De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

Abstract

Background: Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown.

Methods and results: We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02).

Conclusions: Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.

Keywords: cardiogenic shock; critical care cardiology; heart failure.

Figure 1(Take Home Figure):. Study Population by CS Classification

Of patients with cardiogenic shock (n=2,093) identified at contemporary North American CICUs, 1,405 (67%) had heart failure related cardiogenic shock (HF-CS), defined as cardiogenic shock in the absence of acute myocardial infarction. Approximately 1 in 4 patients with HF-CS did not have a prior history of HF (de novo HF-CS). A greater proportion of patients with de novo HF-CS had preceding cardiac arrest as compared to those with acute-on-chronic HF-CS. * Excludes post-cardiotomy shock and shock primarily due to severe valvular disease, arrhythmia, or tamponade

Figure 2:. Distribution of Society of Cardiovascular Angiography and Intervention (SCAI) shock severity by CS classification

*Among patients with available data on SCAI shock stage

Figure 3:. Intensive Care Unit Resource utilization by CS category.

CVC = central venous catheter; PA = pulmonary artery, TTM = targeted temperature management; MCS = mechanical circulatory support. Mechanical circulatory support included intra-aortic balloon pump counter-pulsation, Impella percutaneous ventricular assist systems (2.5, CP, 5.0), TandemHeart percutaneous ventricular assist systems, venoarterial extracorporeal membrane oxygenation (VA-ECMO), and surgically implanted, non-durable MCS devices (e.g., CentriMag).

Figure 4:. In-Hospital Mortality by CS category, inclusive and exclusive of cardiac arrest.

Adjusted for age, sex, history of coronary artery disease, diabetes, hypertension, cerebrovascular disease, peripheral vascular disease, chronic kidney disease, atrial fibrillation, pulmonary hypertension, history of ventricular arrhythmias, and cardiac arrest prior to CICU admission