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. 2023 Oct;11(10):1304-1315.
doi: 10.1016/j.jchf.2023.05.007. Epub 2023 Jun 21.

Clinical Course of Patients in Cardiogenic Shock Stratified by Phenotype

Elric Zweck  1 , Manreet Kanwar  2 , Song Li  3 , Shashank S Sinha  4 , A Reshad Garan  5 , Jaime Hernandez-Montfort  6 , Yijing Zhang  7 , Borui Li  7 , Paulina Baca  7 , Fatou Dieng  7 , Neil M Harwani  7 , Jacob Abraham  8 , Gavin Hickey  9 , Sandeep Nathan  10 , Detlef Wencker  11 , Shelley Hall  11 , Andrew Schwartzman  12 , Wissam Khalife  13 , Claudius Mahr  3 , Ju H Kim  14 , Esther Vorovich  15 , Evan H Whitehead  16 , Vanessa Blumer  17 , Ralf Westenfeld  18 , Daniel Burkhoff  19 , Navin K Kapur  20
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Free article

Clinical Course of Patients in Cardiogenic Shock Stratified by Phenotype

Elric Zweck et al. JACC Heart Fail. 2023 Oct.
Free article

Abstract

Background: Cardiogenic shock (CS) patients remain at 30% to 60% in-hospital mortality despite therapeutic innovations. Heterogeneity of CS has complicated clinical trial design. Recently, 3 distinct CS phenotypes were identified in the CSWG (Cardiogenic Shock Working Group) registry version 1 (V1) and external cohorts: I, "noncongested;" II, "cardiorenal;" and III, "cardiometabolic" shock.

Objectives: The aim was to confirm the external reproducibility of machine learning-based CS phenotypes and to define their clinical course.

Methods: The authors included 1,890 all-cause CS patients from the CSWG registry version 2. CS phenotypes were identified using the nearest centroids of the initially reported clusters.

Results: Phenotypes were retrospectively identified in 796 patients in version 2. In-hospital mortality rates in phenotypes I, II, III were 23%, 41%, 52%, respectively, comparable to the initially reported 21%, 45%, and 55% in V1. Phenotype-related demographic, hemodynamic, and metabolic features resembled those in V1. In addition, 58.8%, 45.7%, and 51.9% of patients in phenotypes I, II, and III received mechanical circulatory support, respectively (P = 0.013). Receiving mechanical circulatory support was associated with increased mortality in cardiorenal (OR: 1.82 [95% CI: 1.16-2.84]; P = 0.008) but not in noncongested or cardiometabolic CS (OR: 1.26 [95% CI: 0.64-2.47]; P = 0.51 and OR: 1.39 [95% CI: 0.86-2.25]; P = 0.18, respectively). Admission phenotypes II and III and admission Society for Cardiovascular Angiography and Interventions stage E were independently associated with increased mortality in multivariable logistic regression compared to noncongested "stage C" CS (P < 0.001).

Conclusions: The findings support the universal applicability of these phenotypes using supervised machine learning. CS phenotypes may inform the design of future clinical trials and enable management algorithms tailored to a specific CS phenotype.

Keywords: SCAI stages; acute heart failure; cardiogenic shock; machine learning; mechanical circulatory support; outcomes; phenotypes.

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Conflict of interest statement

Funding Support and Author Disclosures This work was supported by National Institutes of Health R01 grants (to Dr Kapur) (R01HL139785-01; R01HL159089-01) and institutional grants from Abiomed Inc, Boston Scientific Inc, Abbott Laboratories, Getinge Inc, and LivaNova Inc to Tufts Medical Center. The sponsors had no input on collection, analysis, and interpretation of the data, nor in the preparation, review, or approval of the manuscript. Dr Kapur has received consulting honoraria and institutional grant support from Abbott Laboratories, Abiomed Inc, Boston Scientific, Medtronic, LivaNova, Getinge, and Zoll. Dr Kanwar has served on the Advisory Board for Abiomed Inc. Dr Sinha has served as a consultant for Abiomed Inc. Dr Garan has served as a consultant for NuPulseCV, has served on the Scientific Advisory Board for Abiomed, and is a recipient of research support from Verantos and Abbott. Dr Hernandez-Montfort has served as a consultant for Abiomed Inc. Dr Abraham has served as a consultant for Abbott Laboratories and Abiomed Inc. Dr Nathan has received consulting honoraria from Abiomed, Getinge, and CSI. Dr Hall has served as a consultant to Abiomed, Abbott, and Medtronic. Dr Mahr has served as a consultant to Abbott, Abiomed, and Syncaria. Dr Westenfeld has received research support from Abiomed Inc and accepted a position at Abiomed Inc after submission of this manuscript. Dr Burkhoff has received an unrestricted educational grant from Abiomed Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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