Background: The optimal MAP target for patients with cardiogenic shock (CS) remains unknown. We sought to determine the relationship between mean arterial pressure (MAP) and mortality in the cardiac intensive care unit (CICU) patients with CS. Methods: Using a single-center database of CICU patients admitted between 2007 and 2015, we identified patients with an admission diagnosis of CS. MAP was measured every 15 min, and the mean of all MAP values during the first 24 h (mMAP 24) was recorded. Multivariable logistic regression determined the relationship between mMAP 24 and adjusted hospital mortality. Results: We included 1002 patients with a mean age of 68 ± 13.7 years, including 36% females. Admission diagnoses included acute coronary syndrome in 60%, heart failure in 74%, and cardiac arrest in 38%. Vasoactive drugs were used in 72%. The mMAP 24 was higher (75 vs. 71 mmHg, p < 0.001) among hospital survivors (66%) compared with non-survivors (34%). Hospital mortality was inversely associated with mMAP 24 (adjusted OR 0.9 per 5 mmHg higher mMAP 24 , p = 0.01), with a stepwise increase in hospital mortality at lower mMAP 24. Patients with mMAP 24 < 65 mmHg were at higher risk of hospital mortality (57% vs. 28%, adjusted OR 2.0, 95% CI 1.4-3.0, p < 0.001); no differences were observed between patients with mMAP 24 65-74 vs. ≥ 75 mmHg (p > 0.1). Conclusion: In patients with CS, we observed an inverse relationship between mMAP 24 and hospital mortality. The poor outcomes in patients with mMAP 24 < 65 mmHg provide indirect evidence supporting a MAP goal of 65 mmHg for patients with CS.
Purpose of reviewCardiogenic shock continues to carry a high mortality, and recent randomized trials have not identified novel therapies that improve survival. Early optimization of patients with confirmed or suspected cardiogenic shock is crucial, as patients can quickly transition from a hemodynamic shock state to a treatment-resistant hemometabolic shock state, where accumulated metabolic derangements trigger a selfperpetuating cycle of worsening shock. Recent findingsWe describe a structured ABCDE approach involving stabilization of the airway, breathing and circulation, followed by damage control and etiologic assessment. Respiratory failure is common and many cardiogenic shock patients require invasive mechanical ventilation. Norepinephrine is titrated to restore mean arterial pressure and dobutamine is titrated to restore cardiac output and organ perfusion.Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock. Coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected, followed by culprit-vessel revascularization if indicated. An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary. SummaryEarly stabilization of hemodynamics and end-organ function is necessary to achieve best outcomes in cardiogenic shock. Using a structured approach tailored to initial cardiogenic shock resuscitation may help to demonstrate benefit from novel therapies in the future.
Aims Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. Methods and results We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity–time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883–0.942, P < 0.0001] followed by medial mitral E/e′ ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010–1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality. Conclusions Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e′ ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.
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