Predicting mortality in cardiogenic shock secondary to ACS requiring short-term mechanical circulatory support: The ACS-MCS score
Qussay Marashly MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorIosif Taleb MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorChristos P. Kyriakopoulos MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorElizabeth Dranow PhD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTara L. Jones MD, PharmD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorAnwar Tandar MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorSean D. Overton MD
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorJoseph E. Tonna MD, MS
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKathleen Stoddard RN
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorOmar Wever-Pinzon MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorLine Kemeyou MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorAntigone G. Koliopoulou MD
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKevin S. Shah MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKimiya Nourian BS, MS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTyler J. Richins BS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTyson S. Burnham BS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorFrederick G. Welt MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorStephen H. McKellar MD, MSc
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorJose Nativi-Nicolau MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorCorresponding Author
Stavros G. Drakos MD, PhD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Correspondence
Stavros G. Drakos, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah School of Medicine, 30 North 1900 East, Room 4A150, Salt Lake City, UT.
Email: [email protected]
Search for more papers by this authorQussay Marashly MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorIosif Taleb MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorChristos P. Kyriakopoulos MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorElizabeth Dranow PhD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTara L. Jones MD, PharmD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorAnwar Tandar MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorSean D. Overton MD
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorJoseph E. Tonna MD, MS
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKathleen Stoddard RN
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorOmar Wever-Pinzon MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorLine Kemeyou MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorAntigone G. Koliopoulou MD
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKevin S. Shah MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorKimiya Nourian BS, MS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTyler J. Richins BS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorTyson S. Burnham BS
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorFrederick G. Welt MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorStephen H. McKellar MD, MSc
Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorJose Nativi-Nicolau MD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Search for more papers by this authorCorresponding Author
Stavros G. Drakos MD, PhD
Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
Cardiovascular intensive care unit (CVICU), University of Utah School of Medicine, Salt Lake City, Utah, USA
Correspondence
Stavros G. Drakos, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah School of Medicine, 30 North 1900 East, Room 4A150, Salt Lake City, UT.
Email: [email protected]
Search for more papers by this authorFunding information: AHA Heart Failure Strategically Focused Research Network, Grant/Award Number: 16SFRN29020000; National Heart, Lung, and Blood Institute, Grant/Award Numbers: K23HL141596, NHLBI R01 HL132067-01A1, NHLBI R01 HL135121-01, NHLBI T32HL007576; Nora Eccles Treadwell Foundation
Abstract
Objective
To identify predictors of 30-day all-cause mortality for patients with cardiogenic shock secondary to acute coronary syndrome (ACS-CS) who require short-term mechanical circulatory support (ST-MCS).
Background
ACS-CS mortality is high. ST-MCS is an attractive treatment option for hemodynamic support and stabilization of deteriorating patients. Mortality prediction modeling for ACS-CS patients requiring ST-MCS has not been well-defined.
Methods
The Utah Cardiac Recovery (UCAR) Shock database was used to identify patients admitted with ACS-CS requiring ST-MCS devices between May 2008 and August 2018. Pre-ST-MCS clinical, laboratory, echocardiographic, and angiographic data were collected. The primary endpoint was 30-day all-cause mortality. A weighted score comprising of pre-ST-MCS variables independently associated with 30-day all-cause mortality was derived and internally validated.
Results
A total of 159 patients (mean age, 61 years; 78% male) were included. Thirty-day all-cause mortality was 49%. Multivariable analysis resulted in four independent predictors of 30-day all-cause mortality: age, lactate, SCAI CS classification, and acute kidney injury. The model had good calibration and discrimination (area under the receiver operating characteristics curve 0.80). A predictive score (ranging 0–4) comprised of age ≥ 60 years, pre-ST-MCS lactate ≥2.5 mmol/L, AKI at time of ST-MCS implementation, and SCAI CS stage E effectively risk stratified our patient population.
