portended higher mortality (40% vs 15% vs 9% for UO groups 1, 2, and 3 respectively, p < 0.001). CONCLUSION: Higher UO is incrementally associated with lower in-hospital mortality and better neurological outcomes. Oliguria may be a more sensitive early prognostic marker than creatinine-based AKI after OHCA.

Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest.

BACKGROUND: Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. METHODS: We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. RESULTS: We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. CONCLUSIONS: Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.

Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients.

AIMS: Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. METHODS AND RESULTS: We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality. CONCLUSIONS: Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

Society for cardiovascular angiography and intervention shock classification predicts mortality after out-of-hospital cardiac arrest.

BACKGROUND: Shock is common in patients resuscitated from out-of-hospital-cardiac arrest (OHCA). Shock severity can be classified using the Society for Cardiovascular Angiography and Intervention (SCAI) Shock Classification. We aimed to examine the association of SCAI Shock Stage with in-hospital mortality and neurological outcome in comatose OHCA patients undergoing targeted temperature management (TTM). METHODS: This study included 213 comatose adult patients who underwent TTM after OHCA between January 2007 and December 2017. SCAI shock stage (A through E) was assigned using data from the first 24 hours, with shock defined as SCAI shock stage C/D/E. Good neurological outcome was defined as a modified Rankin Scale (mRS) less than 3. RESULTS: In-hospital mortality was higher in the 144 (67.6%) patients with shock (46.5% v. 23.2%, unadjusted OR 2.88, 95% CI 1.51-5.51, p = 0.001). After multivariable adjustment, each SCAI shock stage was incrementally associated with an increased risk of in-hospital mortality (adjusted OR 1.80 per stage, 95% CI 1.20-2.71, p = 0.003). Good neurological outcome was less likely in patients with shock (31.9% vs. 53.6%, unadjusted OR 0.41, 95% CI 0.23-0.73, p = 0.002) and a higher SCAI shock stage was incrementally associated with a lower likelihood of good neurological outcome after multivariable adjustment (adjusted OR 0.67 per stage, 95% CI 0.48-0.93, p = 0.015). CONCLUSION: Higher shock severity, defined using the SCAI Shock Classification, was associated with increased in-hospital mortality and a lower likelihood of good neurological outcome in OHCA patients treated with TTM.

Outcomes Associated With Cardiac Arrest in Patients in the Cardiac Intensive Care Unit With Cardiogenic Shock.

Cardiac arrest (CA) is common and has been associated with adverse outcomes in patients with cardiogenic shock (CS). We sought to determine the prevalence, patient characteristics, and outcomes of CA in cardiovascular intensive care unit patients with CS. We queried cardiovascular intensive care unit admissions from 2007 to 2018 with an admission diagnosis of CS and compared patients with and without CA. Temporal trends were assessed using linear regression. The primary and secondary outcomes of in-hospital and 1-year mortality were analyzed using logistic regression and Cox proportional-hazards analysis, respectively. We included 1,498 patients, and CA was present in 510 patients (34%), with 258 (50.6% of patients with CA) having ventricular fibrillation (VF). Mean age was 68 ± 14 years, and 37% were females. The prevalence of CA decreased over time (from 43% in 2007 to 24% in 2018, p <0.001). Hospital mortality was 33.3% and decreased over time in patients without CA (from 30% in 2007 to 22% in 2018, p = 0.05), but not in patients with CA (p = 0.71). CA was associated with a higher risk of hospital mortality (51.0% vs 24.2%, adjusted odds ratio 2.15, 95% confidence interval [CI] 1.52 to 3.05, p <0.001), with no difference between VF CA and non-VF CA (p = 0.64). CA was associated with higher 1-year mortality (adjusted hazard ratio 1.53, 95% CI 1.24 to 1.89, p <0.001). In conclusion, CA is present in 1 of 3 of CS hospitalizations and confers a substantially higher risk of hospital and 1-year mortality with no improvement during our 12-year study period contrary to prevailing trends.

Noninvasive echocardiographic cardiac power output predicts mortality in cardiac intensive care unit patients.

BACKGROUND: Low cardiac power output (CPO), measured invasively, can identify critically ill patients at increased risk of adverse outcomes, including mortality. We sought to determine whether non-invasive, echocardiographic CPO measurement was associated with mortality in cardiac intensive care unit (CICU) patients. METHODS: Patients admitted to CICU between 2007 and 2018 with echocardiography performed within one day (before or after) admission and who had available data necessary for calculation of CPO were evaluated. Multivariable logistic regression determined the relationship between CPO and adjusted hospital mortality. RESULTS: A total of 5,585 patients (age of 68.3 ± 14.8 years, 36.7% female) were evaluated with admission diagnoses including acute coronary syndrome (ACS) in 56.7%, heart failure (HF) in 50.1%, cardiac arrest (CA) in 12.2%, shock in 15.5%, and cardiogenic shock (CS) in 12.8%. The mean left ventricular ejection fraction (LVEF) was 47.3 ± 16.2%, and the mean CPO was 1.04 ± 0.37 W. There were 419 in-hospital deaths (7.5%). CPO was inversely associated with the risk of hospital mortality, an association that was consistent among patients with ACS, HF, and CS. On multivariable analysis, higher CPO was associated with reduced hospital mortality (OR 0.960 per 0.1 W, 95CI 0.0.926-0.996, P = .03). Hospital mortality was particularly high in patients with low CPO coupled with reduced LVEF, increased vasopressor requirements, or higher admission lactate. CONCLUSIONS: Echocardiographic CPO was inversely associated with hospital mortality in unselected CICU patients, particularly among patients with increased lactate and vasopressor requirements. Routine calculation and reporting of CPO should be considered for echocardiograms performed in CICU patients.

Peripheral blood neutrophil-to-lymphocyte ratio is associated with mortality across the spectrum of cardiogenic shock severity.

PURPOSE: To evaluate the association between the neutrophil-to-lymphocyte ratio (NLR) and mortality across the cardiogenic shock (CS) severity spectrum, defined using the Society of Cardiovascular Interventions and Angiography (SCAI) shock stages. MATERIALS AND METHODS: We retrospectively analyzed cardiac intensive care unit (CICU) patients between 2007 and 2015. Predictors of in-hospital mortality were analyzed using logistic regression. RESULTS: We included 8280 patients aged 67.3 ± 15.2 years (37.2% females). Elevated NLR (≥7) was present in 45% of patients. NLR increased with worsening SCAI stage and was associated with higher in-hospital mortality in shock stages A to C (all p < 0.001). After multivariable adjustment, NLR remained associated with higher in-hospital mortality (adjusted odds ratio 1.05 per 3.5 NLR units, 95% CI 1.03-1.08, p < 0.001), with an optimal cut-off of ≥7 (in-hospital mortality 13.1% vs. 4.1%, adjusted odds ratio 1.44, 95% CI 1.14-1.81, p = 0.002). Patients in SCAI stage A or B with NLR ≥7 had higher in-hospital mortality than patients in SCAI stage B or C with NLR <7, respectively. CONCLUSIONS: Elevated NLR is associated with higher in-hospital mortality in CICU patients with or at risk for CS, emphasizing the importance of systemic inflammation as a determinant of outcomes in CS patients.

Associations of Vasopressor Requirements With Echocardiographic Parameters After Out-of-Hospital Cardiac Arrest.

BACKGROUND: Post-arrest hypotension is common after out of hospital cardiac arrest (OHCA) and many patients resuscitated after OHCA will require vasopressors. We sought to determine the associations between echocardiographic parameters and vasopressor requirements in OHCA patients. METHODS: We retrospectively analyzed adult patients with OHCA treated with targeted temperature management between December 2005 and September 2016 who underwent a transthoracic echocardiogram (TTE). Categorical variables were compared using 2-tailed Fisher's exact and Pearson's correlation coefficients and variance (r2) values were used to assess relationships between continuous variables. RESULTS: Among 217 included patients, the mean age was 62 ± 12 years, including 74% males. The arrest was witnessed in 90%, the initial rhythm was shockable in 88%, and 58% received bystander CPR. At the time of TTE, 41% of patients were receiving vasopressors; this group of patients was older, had greater severity of illness, higher inpatient mortality and left ventricular ejection fraction (LVEF) was modestly lower (36.8 ± 17.1% vs. 41.4 ± 16.4%, P = 0.04). Stroke volume, cardiac power output and left ventricular stroke work index correlated with number of vasopressors (Pearson r -0.24 to -0.34, all P < 0.002), but the correlation with LVEF was weak (Pearson r -0.13, P = 0.06). CONCLUSIONS: In patients after OHCA, left ventricular systolic dysfunction was associated with the need for vasopressors, and Doppler TTE hemodynamic parameters had higher correlation coefficients compared with vasopressor requirements than LVEF. This emphasizes the complex nature of shock after OHCA, including pathophysiologic processes not captured by TTE assessment alone.