Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN.
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (J.C.J., B.B.), Mayo Clinic, Rochester, MN.
Circ Heart Fail. 2021 Jan;14(1):e007678. doi: 10.1161/CIRCHEARTFAILURE.120.007678. Epub 2021 Jan 19.
Previous studies have defined preshock as isolated hypotension or isolated hypoperfusion, whereas shock has been variably defined as hypoperfusion with or without hypotension. We aimed to evaluate the mortality risk associated with hypotension and hypoperfusion at the time of admission in a cardiac intensive care unit population.
We analyzed Mayo Clinic cardiac intensive care unit patients admitted between 2007 and 2015. Hypotension was defined as systolic blood pressure <90 mm Hg or mean arterial pressure <60 mm Hg, and hypoperfusion as admission lactate >2 mmol/L, oliguria, or rising creatinine. Associations between hypotension and hypoperfusion with hospital mortality were estimated using multivariable logistic regression.
Among 10 004 patients with a median age of 69 years, 43.1% had acute coronary syndrome, and 46.1% had heart failure. Isolated hypotension was present in 16.7%, isolated hypoperfusion in 15.3%, and 8.7% had both hypotension and hypoperfusion. Stepwise increases in hospital mortality were observed with hypotension and hypoperfusion compared with neither hypotension nor hypoperfusion (3.3%; all <0.001): isolated hypotension, 9.3% (adjusted odds ratio, 1.7 [95% CI, 1.4-2.2]); isolated hypoperfusion, 17.2% (adjusted odds ratio, 2.3 [95% CI, 1.9-3.0]); both hypotension and hypoperfusion, 33.8% (adjusted odds ratio, 2.8 [95% CI, 2.1-3.6]). Adjusted hospital mortality in patients with isolated hypoperfusion was higher than in patients with isolated hypotension (=0.02) and not significant different from patients with both hypotension and hypoperfusion (=0.18).
Hypotension and hypoperfusion are both associated with increased mortality in cardiac intensive care unit patients. Hospital mortality is higher with isolated hypoperfusion or concomitant hypotension and hypoperfusion (classic shock). We contend that preshock should refer to isolated hypotension without hypoperfusion, while patients with hypoperfusion can be considered to have shock, irrespective of blood pressure.
既往研究将休克前状态定义为孤立性低血压或孤立性低灌注，而休克则被定义为灌注不足伴或不伴低血压。我们旨在评估在心脏重症监护病房人群中，入院时低血压和灌注不足与死亡率之间的相关性。
我们分析了 2007 年至 2015 年期间在梅奥诊所心脏重症监护病房住院的患者。低血压定义为收缩压<90mmHg 或平均动脉压<60mmHg，灌注不足定义为入院时血乳酸>2mmol/L、少尿或肌酐升高。使用多变量逻辑回归估计低血压和灌注不足与住院死亡率之间的相关性。
在 10004 名中位年龄为 69 岁的患者中，43.1%患有急性冠状动脉综合征，46.1%患有心力衰竭。孤立性低血压占 16.7%，孤立性灌注不足占 15.3%，8.7%同时存在低血压和灌注不足。与既无低血压也无灌注不足相比，低血压和灌注不足的住院死亡率呈逐渐升高趋势（均<0.001）：孤立性低血压组为 9.3%（调整比值比，1.7[95%CI，1.4-2.2]）；孤立性灌注不足组为 17.2%（调整比值比，2.3[95%CI，1.9-3.0]）；低血压和灌注不足组为 33.8%（调整比值比，2.8[95%CI，2.1-3.6]）。孤立性灌注不足患者的调整后住院死亡率高于孤立性低血压患者（=0.02），与低血压和灌注不足同时存在的患者无显著差异（=0.18）。
低血压和灌注不足均与心脏重症监护病房患者死亡率升高相关。孤立性灌注不足或同时存在低血压和灌注不足（经典休克）患者的住院死亡率更高。我们认为休克前状态应指无灌注不足的孤立性低血压，而灌注不足的患者则可被视为存在休克，而与血压无关。