Conclusion
The ACS-MCS score is a simple and practical predictive score to risk-stratify CS secondary to ACS patients based on their mortality risk. Effective mortality risk assessment for ACS-CS patients could have implications on patient selection for available therapeutic strategy options.
CONFLICT OF INTEREST
Frederick G. Welt has served on the advisory board of Medtronic. Joseph E. Tonna has received modest support from LivaNova and Philips Healthcare as a speaking honorarium in relation to this work. Stavros G. Drakos is a consultant to Abbott. All other authors report no conflicts.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
- 1Hollenberg SM, Kavinsky CJ, Parrillo JE. Cardiogenic shock. Ann Intern Med. 1999; 131: 47-59.
- 2Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008; 117: 686-697.
- 3Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med. 1999; 341: 625-634.
- 4Vahdatpour C, Collins D, Goldberg S. Cardiogenic shock. J Am Heart Assoc. 2019; 8:e011991.
- 5Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: this document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019; 94: 29-37.
- 6Schrage B, Ibrahim K, Loehn T, et al. Impella support for acute myocardial infarction complicated by cardiogenic shock. Circulation. 2019; 139: 1249-1258.
- 7Subramaniam AV, Barsness GW, Vallabhajosyula S. Complications of temporary percutaneous mechanical circulatory support for cardiogenic shock: an appraisal of contemporary literature. Cardiol Ther. 2019; 8: 211-228.
- 8Agarwal S, Sud K, Martin JM, Menon V. Trends in the use of mechanical circulatory support devices in patients presenting with ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2015; 8: 1772-1774.
- 9Basir MB, Schreiber TL, Grines CL, et al. Effect of early initiation of mechanical circulatory support on survival in cardiogenic shock. Am J Cardiol. 2017; 119: 845-851.
- 10Basir MB, Schreiber T, Dixon S, et al. Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the Detroit cardiogenic shock initiative. Catheter Cardiovasc Interv. 2018; 91: 454-461.
- 11Ouweneel DM, Eriksen E, Sjauw KD, et al. Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2017; 69: 278-287.
- 12Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012; 367: 1287-1296.
- 13Thiele H, Akin I, Sandri M, et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018; 379: 1699-1710.
- 14Rios SA, Bravo CA, Weinreich M, et al. Meta-analysis and trial sequential analysis comparing percutaneous ventricular assist devices versus intra-aortic balloon pump during high-risk percutaneous coronary intervention or cardiogenic shock. Am J Cardiol. 2018; 122: 1330-1338.
- 15Taleb I, Koliopoulou AG, Tandar A, et al. Shock team approach in refractory cardiogenic shock requiring short-term mechanical circulatory support: a proof of concept. Circulation. 2019; 140: 98-100.
- 16Kellum JA, Lameire N, Group KAGW. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (part 1). Crit Care. 2013; 17: 204.
- 17van Buuren S, Boshuizen HC, Knook DL. Multiple imputation of missing blood pressure covariates in survival analysis. Stat Med. 1999; 18: 681-694.
10.1002/(SICI)1097-0258(19990330)18:6<681::AID-SIM71>3.0.CO;2-R PubMed Web of Science® Google Scholar
- 18Royston P. Multiple imputation of missing values. Stata J. 2004; 4: 227-241.
- 19Royston P. Multiple imputation of missing values: further update of ice, with an emphasis on categorical variables. Stata J. 2009; 9: 466-477.
- 20Royston P, Sauerbrei W. Bootstrap assessment of the stability of multivariable models. Stata J. 2009; 9: 547-570.
- 21Vittinghoff EG, Shiboski DV, McCulloch SC, Charles E. Regression methods in biostatistics: linear, logistic, survival, and repeated measures models. Vol 134. New York: Springer; 2005.
- 22Garcia-Alvarez A, Arzamendi D, Loma-Osorio P, et al. Early risk stratification of patients with cardiogenic shock complicating acute myocardial infarction who undergo percutaneous coronary intervention. Am J Cardiol. 2009; 103: 1073-1077.
