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In-Hospital Trajectory of Heart Failure Cardiogenic Shock
Quick Takes
- Patients with heart failure related cardiogenic shock have high rates of in-hospital death (25%), frequently require acute mechanical circulatory support (45%), and often require heart replacement therapy (28%).
- Patients with de novo heart failure presenting with cardiogenic shock are more likely to have in-hospital death, cardiac arrest, and rapid escalation of shock when compared to patients presenting with acute-on-chronic heart failure.
Study Questions:
In a large cohort of hospitalized patients with heart failure (HF) related cardiogenic shock (HF-CS), what is the relationship between clinical presentation, baseline shock severity, maximal shock severity, use of acute mechanical circulatory support (AMCS), and outcomes?
Methods:
The study used registry data from the Cardiogenic Shock Working Group (CSWG), which is a multicenter research consortium consisting of 17 clinical sites contributing data for patients hospitalized with cardiogenic shock (CS) from 2016 to 2020. Patients with HF-CS and age ≥18 years were included in the analysis. Patients with CS due to acute myocardial infarction (AMI), post-cardiotomy shock, and unknown causes were excluded. Patients with unknown outcome at discharge were excluded.
HF-CS clinical presentations were further classified as de novo HF (DNHF) if the HF diagnosis was new, or acute-on-chronic HF (ACHF) if HF diagnosis was present prior to admission. Outcomes at hospital discharge were classified as in-hospital death, heart replacement therapy (HRT) required such as durable ventricular assist device or heart transplantation, or native heart survival (NHS) with HRT. Treatment data, including use of AMCS, was collected. Severity of CS was classified by the Society for Cardiovascular Angiography and Interventions (SCAI) stages for patients at baseline, and a maximum stage during the hospitalization was identified.
Results:
There were 1,767 patients with HF-CS included in the study. Of these, 349 patients (19.8%) had DNHF, 1,371 (77.6%) had ACHF, 1,279 (72.4%) were male, 1,029 (58.2%) were White, and the mean age was 60.3 ± 14.6 years.
At baseline, most patients presented with SCAI Stage C (245 patients, 34.4%) or D (162 patients, 22.7%) CS. Most patients reached a maximum of SCAI stage D CS (1,028 patients, 60.2%). For discharge outcomes, 441 patients (25%) had in-hospital death, 500 (28.2%) needed HRT, and 826 (46.8%) had NHS. AMCS was used in 7% of patients within 24 hours of admission and 45% during hospitalization. For patients with in-hospital death, mechanical ventilation, renal replacement therapy, laboratory markers of hypoperfusion, and poor hemodynamic markers were more likely.
When compared to ACHF, patients with DNHF were more likely to have in-hospital death (32% vs. 22%, p < 0.001), in-hospital cardiac arrest (IHCA) (23.1% vs. 11.5%, p < 0.001), out-of-hospital cardiac arrest (OHCA) (17.0% vs. 7.5%, p < 0.001), and rapid escalation to maximum achieved SCAI stage when presenting with SCAI stage C CS (101 ± 223.6 vs. 128 ± 165.4 hours, p = 0.04). IHCA was associated with in-hospital death in both DNHF and ACHF. OHCA was associated with in-hospital death in ACHF.
Conclusions:
In a large registry-based cohort of patients with HF-CS, patients with DNHF-CS had higher in-hospital mortality, more frequent IHCA and OHCA, and more rapid escalation to maximum SCAI stage for CS. Use of AMCS was frequent overall.
Perspective:
While HF-CS is prevalent and is associated with poor prognosis, there is still much to learn about the natural history and optimal management of this condition. In comparison to AMI-CS, there is a lack of clinical trial data to guide management of patients with HF-CS. The CSWG registry helps to close many knowledge gaps and provides valuable insights such as this publication. It urges clinicians to recognize the increased risk (in-hospital death, cardiac arrest, clinical decompensation) that patients with DNHF face compared to ACHF. For all HF-CS, it is important to note that significant decompensation occurs even after the critical first 24 hours from admission. Use of AMCS is often needed and potentially serves as a bridge to recovery or HRT. Future work further phenotyping HF-CS may allow for more tailored management strategies.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, ACS and Cardiac Biomarkers, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Heart Transplant, Mechanical Circulatory Support, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, AHA22, AHA Annual Scientific Sessions, Angiography, Biomarkers, Cardiac Surgical Procedures, Heart Arrest, Heart Failure, Heart Transplantation, Heart-Assist Devices, Hemodynamics, Hospital Mortality, Out-of-Hospital Cardiac Arrest, Patient Discharge, Renal Replacement Therapy, Respiration, Artificial, Shock, Cardiogenic
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