Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

Abstract

Background: Prior studies have shown worse outcomes in patients with cardiogenic shock (CS) who have reduced left ventricular ejection fraction (LVEF), but the association between other transthoracic echocardiogram (TTE) findings and mortality in CS patients remains uncertain. We hypothesized that Doppler TTE measurements would outperform LVEF for risk stratification. Methods: Retrospective analysis of cardiac intensive care unit patients with an admission diagnosis of CS and a TTE within 1 day of admission. Hospital survivors and inpatient deaths were compared, and multivariable logistic regression was used to analyze the associations between TTE variables and hospital mortality. Results: We included 1,085 patients, with a median age of 69.5 (59.6, 77.5) years; 37% were females and 62% had an acute coronary syndrome. Most patients (66%) had moderate or severe left ventricular (LV) systolic dysfunction, and 48% had moderate or severe right ventricular (RV) systolic dysfunction. Hospital mortality occurred in 31%, and inpatient deaths had a lower median LVEF (29% vs. 35%, P < 0.001). Patients with mild or no LV or RV dysfunction were at lower risk of adjusted hospital mortality (P < 0.01). The LV outflow tract (LVOT) velocity-time integral (VTI) was the single best predictor of hospital mortality. After multivariable adjustment, both the LVEF and LVOT VTI remained strongly associated with hospital mortality (P < 0.001). Conclusions: Early comprehensive Doppler TTE can provide important prognostic insights in CS patients, highlighting its potential utility in clinical practice. The LVOT VTI, reflecting forward flow, is an important measurement to obtain on bedside TTE.

Prognostic Performance of Serial Determination of the Society for Cardiovascular Angiography and Interventions Shock Classification in Adults With Critical Illness

“…Notably, patients in a on ICU admission had worse outcomes than those who developed late shock after ICU admission, perhaps due to late diagnosis of shock in the non-ICU setting and earlier initiation of definitive therapies in patients who were already under ICU care. We previously observed similar observations in a cohort of CICU patients, finding that patients who required vasoactive drugs on CICU admission had a worse prognosis than those with new vasoactive drug requirements subsequently (10).…”

“…Validated electronic algorithms were used to automatically calculate the Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation III/IV scores, and Charlson Comorbidity Index (30)(31)(32). The Vasoactive-Inotropic Score was calculated using the maximum vasopressor and inotropic doses during each block (7,10). The primary outcome of interest was all-cause in-hospital mortality determined from the medical record.…”

“…The presence of shock, defined as circulatory failure causing tissue and organ hypoperfusion, is a powerful predictor of morbidity and mortality in intensive care unit (ICU) patients regardless of the etiology (1)(2)(3)(4)(5). Many approaches to defining the severity of shock have been described, and these have consistently demonstrated a strong association between more severe shock and higher mortality (6)(7)(8)(9)(10). The Society for Cardiovascular Angiography and Interventions (SCAI) Shock Classification was introduced in 2019 to describe the spectrum of severity in patients with, or at risk for, cardiogenic shock using a 5-stage system (11)(12)(13).…”

The changing face of cardiogenic shock: definitions, epidemiology, and severity assessment

“…Hemodynamic measurements, whether invasive or noninvasive, have been associated with prognosis in patients with CS, although typically these are best considered in the context of the degree of hemodynamic support and perfusion status [23,41]. A lower mean arterial pressure is predictably associated with worse outcomes, particularly when this is accompanied by high vasopressor load [25,32].…”

“…A lower mean arterial pressure is predictably associated with worse outcomes, particularly when this is accompanied by high vasopressor load [25,32]. A lower cardiac power output (CPO), calculated from the mean arterial pressure and cardiac output, is likewise associated with worse outcomes, especially with higher vasopressor requirements [26,[41][42][43]. Markers of underlying right ventricular dysfunction and congestion such as a higher right atrial pressure or a lower pulmonary artery pulsatility index (PAPI) are among the most potent hemodynamic predictors of mortality in CS [25,42].…”