- 23Klein LW, Shaw RE, Krone RJ, et al. Mortality after emergent percutaneous coronary intervention in cardiogenic shock secondary to acute myocardial infarction and usefulness of a mortality prediction model. Am J Cardiol. 2005; 96: 35-41.
- 24Hasdai D, Holmes DR, Califf RM, et al. Cardiogenic shock complicating acute myocardial infarction: predictors of death. GUSTO investigators. Global utilization of streptokinase and tissue-plasminogen activator for occluded coronary arteries. Am Heart J. 1999; 138: 21-31.
- 25Sutton AG, Finn P, Hall JA, Harcombe AA, Wright RA, de Belder MA. Predictors of outcome after percutaneous treatment for cardiogenic shock. Heart. 2005; 91: 339-344.
- 26Sleeper LA, Reynolds HR, White HD, Webb JG, Dzavík V, Hochman JS. A severity scoring system for risk assessment of patients with cardiogenic shock: a report from the SHOCK trial and registry. Am Heart J. 2010; 160: 443-450.
- 27Harjola VP, Lassus J, Sionis A, et al. Clinical picture and risk prediction of short-term mortality in cardiogenic shock. Eur J Heart Fail. 2015; 17: 501-509.
- 28Pöss J, Köster J, Fuernau G, et al. Risk stratification for patients in cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2017; 69: 1913-1920.
- 29Dauerman HL, Goldberg RJ, Malinski M, Yarzebski J, Lessard D, Gore JM. Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock. Am J Cardiol. 2001; 87: 844-848.
- 30Dauerman HL, Ryan TJ, Piper WD, et al. Outcomes of percutaneous coronary intervention among elderly patients in cardiogenic shock: a multicenter, decade-long experience. J Invasive Cardiol. 2003; 15: 380-384.
- 31Dauerman HL, Goldberg RJ, White K, et al. Revascularization, stenting, and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. Am J Cardiol. 2002; 90: 838-842.
- 32Thiele H, Zeymer U, Neumann FJ, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet. 2013; 382: 1638-1645.
- 33Lauten A, Engström AE, Jung C, et al. Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry. Circ Heart Fail. 2013; 6: 23-30.
- 34Rohm CL, Gadidov B, Leitson M, Ray HE, Prasad R. Predictors of mortality and outcomes of acute severe cardiogenic shock treated with the Impella device. Am J Cardiol. 2019; 124: 499-504.
- 35Tarvasmäki T, Haapio M, Mebazaa A, et al. Acute kidney injury in cardiogenic shock: definitions, incidence, haemodynamic alterations, and mortality. Eur J Heart Fail. 2018; 20: 572-581.
- 36Abadeer AI, Kurlansky P, Chiuzan C, et al. Importance of stratifying acute kidney injury in cardiogenic shock resuscitated with mechanical circulatory support therapy. J Thorac Cardiovasc Surg. 2017; 154: 856-864.
- 37Marenzi G, Assanelli E, Campodonico J, et al. Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission. Crit Care Med. 2010; 38: 438-444.
- 38Askenazi DJ, Selewski DT, Paden ML, et al. Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol. 2012; 7: 1328-1336.
- 39Li SY, Yang WC, Chuang CL. Effect of early and intensive continuous venovenous hemofiltration on patients with cardiogenic shock and acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2014; 148: 1628-1633.
- 40Schrage B, Dabboura S, Yan I, et al. Application of the SCAI classification in a cohort of patients with cardiogenic shock. Catheter Cardiovasc Interv. 2020; 96: E213-E219.
- 41Jentzer JC, van Diepen S, Barsness GW, et al. Cardiogenic shock classification to predict mortality in the cardiac intensive care unit. J Am Coll Cardiol. 2019; 74: 2117-2128.
- 42Justice AC, Covinsky KE, Berlin JA. Assessing the generalizability of prognostic information. Ann Intern Med. 1999; 130: 515-524.
