Predicting mortality in cardiogenic shock secondary to ACS requiring short‐term mechanical circulatory support: The ACS‐MCS score

Abstract

Objective To identify predictors of 30‐day all‐cause mortality for patients with cardiogenic shock secondary to acute coronary syndrome (ACS‐CS) who require short‐term mechanical circulatory support (ST‐MCS). Background ACS‐CS mortality is high. ST‐MCS is an attractive treatment option for hemodynamic support and stabilization of deteriorating patients. Mortality prediction modeling for ACS‐CS patients requiring ST‐MCS has not been well‐defined. Methods The Utah Cardiac Recovery (UCAR) Shock database was used to identify patients admitted with ACS‐CS requiring ST‐MCS devices between May 2008 and August 2018. Pre‐ST‐MCS clinical, laboratory, echocardiographic, and angiographic data were collected. The primary endpoint was 30‐day all‐cause mortality. A weighted score comprising of pre‐ST‐MCS variables independently associated with 30‐day all‐cause mortality was derived and internally validated. Results A total of 159 patients (mean age, 61 years; 78% male) were included. Thirty‐day all‐cause mortality was 49%. Multivariable analysis resulted in four independent predictors of 30‐day all‐cause mortality: age, lactate, SCAI CS classification, and acute kidney injury. The model had good calibration and discrimination (area under the receiver operating characteristics curve 0.80). A predictive score (ranging 0–4) comprised of age ≥ 60 years, pre‐ST‐MCS lactate ≥2.5 mmol/L, AKI at time of ST‐MCS implementation, and SCAI CS stage E effectively risk stratified our patient population. Conclusion The ACS‐MCS score is a simple and practical predictive score to risk‐stratify CS secondary to ACS patients based on their mortality risk. Effective mortality risk assessment for ACS‐CS patients could have implications on patient selection for available therapeutic strategy options.

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.…”

Advances in the Staging and Phenotyping of Cardiogenic Shock

“… 45 Each additional SCAI Shock stage confers an incrementally higher risk of short-term mortality in populations of CS patients, CICU patients, patients with CA, and even patients with sepsis. 21 , 22 , 28 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 The SCAI Shock Classification provides postdischarge mortality risk stratification among CICU patients who survive hospitalization. 61 Each publication has utilized a subtly different research definition of the SCAI Shock Classification, but despite these modifications, its ability to perform risk stratification has been preserved ( Figure 2 ).…”

Risk prediction in cardiogenic shock

“…In this issue of the Journal, Marashly et al 1 describe a novel ACS‐MCS score to predict 30‐day mortality in patients treated with short‐term mechanical circulatory support (MCS) for cardiogenic shock associated with acute coronary syndromes (ACS). The authors derived the score from a mixed retrospective–prospective cohort study of 159 patients treated at the University of Utah Health Sciences Center between 2008 and 2018.…”

“…This is particularly important due to the absence of a large, randomized trial demonstrating clear survival benefit with any MCS strategy. The proposed ACS‐MCS risk score 1 and related predictive models should serve as a “call‐to‐action” for systems of care to facilitate earlier diagnosis of cardiogenic shock in at‐risk patients with acute myocardial infarction in order to permit multidisciplinary care before shock severity progresses and end‐organ failure ensues.…”