Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w
De novo vs. acute-on-chronic heart failure-related cardiogenic shock
J. Sundermeyer1, F. Gustafsson2, C. Kellner1, B. Beer1, L. C. Besch1, A. Dettling1, S. Blankenberg1, P. Kirchhof1, L. Bertoldi3, J. Dauw4, D. Eckner5, I. Eitel6, T. Graf6, P. Horn7, U. Landmesser8, P. Lüdike9, E. Lüsebrink10, N. Mangner11, O. Maniuc12, S. Möbius-Winkler13, P. Nordbeck14, M. Orban10, F. Pappalardo15, M. Pauschinger5, M. Pazdernik16, A. Proudfoot17, M. Kelham17, T. Rassaf9, C. Scherer18, C. Schulze13, R. H. G. Schwinger19, C. Skurk8, M. Sramko16, G. Tavazzi20, H. Thiele21, L. Villanova22, N. Morici1, A. Wechsler19, R. Westenfeld7, D. Westermann23, B. Schrage1, für die Studiengruppe: NICSR Investigators
1Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 2Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK; 3Cardio Center, Humanitas Clinical and Research Center - IRCCS, Milano, IT; 4Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium & Doctoral School for Medicine and Life Sciences, LCRC, UHasselt, Genk, BE; 5Klinik für Innere Medizin 8, Schwerpunkt Kardiologie, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg; 6Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck; 7Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf; 8CC 11: Med. Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Berlin; 9Klinik für Kardiologie und Angiologie, Universitätsklinikum Essen, Essen; 10Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München; 11Klinik für Innere Medizin, Kardiologie und Intensivmedizin, Herzzentrum Dresden GmbH an der TU Dresden, Dresden; 12Med. Klinik und Poliklinik I, Klinische Elektrophysiologie, Universitätsklinikum Würzburg, Würzburg; 13Klinik für Innere Medizin I - Kardiologie, Universitätsklinikum Jena, Jena; 14Medizinische Klinik und Poliklinik I, Universitätsklinikum Würzburg, Würzburg; 15Dept Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, IT; 16Department of Cardiology, IKEM, Prague, CZ; 17Department of Perioperative Medicine, St. Bartholomew's Hospital, London, UK; 18Klinikum rechts der Isar der Technischen Universität München, München; 19Medizinische Klinik II, Kardiologie, Kliniken Nordoberpfalz AG, Weiden i. d. Oberpfalz; 20Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Italy; Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, IT; 21Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Leipzig; 22Unità di Cure Intensive Cardiologiche and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milan; 23Innere Medizin III, Kardiologie und Angiologie, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Freiburg im Breisgau;

Background: Decompensated heart failure (HF) without an acute myocardial infarction causes cardiogenic shock (CS) in almost half of patients presenting with CS. Prognostic factors for this large group of patients with CS are not well defined.  Here we compared clinical presentation, shock severity and chance of discharge alive in CS due to de novo HF with patients with acute-on-chronic HF.

Aim: The aim of this study was to evaluate the association between clinical presentation, shock severity and mortality in patients with de novo and acute-on-chronic HF-related CS.

Methods: In this international observational study, patients with non-ischemic CS (e.g. caused by severe de-novo or acute-on-chronic HF; but not by acute myocardial infarction) treated with or without MCS from 16 tertiary-care centers in five countries were enrolled. To investigate differences in clinical presentation and shock severity in patients with de novo vs. acute-on-chronic HF-related CS, logistic regression models were fitted; and Cox regression models were fitted to evaluate the association between type of HF-related CS and 30-day mortality. In all models, adjustments were made for age, sex, SCAI class, lactate and pH, prior resuscitation and mechanical ventilation.

Results: A total of 1030 CS patients were analyzed: mean age was 64 (interquartile range [IQR] 52-75) years, 740 (71.8%) were male. Overall, 486 (47,2%) presented with severe de novo HF and 544 (52.8%) with acute-on-chronic HF; 395 (38.6%) patients had a prior cardiac arrest, the median LVEF was 20 (IQR 15-30) %, baseline lactate 4.7 (IQR 2.5-8.4) mmol/l and the baseline pH was 7.3 (IQR 7.2-7.4).

Cardiovascular risk factors (e.g. diabetes, OR 1.9, 95% CI 1.31-2.75, p<0.001) and cardiac comorbidities (e.g. atrial fibrillation, OR 2.45, 95% CI 1.75-2.42, p<0.001) were more likely in patients with acute-on-chronic HF-related CS, but patients with de novo HF-related CS were more likely to be resuscitated (OR 0.62, 95% CI 0.43-0.89, p=0.01) and subsequently more likely to require mechanical ventilation (OR 0.63, 95% CI 0.42-0.94, p=0.02). 

However, shock severity was not different between groups, illustrated by comparable blood pressure, heart rate and lactate. Treatment modalities (e.g., mechanical circulatory support) were not significantly different between groups. 

Importantly, more patients with de novo HF-related CS survived compared to those with acute-on-chronic HF-related CS (10% absolute mortality difference, de novo HF 45.4%, acute-on-chronic HF 55.9%, hazard ratio 1.32, 95% CI 1.05-1.66, p=0.016, Figure 1). 

Conclusion: CS as a first presentation of HF is associated with better survival compared to CS with pre-existing HF, potentially reflecting a lesser tolerance to the acute hemodynamic decline in patients with a longer (e.g., chronic) exposure to HF. This may help to adapt treatment intensity in CS.


Figure 1: Kaplan-Meier curves, patients with de novo vs. acute-on-chronic heart failure-related cardiogenic shock.
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