Shock Severity Assessment in Cardiac Intensive Care Unit Patients With Sepsis and Mixed Septic-Cardiogenic Shock

Abstract

We sought to validate the Society for Cardiovascular Angiography and Interventions (SCAI) cardiogenic shock classification for mortality risk stratification in patients with sepsis and concomitant cardiovascular disease or mixed septic-cardiogenic shock. We conducted a single-center retropective cohort study of cardiac intensive care unit patients with an admission diagnosis of sepsis. We used clinical, vital sign, and laboratory data during the first 24 hours after admission to assign SCAI shock stage. We included 605 patients with a median age of 69.4 years (interquartile range, 57.9 to 79.8 years), 222 of whom (36.7%) were female. Acute coronary syndrome or heart failure was present in 480 patients (79.3%), and cardiogenic shock or cardiac arrest was present in 271 patients (44.8%). The median day 1 Sequential Organ Failure Assessment (SOFA) cardiovascular subscore was 1.5 (interquartile range, 1 to 4), and the admission SCAI shock stage distribution was stage B, 40.7% (246); stage C, 19.3% (117); stage D, 32.9% (199); and stage E, 7.1% (43). In-hospital mortality occurred in 177 of the 605 patients (29.3%) and increased incrementally with higher SCAI shock stage. After multivariable adjustment, admission SCAI shock stage was associated with in-hospital mortality (adjusted odds ratio per stage, 1.46; 95% CI, 1.14 to 1.88; P=.003). Admission SCAI shock stage had higher discrimination for in-hospital mortality than the day 1 SOFA cardiovascular subscore (area under the receiver operating characteristic curve, 0.68 vs 0.64; P=.04 by the DeLong test). Admission SCAI shock stage was associated with 1-year mortality (adjusted hazard ratio per stage, 1.19; 95% CI, 1.03 to 1.37; P=.02). The SCAI shock classification provides improved mortality risk stratification over the day 1 SOFA cardiovascular subscore in cardiac intensive care unit patients with sepsis and concomitant cardiovascular disease or mixed septic-cardiogenic shock.

Keywords: APACHE, Acute Physiology and Chronic Health Evaluation; AUC, area under the receiver operating characteristic curve; CICU, cardiac intensive care unit; CS, cardiogenic shock; OR, odds ratio; SCAI, Society for Cardiovascular Angiography and Interventions; SIRS, systemic inflammatory response syndrome; SOFA, Sequential Organ Failure Assessment.

Figure 1

Observed in-hospital mortality in the study population and patients with or without an admission diagnosis of cardiac arrest (CA) or cardiogenic shock (CS) as a function of the day 1 Sequential Organ Failure Assessment (SOFA) cardiovascular subscore (A) and admission Society for Cardiovascular Angiography and Intervention (SCAI) shock stage (B). For both scores, the trend was P<.001 for in-hospital mortality across groups.

Figure 2

Kaplan-Meier survival curves illustrating 1-year (A) and 5-year (B) survival as a function of Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. P<.0001 between groups by log-rank test for both.