Comparison between acute and chronic refractory cardiogenic shock: is prognosis different?
Authors: Garcia Martin E P , Dominguez-Perez L , Galan D , Davila E , Vicent L , Durante A , Bruna V , Martin-Asenjo R , Bueno H , Arribas Ynsaurriaga F 
Published: May 2024

Funding Acknowledgements

None.

Background

Short-term mechanical circulatory support (ST-MCS) is essential to reverse refractory cardiogenic shock (RCS). Since compensatory mechanisms are differently activated depending on whether the cause of CS is acute injury or decompensation of advanced chronic heart failure, hypothetically, the prognosis could also be different.

Purposes

The aim of our study was to compare the prognosis of patients with RCS supported with ST-MCS (venoarterial-extracorporeal membrane oxygenation (VA-ECMO), Centrimag, Impella CP and Impella 5.0) according to whether the cause of cardiogenic shock was an acute myocardial injury (acute myocardial infarction, myocarditis...) or a worsening of advanced cardiomyopathy.

Methods

Consecutive patients ≥ 18 years with RCS requiring ST-MCS at a tertiary center from January 2020 to August 2023 were prospectively included. They were stratified according to whether the cause of shock was acute or chronic. Demographic, clinical characteristics before insertion, and outcomes were included in the analysis.

Results

A total of 86 patients with RCS were supported with ST-MCS in that period, 55 of them (64%) for acute injury and the rest (n=31; 36%) as decompensation of chronic heart failure, with a significantly higher Charlson Comorbidity Index in the chronic group (2(0-3) vs 3(2-4); p=0.01). Acute shock was predominantly supported with VA-ECMO (49.1%) and Impella CP (41.8%), while Impella 5.0 was the most commonly used device in chronic patients (32.2%).

The severity of CS was significantly higher in the acute shock group, assessed by SCAI (p=0.005), VIS Score (55.1 (26.19-90.5) vs 8 (3.1-30); p=0.005) and lactate level (5.3 (3-10.3) vs 1.2 (1-2.2) mmol/l; p&lt;0.005) and a higher but non-significant SOFA score (8 (6-10) vs 6 (4-9); p=0,06).

However, no differences were found in prognosis, both in-hospital mortality, mortality during support and 30-day and 1-year mortality (Figure 1).

Most patients with chronic shock were referred to cardiac transplantation (54.8%) while most patients with acute shock were weaned by myocardial recovery(30.9%), but there were no differences in the final destination of these patients (p=0.089). There were no differences in systemic and local complications between the three groups, except for the rate of device-related ischemia (21.8% vs. 6.4%, p=0.015).

Conclusions

In our center, most patients in CS who required short-term mechanical circulatory support debut after an acute cardiac injury. Percutaneous ST-MCS is preferentially selected in the acute group, probably because of its easy accessibility in emergency situations. Although patients with acute CS present a more severe overall situation than patients worsening due to advanced heart failure, there were no differences in the short- and long-term prognosis or in the destination treatment of these patients.Table of resultsFigure 1.Mortality in RCS