Author + information
- Received November 29, 2018
- Revision received December 12, 2018
- Accepted December 21, 2018
- Published online April 1, 2019.
- Behnam N. Tehrani, MDa,∗ (, )@behnam_tehrani,
- Alexander G. Truesdell, MDa,b,
- Matthew W. Sherwood, MDa,
- Shashank Desai, MDa,
- Henry A. Tran, MDa,
- Kelly C. Epps, MDa,
- Ramesh Singh, MDa,
- Mitchell Psotka, MD, PhDa,
- Palak Shah, MDa,
- Lauren B. Cooper, MDa,
- Carolyn Rosner, NPa,
- Anika Raja, BSa,
- Scott D. Barnett, PhDa,
- Patricia Saulino, RN, MPAa,
- Christopher R. deFilippi, MDa,
- Paul A. Gurbel, MDa,
- Charles E. Murphy, MDa and
- Christopher M. O’Connor, MDa,∗∗ (, )@coconnormd
- ↵∗Address for correspondence:
Dr. Behnam N. Tehrani, Cardiac Catheterization Laboratory, INOVA Heart and Vascular Institute, 3300 Gallows Road, Falls Church, Virginia 22042.
- ↵∗∗Dr. Christopher M. O’Connor, Inova Heart and Vascular Institute, Duke University, 3300 Gallows Road, Falls Church, Virginia 22042.
Background Cardiogenic shock (CS) is a multifactorial, hemodynamically complex syndrome associated with high mortality. Despite advances in reperfusion and mechanical circulatory support, management remains highly variable and outcomes poor.
Objectives This study investigated whether a standardized team-based approach can improve outcomes in CS and whether a risk score can guide clinical decision making.
Methods A total of 204 consecutive patients with CS were identified. CS etiology, patient demographic characteristics, right heart catheterization, mechanical circulatory support use, and survival were determined. Cardiac power output (CPO) and pulmonary arterial pulsatility index (PAPi) were measured at baseline and 24 h after the CS diagnosis. Thresholds at 24 h for lactate (<3.0 mg/dl), CPO (>0.6 W), and PAPi (>1.0) were determined. Using logistic regression analysis, a validated risk stratification score was developed.
Results Compared with 30-day survival of 47% in 2016, 30-day survival in 2017 and 2018 increased to 57.9% and 76.6%, respectively (p < 0.01). Independent predictors of 30-day mortality were age ≥71 years, diabetes mellitus, dialysis, ≥36 h of vasopressor use at time of diagnosis, lactate levels ≥3.0 mg/dl, CPO <0.6 W, and PAPi <1.0 at 24 h after diagnosis and implementation of therapies. Either 1 or 2 points were assigned to each variable, and a 3-category risk score was determined: 0 to 1 (low), 2 to 4 (moderate), and ≥5 (high).
Conclusions This observational study suggests that a standardized team-based approach may improve CS outcomes. A score incorporating demographic, laboratory, and hemodynamic data may be used to quantify risk and guide clinical decision-making for all phenotypes of CS.
Dr. Tehrani has served as a consultant for Medtronic and Abiomed. Dr. Truesdell has served as a consultant and is a member of the Speakers Bureau for Abiomed. Dr. Desai is a member of the Speakers Bureau for Abbott and Medtronic; and is a consultant for Abiomed. Dr. Singh is an advisory board member for Baxter; and a speaker for Baxter and Abbott. Dr. Psotka has served as a consultant for Amgen, Cytokinetics, and Roivant. Dr. Shah has received grant support from Merck, Medtronic, American Heart Association/Enduring Hearts; and has served as a consultant for NuPulse CV 5 and Ortho Clinical Diagnostics. Dr. Cooper has received grant support from Abbott. Dr. deFilippi has received research grants from Roche Diagnostics; has received consulting fees from Abbott Diagnostics, FujiRebio, Metabolomics, Ortho Diagnostics, Roche Diagnostics, and Siemens Healthcare; has received honoraria from WebMD; and has received royalties from UpToDate. Dr. Gurbel has received research grants from Amgen, Bayer, Duke Cardiovascular Research Institute, Haemonetics, Idorsia Inois, Janssen, Merck, and the National Institutes of Health; and has served as a consultant for Boehringer Ingelheim, Janssen Pharmaceuticals, Bayer, and Merck. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This study was presented as an oral presentation at the Transcatheter Cardiovascular Therapeutics 30th Annual Scientific Session, September 21 to 25, San Diego, California. William W. O'Neill, M.D. served as guest associate editor on this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received November 29, 2018.
- Revision received December 12, 2018.
- Accepted December 21, 2018.
- 2019 The Authors