Predictors of in-hospital mortality among cardiogenic shock patients. Prognostic and therapeutic implications

Cardiogenic shock (CS) has a poor prognosis. The heterogeneity in the mortality through different subgroups suggests that some factors can be useful to perform risk stratification and guide management. We aimed to find predictors of in-hospital mortality in these patients. We analyzed all cases of cardiogenic shock due to medical conditions admitted in our intensive acute cardiovascular care unity from November 2010 till November 2015. Clinical, biochemical and hemodynamic variables were registered, as was the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile at 24 h of CS diagnosis. From a total of 281 patients, 28 died within the first 24 h and were not included in the analysis. A total of 253 patients survived the first 24 h, mean age was 68.8 ± 14.4 years, and 174 (68.8%) were men. Etiologies: acute coronary syndrome 146 (57.7%), acute heart failure 60 (23.7%), arrhythmias 35 (13.8%), and others 12 (4.8%). A total of 91 patients (36.0%) died during hospitalization. We found the following independent predictors of in-hospital mortality: age (odds ratio [OR] 1.032, 95% confidence interval [CI] 1.003–1.062), blood glucose (OR 1.004, 95% CI 1.001–1.008), heart rate (OR 1.014, 95% CI 1.001–1.028), and INTERMACS profile (OR 0.168, 95% CI 0.107–0.266). In patients with CS the INTERMACS profile at 24 h of diagnosis was associated with higher in-hospital mortality. This and other prognostic variables (age, blood glucose, and heart rate) may be useful for risk stratification and to select appropriate medical or invasive interventions.

Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: Results from the Metocard-CNIC trial (Effect of Metoprolol in Cardioprotection during an Acute Myocardial Infarction)

The goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events. Early IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI). The METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up. Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046). In patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions.