AIMS:The prognosis of right heart failure (RHF) is purported to be poor, yet there are limited data detailing the implications of concomitant cardiogenic shock (CS) and RHF. We sought to characterize the prevalence and impact of RHF on patients with CS. METHODS AND RESULTS:We queried the Vizient® Clinical Database to identify adults ≥18 years old admitted 1 October 2015 to 30 June 2023, with a diagnosis of CS. Using inverse probability of treatment weighting (IPTW), adjusting for demographics, comorbidities, and markers of acuity, we compared in-hospital mortality between patients with and without a diagnosis of RHF as well as by Society of Cardiovascular Angiography and Interventions (SCAI) shock stages B through E. We identified 348 919 patients with CS, including 11.3% (n = 39 610) with RHF. Patients with RHF were younger (60.5 vs. 65.5; P < 0.001), more frequently had heart failure (HF) as their primary admission diagnosis (40.8% vs. 23.2%; P < 0.001), and presented in earlier SCAI shock stages. Patients with non-RHF CS were more likely to have acute myocardial infarction (AMI) as primary admission diagnosis (20.7% vs. 8.2%; P < 0.001) and present with out-of-hospital cardiac arrest (11.5% vs. 5.8%; P < 0.001). After adjustment, RHF was associated with a 2.4% [95% confidence interval (CI): 1.9-2.9%; P < 0.001] increase in absolute mortality and when stratified by SCAI shock stage. Patients with isolated RHF were found to have a higher absolute in-hospital mortality [9.8%; 95% (CI): 8.6-11.0%; P < 0.001]. CONCLUSION:The presence of RHF is associated with increased in-hospital mortality in patients admitted with CS.
Durable left ventricular assist devices (dLVAD) remain a lifesaving therapy in patients with stage D heart failure that is refractory to conventional medical therapies. Owing to improvements in technology and patient outcomes, the number of patients supported with dLVADs has increased over the past decade. Despite this growing population, there are few resources for cardiovascular intensivists that integrate epidemiology, diagnostic workup and multidisciplinary medical management of acute emergencies in patients supported with dLVADs.
The population found in today’s cardiac intensive care unit (CICU) is strikingly different from that found in traditional coronary care units from decades ago, with increasing illness severity and higher prevalence of noncardiac critical illness. Cardiogenic shock (CS) is a heterogeneous syndrome commonly found in modern CICU with a variety of etiologies and presentations; despite advances in noninvasive monitoring and hemodynamic support, as well as efforts to standardize early identification and delivery of therapy, outcomes remain relatively poor. The establishment of critical care cardiology (CCC) as a distinct subspecialty was intended to address the acute needs of the patients in modern CICU, combining cardiovascular medicine expertise with the knowledge and skillset of a critical care intensivist to manage the spectrum of illnesses seen in modern CICU. With this dual expertise, the critical care cardiologist is uniquely positioned to coordinate multidisciplinary care for CS patients—integrating hemodynamic data, knowledge of multiorgan insult and failure driven by shock, procedural skill, and interpersonal influence to foster collaboration and timely decision-making within CS teams. This review aims to provide the history and development of CCC, discuss intensive care unit staffing models, and summarize the evidence supporting CS team utilization. Finally, we propose that continued investment in CCC training, research, and infrastructure is crucial to meet the demands of patients in the modern CICU.
ABSTRACT Background The importance of lactate trajectory during the first day of cardiogenic shock is increasingly recognized. We aimed to assess the association between admission-day lactate trajectory and in-hospital mortality, and to identify same-day interventions predictive of lactate clearance. Methods We analyzed adult patients admitted with cardiogenic shock between October 2015 and June 2023, using the Vizient® Clinical Data Base. Early lactate clearance was defined as lactate <2.5 mmol/L by the end of the admission day. We used multivariable logistic regression to assess the association between lactate change and in-hospital mortality, and to identify interventions associated with lactate clearance. Results Among 40,434 patients with cardiogenic shock, 30.1% achieved same-day lactate normalization, which was associated with lower in-hospital mortality (aOR 0.51; 95% CI 0.48–0.54). Lactate change showed the greatest prognostic importance, with observed mortality exceeding 80% among those with lactate increase >5 mmol/L regardless of baseline values. After adjustment, lactate change showed a positive exponential relationship with mortality, with aORs ranging from 0.25 (95% CI 0.23–0.27) for a -10 mmol/L change to 3.99 (95% CI 3.58–4.40) for a +10 mmol/L change. The intervention most strongly associated with early lactate clearance was pulmonary artery catheter (PAC; aOR 1.28 [95% CI 1.19–1.37]). Conclusions Nearly 1 in 3 patients with cardiogenic shock achieved early lactate clearance, which was associated with lower mortality. The magnitude of lactate change had profound prognostic implications regardless of the initial value. Among day 1 interventions, PAC use had the strongest association with lactate clearance. CLINICAL PERSPECTIVE What is new? - In this real-world cohort of patients with cardiogenic shock, nearly 1 in 3 achieved normal lactate values on the first day of admission. - Early lactate clearance was associated with nearly half the odds of in-hospital death, but the magnitude of lactate change on admission day had the strongest prognostic value regardless of the initial lactate value. - The intervention on the first day of admission most associated with early lactate clearance was pulmonary artery catheterization placement. What are the clinical implications? - Both the normalization of and magnitude of change in lactate on the first day of admission offer prognostic information that can help guide risk stratification in patients with cardiogenic shock. - Our findings are further support for the importance of early trajectory in patients with cardiogenic shock and highlight the importance of lactate trends in that assessment.
