Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Danish Heart Foundation Odense University Hospital and Rigshospitalets Research Council. Background Acute myocardial infarction complicated by cardiogenic shock (AMICS) comprises a heterogenous population with high mortality. Insight in timing and cause of death may improve understanding of the condition and aid individualization of treatment. Purpose To determine the cause and timing of death in patients admitted with AMICS. Methods This was a retrospective, multi-center observational cohort study based on 1716 AMICS patients treated during the period of 2010-2017, of whom 904 died prior to hospital discharge from either of two tertiary cardiac centers in Denmark providing advanced care for cardiogenic shock for 3.9 million inhabitants. Patients admitted with AMICS were identified through national registries and review of individual patient charts. Only patients dying during hospitalization were eligible. Cause of death was categorized as caused by progressive cardiac failure, multi organ failure or due to neurological damage. Time to death was calculated in hours from first medical contact to death. Results Among 904 patients with AMICS who died prior to hospital discharge (median age 72 years [IQR: 63 - 79], 70% men), 342 (38%) patients had suffered an out-of-hospital cardiac arrest (OHCA). The most frequent cause of death was primary cardiac (54%), whereas 24% died of neurologic injury and 20% of multi-organ failure. Time to death was 13 hours [IQR: 5, 43] for cardiac failure; 140 hours [IQR: 95, 209] in neurological injury; and 137 hours [IQR: 59, 321] in multi-organ failure, p<0.001. The causes of death in patients presenting with OHCA were neurological injury in 57%, as opposed to 4% among patients not presenting with OHCA, p<0.001. No specific phenotype on admission characterized patients with OHCA who died from neurological injury or cardiac causes. Conclusion In patients with AMICS, cause of death was mainly primary cardiac failure followed by neurological injury and multi-organ failure. Median time from first medical contact to death was only 13 hours in patients dying from cardiac causes. The risk of dying of neurological injury was low in patients without OHCA.
Funding Acknowledgements Type of funding sources: None. Introduction Invasive mechanical ventilation (IMV) provides up to a 30% reduction in cardiac output requirements and is frequently used in patients with cardiogenic shock following acute myocardial infarction (AMICS). However, practice of IMV in the setting of AMICS is sparsely described. Purpose The aim was to evaluate the use of IMV in a contemporary cohort of patients with AMICS. Methods Between 2010 and 2017, all adult AMICS patients admitted to two tertiary heart centres, providing AMICS care for two thirds of the Danish population, were individually identified through patient records. Temporal changes in application of IMV were registered as well as patient characteristics. Real-time electronic ICU data were available for a subset of mechanically ventilated ICU patients (n=566), and were retrieved for the first 24 hours of IMV, following ICU admission, and described in relation to 30-day survival and the presence of out-of-hospital cardiac arrest (OHCA). Results A total of 1716 AMICS patients were retrospectively identified, of which 1274 (74%) received IMV during ICU admission (IMV-ICU). The proportion of IMV increased from 70% in 2010 to 78% in 2017. IMV-ICU patients were younger (67 vs 76 years), more frequently male (79% vs 61%), and more likely to have OHCA (54% vs 3%) and higher lactate at diagnosis of cardiogenic shock (5.8 vs 4.1 mmol/L) compared with non-intubated patients (p for all<0.001). Among IMV-ICU patients, 69% were intubated in the prehospital setting, of which three quarters presented with OHCA. Median PaO2 and PCO2 were both within normal ranges among 30-day survivors and non-survivors. However, non-survivors required 10-25% higher median fraction of inspired oxygen (p<0.001; FiO2), positive-end-expiratory pressure (p=0.002; PEEP), and minute ventilation (p<0.001; MV). Differences in IMV settings were mainly driven by non-survivors without OHCA (see table). Conclusion In a contemporary cohort of patients with AMICS, use of IMV increased during the observation period from 2010 to 2017. Observations did not reveal any association between 30-day mortality and IMV parameters in OHCA-patients, whereas FiO2, PEEP, and MV were significantly elevated in 30-day non-survivors without OHCA.
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