Chest
Volume 161, Issue 3, March 2022, Pages 697-709
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Critical Care: Original Research
Biventricular Function and Shock Severity Predict Mortality in Cardiac ICU Patients

https://doi.org/10.1016/j.chest.2021.09.032Get rights and content

Background

Ventricular function, including left ventricular systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and biventricular dysfunction (BVD), contribute to shock in cardiac ICU (CICU) patients, but the prognostic usefulness remains unclear.

Research Question

Do patients with ventricular dysfunction have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage?

Study Design and Methods

We identified patients in the CICU admitted with available echocardiography data. LVSD was defined as left ventricular ejection fraction < 40%, RVSD as moderate or greater systolic dysfunction by semiquantitative measurement, and BVD as the presence of both. Multivariate logistic regression determined the relationship between ventricular dysfunction and adjusted in-hospital mortality as a function of SCAI stage.

Results

The study population included 3,158 patients with a mean ± SD age of 68.2 ± 14.6 years, of which 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and BVD in 16.4%. After adjustment for SCAI shock stage, no difference in in-hospital mortality was found between patients with LVSD or RVSD and those without ventricular dysfunction (P > .05), but BVD was associated independently with higher in-hospital mortality (adjusted hazard ratio, 1.815; 95% CI, 1.237-2.663; P = .0023). The addition of ventricular dysfunction to the SCAI staging criteria increased discrimination for hospital mortality (area under the receiver operating characteristic curve, 0.784 vs 0.766; P < .001).

Interpretation

Among patients admitted to the CICU, only BVD was associated independently with higher hospital mortality. The addition of echocardiography assessment to the SCAI shock criteria may facilitate improved clinical risk stratification.

Section snippets

Study Population

This study was approved by the institutional review board of Mayo Clinic (Identifier, 16-000722) as posing minimal risk to patients and was performed under a waiver of informed consent. We retrospectively analyzed the index CICU admission of consecutive unique adult patients ≥ 18 years of age admitted to the CICU at Mayo Clinic Hospital St. Mary’s Campus between January 1, 2007, and December 31, 2015, who had undergone transthoracic echocardiography (TTE) within 1 day before or after CICU

Study Population

Of 10,004 unique CICU patient admissions, only 5,906 patients had an appropriately timed TTE, and the 4,098 others were excluded (1,616 without TTE and 2,482 with TTE more than 1 day before or after CICU admission). Among this group, only 3,158 had data on RV and left ventricular (LV) function and were included in the final study population; 531 patients were excluded because of missing data for LVEF, and 2,217 were excluded because of missing data on RV function (e-Fig 1). Patients in the

Discussion

In this novel study of a large single-center CICU patient population with comprehensive echocardiographic data, we demonstrate that hospital mortality is associated with the presence and type of ventricular dysfunction in a manner additive to the clinical assessment of shock severity. The prevalence of all forms of ventricular dysfunction increased with increasing CS severity, but a significant minority of patients classified as SCAI shock stage D or E showed no more than mild ventricular

Interpretation

Echocardiographic assessment of ventricular dysfunction provides important clinical and prognostic information to clinicians caring for patients in the CICU. The presence of BVD is associated with higher hospital mortality at any SCAI CS stage, and patients without echocardiographic ventricular dysfunction are a lower-risk cohort. Future CS staging criteria may benefit from the inclusion of ventricular dysfunction assessment in the risk stratification of patients with CS.

Acknowledgments

Author contributions: J. C. J. conceived of the study, designed the data analysis plan, acquired the data, performed statistical analysis, and drafted the manuscript. B. B. conceived of the study, assisted with analysis, and drafted the manuscript. S. v. D., B. M. W., and N. S. A. contributed to the data analysis and drafting of the manuscript. All authors were involved in data interpretation and manuscript revision for intellectual content. All authors provided approval of the final

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    FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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