Cardiogenic shock - can we do more?

Despite advances in diagnosis and treatment, in-hospital mortality in patients with cardiogenic shock (CS) remains high. Until recently, acute myocardial infarction (AMI) was the cause of CS in more than 80% of cases, however, the results of numerous new studies support the increasing frequency of other causes of CS, with a low percentage of in-hospital survival.

The aim of our study was to determine demographic, laboratory, clinical and therapeutical predictors of in-hospital mortality in patients with CS, independent of etiology.

The research was conducted as an observational cohort study on a sample of 110 patients hospitalized at our institute from January 2022 to December 2023 due to CS of various etiologies. CS was defined as systolic blood pressure < 90mmHg with clinical signs of hypoperfusion and lactate ≥ 2mmol/l.

In the examined group of 110 patients, 64 (58.2%) were men and AMI was the cause of CS in 83 (75%) patients. Overall mortality was 65 (59%). Mortality among patients with CS caused by AMI was 49.4% which was significantly lower compared to 88.9% among patients with other causes of CS (p<0.0005). Age significantly influenced mortality (69.3% among patients ≥ 65 years compared to 37.1% among patients < 65 years; p=0.002). In comparison with survivors, deceased patients had statistically significantly lower average hemoglobin (125.5 mmol/l vs. 134 mmol/l; p=0.001), higher average creatinine (172 umol/l vs. 110.5 umol/l; p<0.0005) and higher average high-sensitivity troponin (11601.3 mmol/l vs. 659.8 mmol/l; p=0.01). Of the clinical parameters, mortality was significantly influenced by SHOCK index >0.7 (64.4% among deceased vs. 35.6% among survivors; p=0.034), Glasgow Coma Score ≤ 8 (70.8% vs. 29.2%; p=0.033), out-of-hospital cardiac arrest (83.1% vs. 3%, p < 0.0005), as well as the time elapsed from the onset of symptoms to admission (80.6% with duration of symptoms >24h vs. 28.6% (12h-24h) vs. 60% (2-12h) vs. 20% (<2h); p<0.0005). According to the SCAI classification, mortality in stage B CS was 0%, in stage C 11.1%, in stage D 20%, and in stage E 98.4%, which represented a statistically significant difference (p<0.0005). Mortality was higher among patients who were not revascularized (96.4% vs. 45.2%; p<0.0005), as well as those who required the use of vasopressors and inotropes (72.5% vs. 51.4%; p=0.043). The application of mechanical circulatory support (MCP) did not significantly affect the in-hospital outcome, given that mortality among patients who did not receive MCP was 51.4% vs. 72.5% among patients who received MCP (p=0.133).

In our examined group of patients with CS, in-hospital mortality was higher among patients with causes of CS other than AMI, in those with advanced stages of CS, who were not revascularized and who required the use of vasoactive drugs, while the use of MCP failed to improve in-hospital outcome.