Admission blood glucose level has prognostic significance in CS. Mortality is highest among patients with severe hyperglycemia or hypoglycemia. Severe hyperglycemia is independently associated with high in-hospital mortality in CS. It is also associated with biomarkers of systemic hypoperfusion and stress response.

Introduction The prevalence of hypoalbuminemia, early changes of plasma albumin (P-Alb) levels, and their effects on mortality in cardiogenic shock are unknown. Materials and methods P-Alb was measured from serial blood samples in 178 patients from a prospective multinational study on cardiogenic shock. The association of hypoalbuminemia with clinical characteristics and course of hospital stay including treatment and procedures was assessed. The primary outcome was all-cause 90-day mortality. Results Hypoalbuminemia (P-Alb < 34g/L) was very frequent (75%) at baseline in patients with cardiogenic shock. Patients with hypoalbuminemia had higher mortality than patients with normal albumin levels (48% vs. 23%, p = 0.004). Odds ratio for death at 90 days was 2.4 [95% CI 1.5–4.1] per 10 g/L decrease in baseline P-Alb. The association with increased mortality remained independent in regression models adjusted for clinical risk scores developed for cardiogenic shock (CardShock score adjusted odds ratio 2.0 [95% CI 1.1–3.8], IABP-SHOCK II score adjusted odds ratio 2.5 [95%CI 1.2–5.0]) and variables associated with hypoalbuminemia at baseline (adjusted odds ratio 2.9 [95%CI 1.2–7.1]). In serial measurements, albumin levels decreased at a similar rate between 0h and 72h in both survivors and nonsurvivors (ΔP-Alb -4.6 g/L vs. 5.4 g/L, p = 0.5). While the decrease was higher for patients with normal P-Alb at baseline (p<0.001 compared to patients with hypoalbuminemia at baseline), the rate of albumin decrease was not associated with outcome. Conclusions Hypoalbuminemia was a frequent finding early in cardiogenic shock, and P-Alb levels decreased during hospital stay. Low P-Alb at baseline was associated with mortality independently of other previously described risk factors. Thus, plasma albumin measurement should be part of the initial evaluation in patients with cardiogenic shock. Trial registration NCT01374867 at ClinicalTrials.gov.

Altered mental status is a common clinical sign of systemic hypoperfusion in cardiogenic shock and is associated with poor outcome. It is also associated with several biochemical findings that reflect inadequate tissue perfusion, of which low arterial pH is independently associated with altered mental status.

Cardiogenic shock (CS) is the most severe form of acute heart failure, characterized by low cardiac output, hypotension, and systemic hypoperfusion. CS is the leading cause of death in acute coronary syndrome (ACS) that accounts for about 80% of CS cases. In addition to acute cardiac cause, the diagnostic criteria for CS include persistent hypotension (systolic blood pressure < 90 mmHg) and clinical signs of hypoperfusion. Mortality rates in CS remain as high as 35-50%. Severe left ventricular dysfunction usually triggers the shock and leads to the activation of systemic inflammatory response and hypothalamic-pituitary-adrenal axis. Immediately after detection of the shock, electrocardiography and echocardiography should be performed to determine the etiology of CS and to rule out mechanical complications. Urgent revascularization by percutaneous coronary intervention, or less often by coronary artery bypass graft, is the most important treatment in CS caused by ACS. In the case of mechanical complication, immediate surgical treatment is essential. Regardless of the etiology, the basic treatment strategy includes fluid challenge that aims at obtaining euvolemia and relieving tissue hypoperfusion. Inotropes and vasopressors are often needed to improve cardiac performance and to maintain sufficient blood pressure. Ventilation is often supported mechanically and CS patients are best treated in intensive cardiac care unit. Continuous invasive blood pressure monitoring, electrocardiography, and repeated echocardiography are required. In CS refractory to other treatments, mechanical circulatory support may be considered to maintain adequate perfusion pressure and to prevent multiorgan failure.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/ 5608947/Activity.aspx Definition Cardiogenic shock (CS) is the most severe form of acute heart failure and the leading cause of death in acute myocardial infarction. CS is characterized by low cardiac output, hypotension, and systemic hypoperfusion, resulting in end-organ dysfunction. In addition to acute cardiac cause, the contemporary diagnostic criteria for CS are (1) systolic blood pressure <90 mmHg for over 30 min despite adequate fluid resuscitation or need for vasopressor therapy to maintain systolic blood pressure ≥90 mmHg and (2) clinical signs of hypoperfusion (altered mental status, cold extremities or oliguria) or increased blood lactate level. The diagnosis of CS can thus be made by clinical evaluation, instead of invasive assessment of pulmonary artery wedge pressure and cardiac index with pulmonary artery catheter routinely [1]. Electrocardiography (ECG) and echocardiography should be performed immediately after detection of the shock to assess the etiology of CS and to rule out mechanical complications. Low output syndrome caused by advanced chronic heart failure may clinically resemble cardiogenic shock, but the onset is more gradual and, due to adaptive mechanisms, patients may sustain the syndrome relatively long. EtiologyThe most common c...

