Comparison of risk prediction models in infarct-related cardiogenic shock

Abstract

Background Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. Objectives To externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course. Methods The Simplified Acute Physiology Score (SAPS)-II Score, the CardShock score, the IABP-SHOCK II score and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. Discriminative power was assessed by comparing area under the curves (AUC) in case of continuous scores. Results In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination (AUC=0.74), followed by the CardShock score (AUC=0.69) and the SAPS-II score, giving only moderate discrimination (AUC=0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (stage E), but showed poor discrimination between stages C and D with respect to short-term-mortality. Conclusion Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification or even development of new scores might be necessary to reach higher levels of discrimination. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, German Centre for Cardiovascular Research Survival probabilities continuous scores Survival probabilities SCAI

PRospective REgistry of PAtients in REfractory cardiogenic shock—The PREPARE CardShock registry

“…Although some studies report only a minor impact of age with respect to prognosis in cardiogenic shock, 29,30 this might be due to selection bias as older patients in these studies displayed less comorbidities, indicating a highly selected group of older patients. More likely, increasing age is associated with higher mortality in CS, regardless of shock severity as shown in a recent analysis of a large cohort of the Cardiogenic Shock Work Group registry, 31 a cohort of shock patients out of the Utah Cardiac Recovery shock database, 32 broad analysis of risk scores based on the CULPRIT‐shock cohort 33 and most other trials and registries 26,34,35 . These findings are supported by our observation, too, as age was found to be a strong predictor of mortality, especially in patients with cardiac arrest.…”

Risk stratification in cardiogenic shock: from clinical utility to improving outcomes

“…Even if not mentioned by the authors, this type of score could be reapplied later during hospitalization to capture the response to initial therapeutic measures. The CSS includes a ‘dynamic’ component (given by some of its elements: systolic blood pressure, heart rate, pH, lactate and glucose) with substantial variations during hospitalization as a result of the therapies applied and may help to identify CS patients who need intensification (increasing risk score) or weaning (decreasing risk score) of advanced support 15 …”

“…The CSS includes a 'dynamic' component (given by some of its elements: systolic blood pressure, heart rate, pH, lactate and glucose) with substantial variations during hospitalization as a result of the therapies applied and may help to identify CS patients who need intensification (increasing risk score) or weaning (decreasing risk score) of advanced support. 15 However, one important issue is calibration of the risk score. Although the authors reported a strong, almost linear correlation between CSS points and 30-day mortality, 14 in both derivation and validation cohorts, the relative risk ratios varied substantially between the derivation and validation cohorts, limiting its performance as multiplier of risk.…”