De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

doi:10.1016/j.cardfail.2021.08.014

Journal of Cardiac Failure

Volume 27, Issue 10, October 2021, Pages 1073-1081

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https://doi.org/10.1016/j.cardfail.2021.08.014 Get rights and content

Key Points

•
A majority (67%) of patients with cardiogenic shock (CS) admitted to North American cardiac intensive care units have heart failure-related CS (HF-CS) unrelated to acute myocardial infarction.
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Approximately 1 in 4 patients with HF-CS present with de novo HF-CS, defined as no known prior history of heart failure.
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Compared to patients with acute-on-chronic HF-CS, those with de novo HF-CS have more severe shock, greater end-organ injury and higher in-hospital mortality.

ABSTRACT

Background

Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown.

Methods and Results

We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017–2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th–75th: 5–11) vs acute-on-chronic HF-CS (6; 25th–75th: 4–9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05–1.75, P = 0.02).

Conclusions

Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.

Section snippets

Study Population

The Critical Care Cardiology Trials Network (CCCTN) is a collaborative research network of American Heart Association Level 1 CICUs¹² located in North America and coordinated by the Thrombolysis in Myocardial Infarction (TIMI) Study Group (Brigham and Women's Hospital, Boston, MA).¹³ In this analysis of data from 2017 to 2020, each participating center (n = 28) contributed an annual 2-month snapshot of all consecutive medical admissions to the CICU; consecutive admissions were recorded, but the

Epidemiology of Heart Failure-Related Cardiogenic Shock

Overall, 2093 admissions with CS were included. Of these admissions, 688 (32.9%) had AMI-CS. The analysis cohort of HF-CS included 1,405 (67.1%) admissions, 370 of which had de novo HF-CS (26.3%), while the remainder had acute-on-chronic HF-CS (Fig. 1). Cardiac arrest preceding CICU admission occurred more commonly in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (32.4% vs 11.8%; P < 0.01).

Baseline Characteristics

Baseline characteristics are summarized according to CS type in Table 1. Patients

Discussion

In this analysis of > 2000 CS presentations to contemporary CICUs in North America, only 1 in 3 patients had AMI-CS. Approximately 1 in 4 patients presenting with HF-CS did not have a prior history of HF. Patients with de novo HF-CS had more severe shock presentations, greater end-organ injury and higher in-hospital mortality compared with those with acute-on-chronic presentations with HF-CS. Even after accounting for clinical characteristics and the greater prevalence of preceding cardiac

Conclusion

Approximately 2 of 3 patients with CS admitted to contemporary North American CICUs have HF-CS. Among such patients, those with de novo HF-CS appear to have clinical presentations and outcomes that are distinct from those of patients with acute-on-chronic HF-CS. Our findings highlight the need to study whether distinct pathobiological compensatory mechanisms and responses to treatment exist in patients presenting with HF-CS based on prior histories of HF.

Lay summary

Inadequate blood flow to vital organs related to a failing heart is caused by a process other than a new heart attack in the majority of cases (67%). One out of every 4 of these patients have no prior history of heart failure. Such patients with new heart failure and shock have more severe presentations, greater organ injury, and higher rates of death compared to those with a prior history of heart failure. These findings underscore the need to understand possible compensatory adaptations in

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Cited by (37)

Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis
2024, Journal of Cardiac Failure
Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of “spoke” centers to tertiary/“hub” centers with higher capabilities. However, outcomes associated with such transfers are largely unknown beyond those reported in individual health networks.
To analyze a contemporary, multicenter CS cohort with the aim of comparing characteristics and outcomes of patients between transfer (between spoke and hub centers) and nontransfer cohorts (those primarily admitted to a hub center) for both acute myocardial infarction (AMI-CS) and heart failure-related HF-CS. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality.
The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high-volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016–2020.
Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these patients, 528 (58.1%) had heart failure-related CS (HF-CS), and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stages C and D, when compared to nontransfer patients. Transfer patients had higher mortality rates (37% vs 29%, < 0.001) than nontransfer patients; the differences were driven primarily by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer or within 24 hours of arrival was associated with decreased mortality rates. Among transfer AMI-CS patients, BMI > 28 kg/m², worsening renal failure, lactate > 3 mg/dL, and increasing numbers of vasoactive drugs were associated with increased mortality rates.
More than half of patients with CS managed at high-volume CS centers were transferred from another hospital. Although transfer patients had higher mortality rates than those who were admitted primarily to hub centers, the outcomes and their predictors varied significantly when classified by HF-CS vs AMI-CS.
Concomitant use of extracorporeal membrane oxygenation and percutaneous microaxial assist device support for cardiogenic shock
2024, JTCVS Open
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) with concomitant percutaneous microaxial left ventricular assist device support is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with this support strategy have not been well described.
This study was a retrospective, single-center analysis of patients with CS due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support from December 2020 to January 2023.
A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival at 90 days postdischarge (P = .267) with similar destinations after support (P = .220). Patients with AMI-CS initially supported with VA-ECMO were less likely to survive 90 days postdischarge (P = .038) when compared with other cohorts. Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (P =.013; P = .030). Subanalysis of ADHF-CS patients into acute-on-chronic decompensated HF and de novo HF demonstrated no difference in survival or destination.
VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS with this support strategy. AMI-CS patients with initial VA-ECMO support have increased mortality in comparison to other cohorts. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with this support strategy.
Heart failure related cardiogenic shock: An ISHLT consensus conference content summary
2024, Journal of Heart and Lung Transplantation
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
Cardiogenic Shock: Pathogenesis, Classification, and Management
2024, Critical Care Clinics
Impact of Female Sex on Cardiogenic Shock Outcomes: A Cardiogenic Shock Working Group Report
2023, JACC: Heart Failure
Studies reporting cardiogenic shock (CS) outcomes in women are scarce.
The authors compared survival at discharge among women vs men with CS complicating acute myocardial infarction (AMI-CS) and heart failure (HF-CS).
The authors analyzed 5,083 CS patients in the Cardiogenic Shock Working Group. Propensity score matching (PSM) was performed with the use of baseline characteristics. Logistic regression was performed for log odds of survival.
Among 5,083 patients, 1,522 were women (30%), whose mean age was 61.8 ± 15.8 years. There were 30% women and 29.1% men with AMI-CS (P = 0.03). More women presented with de novo HF-CS compared with men (26.2% vs 19.3%; P < 0.001). Before PSM, differences in baseline characteristics and sex-specific outcomes were seen in the HF-CS cohort, with worse survival at discharge (69.9% vs 74.4%; P = 0.009) and a higher rate of maximum Society for Cardiac Angiography and Interventions stage E (26% vs 21%; P = 0.04) in women than in men. Women were less likely to receive pulmonary artery catheterization (52.9% vs 54.6%; P < 0.001), heart transplantation (6.5% vs 10.3%; P < 0.001), or left ventricular assist device implantation (7.8% vs 10%; P = 0.01). Regardless of CS etiology, women had more vascular complications (8.8% vs 5.7%; P < 0.001), bleeding (7.1% vs 5.2%; P = 0.01), and limb ischemia (6.8% vs 4.5%; P = 0.001). More vascular complications persisted in women after PSM (10.4% women vs 7.4% men; P = 0.06).
Women with HF-CS had worse outcomes and more vascular complications than men with HF-CS. More studies are needed to identify barriers to advanced therapies, decrease complications, and improve outcomes of women with CS.
Acute Coronary Syndrome and Heart Failure: Another Piece of the Puzzle
2023, Journal of Cardiac Failure

View all citing articles on Scopus

^†: Dr. Bhatt and Dr. Berg contributed to the study equally.

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Research ArticleDe Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

Key Points

ABSTRACT

Background

Methods and Results

Conclusions

Section snippets

Study Population

Epidemiology of Heart Failure-Related Cardiogenic Shock

Baseline Characteristics

Discussion

Conclusion

Lay summary

J Am Coll Cardiol

Lancet

Lancet

J Am Coll Cardiol

JACC Basic Transl Sci

J Am Coll Cardiol

JACC Heart Fail

Cardiogenic shock: current concepts and improving outcomes

Circulation

Epidemiology of shock in contemporary cardiac intensive care units

Circ Cardiovasc Qual Outcomes

Clinical picture and risk prediction of short-term mortality in cardiogenic shock

Eur J Heart Fail

Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association

Circulation

Clinical outcomes associated with acute mechanical circulatory support utilization in heart failure-related cardiogenic shock

Circ Heart Fail

Invasive hemodynamic assessment and classification of in-hospital mortality risk among patients with cardiogenic shock

Circ Heart Fail

Epidemiology and causes of cardiogenic shock

Curr Opin Crit Care

Heart disease and stroke statistics-2021 update: a report from the American Heart Association

Circulation

Temporal trends and clinical outcomes associated with vasopressor and inotrope use in the cardiac intensive care unit

Shock

Clinical practice patterns in temporary mechanical circulatory support for shock in the critical care cardiology trials network (CCCTN) registry

Circ Heart Fail

Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association

Circulation

Research Article
De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry