Berg David D, Bohula Erin A, van Diepen Sean, Katz Jason N, Alviar Carlos L, Baird-Zars Vivian M, Barnett Christopher F, Barsness Gregory W, Burke James A, Cremer Paul C, Cruz Jennifer, Daniels Lori B, DeFilippis Andrew P, Haleem Affan, Hollenberg Steven M, Horowitz James M, Keller Norma, Kontos Michael C, Lawler Patrick R, Menon Venu, Metkus Thomas S, Ng Jason, Orgel Ryan, Overgaard Christopher B, Park Jeong-Gun, Phreaner Nicholas, Roswell Robert O, Schulman Steven P, Jeffrey Snell R, Solomon Michael A, Ternus Bradley, Tymchak Wayne, Vikram Fnu, Morrow David A
Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.).
Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D., W.T.).
Circ Cardiovasc Qual Outcomes. 2019 Mar;12(3):e005618. doi: 10.1161/CIRCOUTCOMES.119.005618.
Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
背景 心脏重症监护病房（CICU）中休克的临床研究主要集中在急性心肌梗死（AMI）合并心源性休克（AMICS）。很少有研究评估当代CICU中休克的全貌。方法与结果 重症监护心脏病学试验网络是北美先进CICU的多中心网络。在2017年9月至2018年9月期间的任何时间，每个中心（n = 16）提供了CICU所有连续医疗入院病例的2个月快照。数据提交至中央协调中心（TIMI研究组，马萨诸塞州波士顿）。休克定义为收缩压持续<90 mmHg且存在归因于低血压的终末器官功能障碍。休克类型由现场研究人员分类为心源性、分布性、低血容量性或混合型。在3049例CICU入院病例中，677例（22%）符合休克的临床标准。休克类型多样，66%被评估为心源性休克（CS），7%为分布性休克，3%为低血容量性休克，20%为混合型休克，4%为不明类型。在CS患者（n = 450）中，30%患有AMICS，18%患有无AMI的缺血性心肌病，28%患有非缺血性心肌病，17%有除原发性心肌功能障碍以外的心脏病因。混合型休克患者的心血管合并症与CS患者相似。AMICS患者在CICU的中位住院时间为4.0天（四分位间距[IQR]，2.5 - 8.1天），与AMI无关的CS患者为4.3天（IQR，2.1 - 8.5天），混合型休克患者为5.8天（IQR，2.9 - 10.0天），而无休克患者为1.9天（IQR，1.0 - 3.6天）（各比较P<0.01）。混合型休克患者的序贯器官衰竭评估中位评分（10；IQR，6 - 13）高于AMICS患者（8；IQR
