Advertisement

Biventricular Function and Shock Severity Predict Mortality in Cardiac ICU Patients

Published:October 01, 2021DOI:https://doi.org/10.1016/j.chest.2021.09.032

      Background

      Ventricular function, including left ventricular systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and biventricular dysfunction (BVD), contribute to shock in cardiac ICU (CICU) patients, but the prognostic usefulness remains unclear.

      Research Question

      Do patients with ventricular dysfunction have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage?

      Study Design and Methods

      We identified patients in the CICU admitted with available echocardiography data. LVSD was defined as left ventricular ejection fraction < 40%, RVSD as moderate or greater systolic dysfunction by semiquantitative measurement, and BVD as the presence of both. Multivariate logistic regression determined the relationship between ventricular dysfunction and adjusted in-hospital mortality as a function of SCAI stage.

      Results

      The study population included 3,158 patients with a mean ± SD age of 68.2 ± 14.6 years, of which 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and BVD in 16.4%. After adjustment for SCAI shock stage, no difference in in-hospital mortality was found between patients with LVSD or RVSD and those without ventricular dysfunction (P > .05), but BVD was associated independently with higher in-hospital mortality (adjusted hazard ratio, 1.815; 95% CI, 1.237-2.663; P = .0023). The addition of ventricular dysfunction to the SCAI staging criteria increased discrimination for hospital mortality (area under the receiver operating characteristic curve, 0.784 vs 0.766; P < .001).

      Interpretation

      Among patients admitted to the CICU, only BVD was associated independently with higher hospital mortality. The addition of echocardiography assessment to the SCAI shock criteria may facilitate improved clinical risk stratification.

      Key Words

      Abbreviations:

      ACS (acute coronary syndrome), BVD (biventricular dysfunction), CART (classification and regression tree), CICU (cardiac ICU), CS (cardiogenic shock), HF (heart failure), LV (left ventricular), LVEF (left ventricular ejection fraction), LVSD (left ventricular systolic dysfunction), MCS (mechanical circulatory support), RV (right ventricular), RVSD (right ventricular systolic dysfunction), SCAI (Society for Cardiovascular Angiography and Interventions), SOFA (Sequential Organ Failure Assessment), TTE (transthoracic echocardiography)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Berg D.D.
        • Bohula E.A.
        • van Diepen S.
        • et al.
        Epidemiology of shock in contemporary cardiac intensive care units.
        Circ Cardiovasc Qual Outcomes. 2019; 12e005618
        • Jentzer J.C.
        • Ahmed A.M.
        • Vallabhajosyula S.
        • et al.
        Shock in the cardiac intensive care unit: changes in epidemiology and prognosis over time.
        Am Heart J. 2021; 232: 94-104
        • Lala A.
        • Guo Y.
        • Xu J.
        • et al.
        Right ventricular dysfunction in acute myocardial infarction complicated by cardiogenic shock: a hemodynamic analysis of the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) Trial and Registry.
        J Card Fail. 2018; 24: 148-156
        • Thayer K.L.
        • Zweck E.
        • Ayouty M.
        • et al.
        Invasive hemodynamic assessment and classification of in-hospital mortality risk among patients with cardiogenic shock.
        Circ Heart Fail. 2020; 13e007099
        • Jentzer J.C.
        • Wiley B.M.
        • Anavekar N.S.
        • et al.
        Noninvasive hemodynamic assessment of shock severity and mortality risk prediction in the cardiac intensive care unit.
        JACC Cardiovasc Imaging. 2020;
        • Baran D.A.
        • Long A.
        • Badiye A.P.
        • Stelling K.
        Prospective validation of the SCAI shock classification: single center analysis.
        Catheter Cardiovasc Interv. 2020; 96: 1339-1347
        • Jentzer J.C.
        • Baran D.A.
        • van Diepen S.
        • et al.
        Admission Society for Cardiovascular Angiography and Intervention shock stage stratifies post-discharge mortality risk in cardiac intensive care unit patients.
        Am Heart J. 2020; 219: 37-46
        • Schrage 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
        • Baran D.A.
        • Grines C.L.
        • Bailey S.
        • et al.
        SCAI Clinical Expert Consensus Statement on the Classification of Cardiogenic Shock.
        Catheter Cardiovasc Interv, 2019
        • Jentzer J.C.
        • van Diepen S.
        • Barsness G.W.
        • et al.
        Cardiogenic shock classification to predict mortality in the cardiac intensive care unit.
        J Am Coll Cardiol. 2019; 74: 2117-2128
        • Garan A.R.
        • Kanwar M.
        • Thayer K.L.
        • et al.
        Complete hemodynamic profiling with pulmonary artery catheters in cardiogenic shock is associated with lower in-hospital mortality.
        JACC Heart Fail. 2020; 8: 903-913
        • Jentzer J.C.
        • Bennett C.
        • Wiley B.M.
        • et al.
        Predictive value of the sequential organ failure assessment score for mortality in a contemporary cardiac intensive care unit population.
        J Am Heart Assoc. 2018; 7
        • Jentzer J.C.
        • Murphree D.H.
        • Wiley B.
        • et al.
        Comparison of mortality risk prediction among patients >/=70 versus <70 years of age in a cardiac intensive care unit.
        Am J Cardiol. 2018; 122: 1773-1778
        • Bennett C.E.
        • Wright R.S.
        • Jentzer J.
        • et al.
        Severity of illness assessment with application of the APACHE IV predicted mortality and outcome trends analysis in an academic cardiac intensive care unit.
        J Crit Care. 2018; 50: 242-246
        • Jentzer J.C.
        • Wiley B.
        • Bennett C.
        • et al.
        Temporal trends and clinical outcomes associated with vasopressor and inotrope use in the cardiac intensive care unit.
        Shock. 2019;
        • Jentzer J.C.
        • Baran D.A.
        • van Diepen S.
        • et al.
        Admission Society for Cardiovascular Angiography and Intervention shock stage stratifies post-discharge mortality risk in cardiac intensive care unit patients.
        Am Heart J. 2019; 219: 37-46
        • Jentzer J.C.
        • Bennett C.
        • Wiley B.M.
        • Murphree D.H.
        • Keegan M.T.
        • Barsness G.W.
        Predictive value of individual Sequential Organ Failure Assessment sub-scores for mortality in the cardiac intensive care unit.
        PLoS One. 2019; 14e0216177
        • Jentzer J.C.
        • Wiley B.
        • Bennett C.
        • et al.
        Early noncardiovascular organ failure and mortality in the cardiac intensive care unit.
        Clin Cardiol. 2020; 45: 516-523
        • Singh B.
        • Singh A.
        • Ahmed A.
        • et al.
        Derivation and validation of automated electronic search strategies to extract Charlson comorbidities from electronic medical records.
        Mayo Clin Proc. 2012; 87: 817-824
        • Jentzer J.C.
        • Breen T.
        • Sidhu M.
        • Barsness G.W.
        • Kashani K.
        Epidemiology and outcomes of acute kidney injury in cardiac intensive care unit patients.
        J Crit Care. 2020; 60: 127-134
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39 e14
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23 (quiz 786-688): 685-713
        • Padkins M.
        • Breen T.
        • Anavekar N.
        • et al.
        Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure.
        ESC Heart Fail, 2020
        • Jentzer J.C.
        • Lawler P.R.
        • van Diepen S.
        • et al.
        Systemic inflammatory response syndrome is associated with increased mortality across the spectrum of shock severity in cardiac intensive care patients.
        Circ Cardiovasc Qual Outcomes. 2020; 13e006956
        • Jentzer J.C.
        • Henry T.D.
        • Barsness G.W.
        • Menon V.
        • Baran D.A.
        • Van Diepen S.
        Influence of cardiac arrest and SCAI shock stage on cardiac intensive care unit mortality.
        Catheter Cardiovasc Interv. 2020; 96: 1350-1359
      1. Jentzer J, Burstein B, van Diepen S, et al. Defining shock and preshock for mortality risk stratification in cardiac intensive care unit patients. Circ Heart Fail. In press.

