Outcome differences in acute vs. acute on chronic heart failure and cardiogenic shock

Abstract

Aims Despite advances in coronary reperfusion and percutaneous mechanical circulatory support, mortality among patients presenting with cardiogenic shock (CS) remains unacceptably high. Clinical trials and risk stratification tools have largely focused on acute CS, particularly secondary to acute coronary syndrome. Considerably less is understood about CS in the setting of acute decompensation in patients with chronic heart failure (HF). We sought to compare outcomes between patients with acute CS and patients with acute on chronic decompensated HF presenting with laboratory and haemodynamic features consistent with CS. Methods and results Sequential patients admitted with CS at a single quaternary centre between January 2014 and August 2017 were identified. Acute on chronic CS was defined by having a prior diagnosis of HF. Initial haemodynamic and laboratory data were collected for analysis. The primary outcome was in-hospital mortality. Secondary outcomes were use of temporary mechanical circulatory support, durable ventricular assist device implantation, total artificial heart implantation, or heart transplantation. Comparison of continuous variables was performed using Student's t-test. For categorical variables, the χ 2 statistic was used. A total of 235 patients were identified: 51 patients (32.8%) had acute CS, and 184 patients (64.3%) had acute decompensation of chronic HF with no differences in age (52 ± 22 vs. 55 ± 14 years, P = 0.28) or gender (26% vs. 23%, P = 0.75) between the two groups. Patients with acute CS were more likely to suffer in-hospital death (31.4% vs. 9.8%, P < 0.01) despite higher usage of temporary mechanical circulatory support (52% vs. 25%, P < 0.01) compared with patients presenting with acute on chronic HF. The only clinically significant haemodynamic differences at admission were a higher heart rate (101 ± 29 vs. 82 ± 17 b.p.m., P < 0.01) and wider pulse pressure (34 ± 19 vs. 29 ± 10 mmHg, P < 0.01) in the acute CS group. There were no significant differences in degree of shock based on commonly used CS parameters including mean arterial pressure (72 ± 12 vs. 74 ± 10 mmHg, P = 0.23), cardiac output (3.9 ± 1.2 vs. 3.8 ± 1.2 L/min, P = 0.70), or cardiac power index (0.32 ± 0.09 vs. 0.30 ± 0.09 W/m 2 , P = 0.24) between the two groups. Conclusions Current definitions and risk stratification models for CS based on clinical trials performed in the setting of acute coronary syndrome may not accurately reflect CS in patients with acute on chronic HF. Further investigation into CS in patients with acute on chronic HF is warranted.

Impact of Pre-Existing History of Heart Failure on Patient Profile, Therapeutic Management, and Prognosis in Cardiogenic Shock: Insights from the FRENSHOCK Registry

“…Worsening CHF patients had significantly lower eGFRs (40 (25-59) vs. 56 (39-77), p < 0.001) and hemoglobin levels (12 (10.6-14) vs. 13 (11.2-14.6), p < 0.001) than those with new-onset HF. They also had higher bilirubin (20 (11-34) vs. 13 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23), p < 0.001) and lower PT (48 (29-68) vs. 70 (52-85), p < 0.001). When assessed by deciles, BNP/NT-pro-BNP was significantly higher in patients with worsening CHF (p < 0.001).…”

“…The median cardiac index (CI) was 2.1 (1.9-3) L/min/m 2 . Patients of the worsening CHF group had higher RAP (12 (6-16) vs. 8 (5)(6)(7)(8)(9)(10)(11), p = 0.028) and a trend for higher PCWP (22 (15-29) vs. 16 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23), p = 0.062).…”

“…In our population, 83 patients had right heart catheterization: 36 in the new-onset HF group and 47 in the worsening CHF group (Table 4). The median right atrial pressure (RAP) was 10 (6-14) mmHg, the median mean pulmonary artery pressure (mPAP) was 29 (24-35) mmHg, and the median pulmonary capillary wedge pressure (PCWP) was 19 (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). The median cardiac index (CI) was 2.1 (1.9-3) L/min/m 2 .…”

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Acute MI-Cardiogenic Shock and Endorsed by the Asian Pacific Society of Interventional Cardiology

“…[6][7][8][9]28 It is also associated with higher inpatient mortality compared with patients with acute on chronic heart failure-related CS even with similar haemodynamic characteristics. [6][7][8][9]29 Hence, it is difficult to extrapolate the benefits of PAC on AMI-CS from the results of the aforementioned trials. 27 Recent American Heart Association (AHA) consensus statements on CS and AMI-CS strongly support the use of PACdemand haemodynamic data.…”

Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock: A review of contemporary literature

“…CS from AMI has low filling, lower pulmonary artery pressures, higher oxygen delivery (DO 2 ), lower oxygen-hemoglobin affinity (P50), and more severe metabolic acidosis in comparison with CS from end-stage heart failure (ESHF)[ 49 ]. Further, there is higher inpatient mortality in patients with acute HF related vs acute on chronic HF related CS even with similar hemodynamic characteristics such as MAP, CO, cardiac power index (CPI)[ 50 ].…”