Aims Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF. Methods and results We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007-2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2-1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage. Conclusions Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Purpose: To study the effect of hypoalbuminemia on short- and long-term mortality in Cardiac Intensive Care Unit (CICU) patients. Methods: We reviewed 12,418 unique CICU patients from 2007 to 2018. Hypoalbuminemia was defined as an admission albumin level <3.5 g/dL. Predictors of hospital mortality were identified using multivariable logistic regression. Results: We included 2,680 patients (22%) with a measured admission albumin level. The median age was 68 (39% females). Admission diagnoses included acute coronary syndrome, heart failure, cardiac arrest, and cardiogenic shock. The median albumin level was 3.4 g/dL and 55% of patients had hypoalbuminemia. Hospital mortality occurred in 16%, and patients with hypoalbuminemia had higher hospital mortality (21% vs. 9%, adjusted OR 2.64, 95% CI 2.09-3.34, p < 0.001). Albumin level was inversely associated with hospital mortality (adjusted OR 0.60 per 1 g/dL higher albumin level, 95% CI 0.47-0.75, p <0.001), with a stepwise increase in the hospital mortality at lower albumin levels. Post-discharge mortality was higher in hospital survivors with hypoalbuminemia, and increased as a function of lower albumin levels. Conclusion: Hypoalbuminemia is common in CICU patients and associated with higher short- and long-term mortality. Progressively lower serum albumin was incrementally associated with higher hospital and post-discharge mortality.

Background Acute kidney injury (AKI) is common among patients with cardiogenic shock (CS) and it is independently associated with mortality. We sought to assess the prevalence, severity, and prognosis of AKI as a function of cardiogenic shock severity in unselected Cardiac Intensive Care Unit (CICU) patients. Methods We retrospectively reviewed admissions to the Mayo Clinic between 2007 to 2015 and stratified patients by the AKI stage (based on modified Kidney Disease: Improving Global Outcomes criteria) and Society for cardiovascular angiography and interventions (SCAI) shock stage. The association with in‐hospital mortality was analyzed using multivariable logistic regression. Results We included 9,311 unique patients with a mean age of 67 years and 37% females. SCAI shock stages A, B, C, D, and E were present in 47%, 30%, 15%, 7%, and 1% of patients. The incidence of AKI of any severity was 39% in the CICU and 51% during the hospitalization. Hospital mortality occurred in 8% of all patients, and the risk increased as a function of the rising AKI and SCAI shock stage. Worsening AKI stage was associated with increased adjusted hospital mortality (adjusted OR per AKI stage 1.22, 95% CI 1.10–1.36, p < .001). Higher AKI stages were associated with increased adjusted hospital mortality in SCAI stage A/B (p < .001), but not in SCAI stage C, D, or E (all p > .05). Conclusions Higher AKI stages were independently associated with mortality in CICU patients after accounting for shock severity and may add incremental prognostic utility in patients with lower SCAI stages.

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BACKGROUND: Cardiovascular and critical care professional societies recommend incorporating family engagement practices into routine clinical care. However, little is known about current family engagement practices in contemporary cardiac intensive care units (CICUs). METHODS: We implemented a validated 12-item family engagement practice survey among site investigators participating in the Critical Care Cardiology Trials Network, a collaborative network of CICUs in North America. The survey includes 9 items assessing specific engagement practices, 1 item about other family-centered care practices, and 2 open-ended questions on strategies and barriers concerning family engagement practice. We developed an engagement practice score by assigning 1 point for each family engagement practice partially or fully adopted at each site (max score 9). We assessed for relationships between the engagement practice score and CICU demographics. RESULTS: All sites (N=39; 100%) completed the survey. The most common family engagement practices were open visitation (95%), information and support to families (85%), structured care conferences (n=82%), and family participation in rounds (77%). The median engagement practice score was 5 (interquartile range, 4). There were no differences in engagement practice scores by geographic region or CICU type. The most commonly used strategies to promote family engagement were family presence during rounds (41%), communication (28%), and family meetings (28%). The most common barriers to family engagement were COVID-related visitation policies (38%) and resource limitations (13%). CONCLUSIONS: Family engagement practices are routinely performed in many CICUs; however, considerable variability exists. There is a need for strategies to address the variability of family engagement practices in CICUs.

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Hypoalbuminemia is associated with worse outcomes in critically ill patients. We hypothesized that hypoalbuminemia would be associated with higher short-and long-term mortality in unselected Cardiac Intensive Care Unit (CICU) patients. METHODS: We retrospectively reviewed 12,418 unique CICU patients from 2007 to 2018. Hypoalbuminemia was defined as an admission albumin level < 3.5 g/dL. Predictors of hospital mortality were identified using multivariable logistic regression with stepwise variable selection. RESULTS: We included 2,680 patients (22%) with a measured admission albumin level. The median age was 68 (39% females). Admission diagnoses included acute coronary syndrome (ACS; 31%), heart failure (HF; 67%), cardiac arrest (15%), and cardiogenic shock (20%). The median albumin level was 3.4 (IQR 2.9, 3.8) g/dL, and 55% of patients had hypoalbuminemia. Patients with hypoalbuminemia were older, with more comorbidities, and higher illness severity. Hospital mortality occurred in 16%, and patients with hypoalbuminemia had higher hospital mortality (21% vs. 9%, adjusted OR 2.64, 95% CI 2.09-3.34, p < 0.001). Albumin level was inversely associated with hospital mortality (adjusted OR 0.60 per 1 g/dL higher albumin level, 95% CI 0.47-0.75, p < 0.001), with a stepwise increase in the hospital mortality at lower albumin levels that was present in patients with ACS or HF. Post-discharge mortality was higher in hospital survivors with hypoalbuminemia, and increased as a function of lower albumin levels. CONCLUSIONS: Hypoalbuminemia is common in CICU patients and associated with higher short-and long-term mortality. Progressively lower serum albumin was incrementally associated with higher hospital and post-discharge mortality. CLINICAL IMPLICATIONS: Hypoalbuminemia is a common occurrence in critically-ill patients. This study demonstrates that hypoalbuminemia can be used as a negative prognostic factor in critically-ill cardiac intensive care unit patients. Prior studies have demonstrated the relationship between hypoalbuminemia and mortality in intensive care units but this is the largest study to exemplify this relationship in cardiac intensive care unit patients.

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