Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions

Abstract

Aims: The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population.

Methods and results: The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001).

Conclusion: SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.

Keywords: Cardiac intensive care unit; Cardiogenic shock; Epidemiology.

Figure 1

Shock profile and aetiology in a cardiac intensive care unit (CICU) population. Shock cases were classified according to primary haemodynamic profile. Cardiogenic shock (CS) cases were sub-classified according to primary aetiology. Mixed shock indicates that more than one shock category substantially contributed to the haemodynamic profile, and mixed CS refers to mixed shock cases with a known cardiogenic component (∼93% of all mixed shock). Cases for which the shock category was uncertain (n = 188; 2% of all shock cases) are not included in the figure. AMI-CS, acute myocardial infarction-related cardiogenic shock; CS, cardiogenic shock; HF-CS, heart failure-related cardiogenic shock.

Figure 2

In-hospital mortality by shock profile and aetiology. Error bars indicate the 95% confidence intervals around the in-hospital mortality estimates for each shock category. AMI-CS, acute myocardial infarction-related cardiogenic shock; CS, cardiogenic shock; HF-CS, heart failure-related cardiogenic shock.