Jones Tara L, Tan Michael C, Nguyen Vidang, Kearney Kathleen E, Maynard Charles C, Anderson Emily, Mahr Claudius, McCabe James M
Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA.
Division of Cardiology, Department of Medicine, University of Washington Heart Institute, 1959 NE Pacific St., 3rd Floor, Seattle, WA, 98195, USA.
ESC Heart Fail. 2020 Jun;7(3):1118-1124. doi: 10.1002/ehf2.12670. Epub 2020 Mar 11.
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.
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 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 , P = 0.24) between the two groups.
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.
尽管在冠状动脉再灌注和经皮机械循环支持方面取得了进展，但心源性休克（CS）患者的死亡率仍然高得令人难以接受。临床试验和风险分层工具主要集中在急性CS，尤其是继发于急性冠状动脉综合征的情况。对于慢性心力衰竭（HF）患者急性失代偿情况下的CS，人们了解得要少得多。我们试图比较急性CS患者与慢性失代偿性HF急性发作且具有与CS一致的实验室和血流动力学特征的患者之间的结局。
确定了2014年1月至2017年8月期间在单一四级中心因CS入院的连续患者。慢性HF急性发作的CS定义为先前有HF诊断。收集初始血流动力学和实验室数据进行分析。主要结局是住院死亡率。次要结局是使用临时机械循环支持、植入耐用的心室辅助装置、植入全人工心脏或进行心脏移植。连续变量的比较采用Student t检验。对于分类变量，使用χ统计量。共确定了235例患者：51例（32.8%）为急性CS，184例（64.3%）为慢性HF急性失代偿，两组在年龄（52±22岁对55±14岁，P = 0.28）或性别（26%对23%，P = 0.75）方面无差异。与慢性HF急性发作的患者相比，急性CS患者尽管使用临时机械循环支持的比例更高（52%对25%，P < 0.01），但仍更有可能在住院期间死亡（31.4%对9.8%，P < 0.01）。入院时唯一具有临床意义的血流动力学差异是急性CS组心率更高（101±29对82±17次/分钟，P < 0.01）和脉压更宽（34±19对29±10 mmHg，P < 0.01）。基于常用的CS参数，包括平均动脉压（72±12对74±10 mmHg，P = 0.23）、心输出量（3.9±1.2对3.8±1.2 L/分钟，P = 0.70）或心脏功率指数（0.32±0.09对0.30±0.09 W/m，P = 0.24），两组之间的休克程度无显著差异。
基于在急性冠状动脉综合征背景下进行的临床试验得出的当前CS定义和风险分层模型可能无法准确反映慢性HF急性发作患者的CS情况。有必要对慢性HF急性发作患者的CS进行进一步研究。