        • Picard M.H.
        • Davidoff R.
        • Sleeper L.A.
        • et al.
        Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock.
        Circulation. 2003; 107: 279-284
        • Acharya D.
        Predictors of outcomes in myocardial infarction and cardiogenic shock.
        Cardiol Rev. 2018; 26: 255-266
        • Jentzer J.C.
        • Anavekar N.S.
        • Burstein B.J.
        • Borlaug B.A.
        • Oh J.K.
        Noninvasive echocardiographic left ventricular stroke work index predicts mortality in cardiac intensive care unit patients.
        Circ Cardiovasc Imaging. 2020; 13e011642
        • Goldstein J.A.
        • Tweddell J.S.
        • Barzilai B.
        • Yagi Y.
        • Jaffe A.S.
        • Cox J.L.
        Importance of left ventricular function and systolic ventricular interaction to right ventricular performance during acute right heart ischemia.
        J Am Coll Cardiol. 1992; 19: 704-711
        • Jacobs A.K.
        • Leopold J.A.
        • Bates E.
        • et al.
        Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry.
        J Am Coll Cardiol. 2003; 41: 1273-1279
        • Goldstein J.A.
        • Barzilai B.
        • Rosamond T.L.
        • Eisenberg P.R.
        • Jaffe A.S.
        Determinants of hemodynamic compromise with severe right ventricular infarction.
        Circulation. 1990; 82: 359-368
        • Van Diepen S.
        • Katz J.N.
        • Albert N.M.
        • et al.
        Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.
        Circulation. 2017; 136: e232-e268
        • Harjola V.-P.
        • 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
        • Carluccio E.
        • Biagioli P.
        • Alunni G.
        • et al.
        Prognostic value of right ventricular dysfunction in heart failure with reduced ejection fraction.
        Circ Cardiovasc Imaging. 2018; 11e006894
        • Haddad F.
        • Doyle R.
        • Murphy D.J.
        • Hunt S.A.
        Right ventricular function in cardiovascular disease, part II.
        Circulation. 2008; 117: 1717-1731
        • Alviar C.L.
        • Miller P.E.
        • McAreavey D.
        • et al.
        Positive pressure ventilation in the cardiac intensive care unit.
        J Am Coll Cardiol. 2018; 72: 1532-1553
        • Klinke A.
        • Schubert T.
        • Müller M.
        • et al.
        Emerging therapies for right ventricular dysfunction and failure.
        Cardiovasc Diagn Ther. 2020; 10: 1735-1767