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Background Acute kidney injury (AKI) is a frequent form of organ injury in cardiogenic shock. However, data on AKI markers such as plasma proenkephalin (P-PENK) and neutrophil gelatinase-associated lipocalin (P-NGAL) in cardiogenic shock populations are lacking. The objective of this study was to assess the ability of P-PENK and P-NGAL to predict acute kidney injury and mortality in cardiogenic shock. Results P-PENK and P-NGAL were measured at different time points between baseline and 48 h in 154 patients from the prospective CardShock study. The outcomes assessed were AKI defined by an increase in creatinine within 48 h and all-cause 90-day mortality. Mean age was 66 years and 26% were women. Baseline levels of P-PENK and P-NGAL (median [interquartile range]) were 99 (71–150) pmol/mL and 138 (84–214) ng/mL. P-PENK > 84.8 pmol/mL and P-NGAL > 104 ng/mL at baseline were identified as optimal cut-offs for AKI prediction and independently associated with AKI (adjusted HRs 2.2 [95% CI 1.1–4.4, p = 0.03] and 2.8 [95% CI 1.2–6.5, p = 0.01], respectively). P-PENK and P-NGAL levels at baseline were also associated with 90-day mortality. For patients with oliguria < 0.5 mL/kg/h for > 6 h before study enrollment, 90-day mortality differed significantly between patients with low and high P-PENK/P-NGAL at baseline (5% vs. 68%, p < 0.001). However, the biomarkers provided best discrimination for mortality when measured at 24 h. Identified cut-offs of P-PENK24h > 105.7 pmol/L and P-NGAL24h > 151 ng/mL had unadjusted hazard ratios of 5.6 (95% CI 3.1–10.7, p < 0.001) and 5.2 (95% CI 2.8–9.8, p < 0.001) for 90-day mortality. The association remained significant despite adjustments with AKI and two risk scores for mortality in cardiogenic shock. Conclusions High levels of P-PENK and P-NGAL at baseline were independently associated with AKI in cardiogenic shock patients. Furthermore, oliguria before study inclusion was associated with worse outcomes only if combined with high baseline levels of P-PENK or P-NGAL. High levels of both P-PENK and P-NGAL at 24 h were found to be strong and independent predictors of 90-day mortality. Trial registration: NCT01374867 at www.clinicaltrials.gov, registered 16 Jun 2011—retrospectively registered

Aims This study aimed to assess the utility of contemporary clinical risk scores and explore the ability of two biomarkers [growth differentiation factor-15 (GDF-15) and soluble ST2 (sST2)] to improve risk prediction in elderly patients with cardiogenic shock. Methods and results Patients (n = 219) from the multicentre CardShock study were grouped according to age (elderly ≥75 years and younger). Characteristics, management, and outcome between the groups were compared. The ability of the CardShock risk score and the IABP-SHOCK II score to predict in-hospital mortality and the additional value of GDF-15 and sST2 to improve risk prediction in the elderly was evaluated. The elderly constituted 26% of the patients (n = 56), with a higher proportion of women (41% vs. 21%, P < 0.05) and more co-morbidities compared with the younger. The primary aetiology of shock in the elderly was acute coronary syndrome (84%), with high rates of percutaneous coronary intervention (87%). Compared with the younger, the elderly had higher in-hospital mortality (46% vs. 33%; P = 0.08), but 1 year post-discharge survival was excellent in both age groups (90% in the elderly vs. 88% in the younger). In the elderly, the risk prediction models demonstrated an area under the curve of 0.75 for the CardShock risk score and 0.71 for the IABP-SHOCK II score. Incorporating GDF-15 and sST2 improved discrimination for both risk scores with areas under the curve ranging from 0.78 to 0.84. Conclusions Elderly patients with cardiogenic shock have higher in-hospital mortality compared with the younger, but post-discharge outcomes are similar. Contemporary risk scores proved useful for early mortality risk prediction also in the elderly, and risk stratification could be further improved with biomarkers such as GDF-15 or sST2.

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