TY - JOUR
T1 - Epidemiology of Shock in Contemporary Cardiac Intensive Care Units
T2 - Data from the Critical Care Cardiology Trials Network Registry
AU - Berg, David D.
AU - Bohula, Erin A.
AU - Van Diepen, Sean
AU - Katz, Jason N.
AU - Alviar, Carlos L.
AU - Baird-Zars, Vivian M.
AU - Barnett, Christopher F.
AU - Barsness, Gregory W.
AU - Burke, James A.
AU - Cremer, Paul C.
AU - Cruz, Jennifer
AU - Daniels, Lori B.
AU - Defilippis, Andrew P.
AU - Haleem, Affan
AU - Hollenberg, Steven M.
AU - Horowitz, James M.
AU - Keller, Norma
AU - Kontos, Michael C.
AU - Lawler, Patrick R.
AU - Menon, Venu
AU - Metkus, Thomas S.
AU - Ng, Jason
AU - Orgel, Ryan
AU - Overgaard, Christopher B.
AU - Park, Jeong Gun
AU - Phreaner, Nicholas
AU - Roswell, Robert O.
AU - Schulman, Steven P.
AU - Jeffrey Snell, R.
AU - Solomon, Michael A.
AU - Ternus, Bradley
AU - Tymchak, Wayne
AU - Vikram, Fnu
AU - Morrow, David A.
N1 - Funding Information:
Dr Berg is supported by a T32 postdoctoral training grant from the National Heart, Lung, and Blood Institute (T32 HL007604). Dr Solomon is supported by National Institutes of Health Clinical Center intramural research funds.
Publisher Copyright:
© 2019 American Heart Association, Inc.
PY - 2019/3/1
Y1 - 2019/3/1
N2 - Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock (P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
AB - Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock (P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
KW - North America
KW - cardiogenic shock
KW - epidemiology
KW - hypotension
KW - intensive care units
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U2 - 10.1161/CIRCOUTCOMES.119.005618
DO - 10.1161/CIRCOUTCOMES.119.005618
M3 - Article
C2 - 30879324
AN - SCOPUS:85063290277
SN - 1941-7713
VL - 12
JO - Circulation: Cardiovascular Quality and Outcomes
JF - Circulation: Cardiovascular Quality and Outcomes
IS - 3
M1 - e005618
ER -