External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients

Abstract

Background: Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy. The CardShock and the Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk scores have shown good results in predicting short-term mortality in cardiogenic shock. However, to date, they have not been compared in a large cohort of ischaemic and non-ischaemic real-world cardiogenic shock patients. Methods: The Red-Shock is a multicentre cohort of non-selected cardiogenic shock patients. We calculated the CardShock and IABP-SHOCK II risk scores in each patient and assessed discrimination and calibration. Results: We included 696 patients. The main cause of cardiogenic shock was acute coronary syndrome, occurring in 62% of the patients. Compared with acute coronary syndrome patients, non-acute coronary syndrome patients were younger and had a lower proportion of risk factors but higher rates of renal insufficiency; intra-aortic balloon pump was also less frequently used (31% vs 56%). In contrast, non-acute coronary syndrome patients were more often treated with mechanical circulatory support devices (11% vs 3%, p<0.001 for both). Both risk scores were good predictors of in-hospital mortality in acute coronary syndrome patients and had similar areas under the receiver-operating characteristic curve (area under the curve: 0.742 for the CardShock vs 0.752 for IABP-SHOCK II, p=0.65). Their discrimination performance was only modest when applied to non-acute coronary syndrome patients (0.648 vs 0.619, respectively, p=0.31). Calibration was acceptable for both scores (Hosmer-Lemeshow p=0.22 for the CardShock and 0.68 for IABP-SHOCK II). Conclusions: In our cohort, both the CardShock and the IABP-SHOCK II risk scores were good predictors of in-hospital mortality in acute coronary syndrome-related cardiogenic shock.

Risk stratification to guide management in cardiogenic shock due to acute myocardial infarction. An illustrative case series and review of the literature

“…The IABP-SHOCK II [2] and CardShock risk scores [3], have recently been externally validated as good predictors of inpatient mortality in CS after AMI [5]. However, the present case highlights the challenges with their use in the acute setting.…”

“…It has therefore been suggested that risk stratifi cation be used to guide the advanced management of CS. Whilst validated risk scores are available [3][4][5], as highlighted in the present illustrative case, their use must be guided by clinical judgement.…”

“…However, the severity of CS after AMI and clinical outcome vary greatly [1][2][3][4][5][6]. Whilst patients over 75 years of age are at highest risk of CS and death [7,9], this cohort may still benefi t from aggressive management when appropriate [9].…”

“…The severity of CS after AMI and clinical outcome vary greatly [1][2][3][4][5][6]. However, increasing age is associated with worse Citation: Rajendram R (2020) Risk stratification to guide management in cardiogenic shock due to acute myocardial infarction.…”

“…Accurate risk stratifi cation is therefore required to guide complex treatment decisions (e.g.,use of cardiac assist devices and other advanced therapies) in the acute setting 9. Whilst validated risk scores are available [2,3,5], as highlighted in the present illustrative case series, their use must be guided by clinical judgement. [2].…”