International cooperation in cardiogenic shock is key to improving outcomes: Cardiogenic Shock Working Group impacts a single-center in a developing country
Authors: Ortega-Hernandez J A , Gonzalez-Pacheco H , Hernandez-Montfort J , Manzur-Sandoval D , Gopar-Nieto R , Sierra-Lara-Martinez D , Araiza-Garaygordobil D , Kanwar M , Sinha S S , Garan A R , Burkhoff D , Kapur N , Arias-Mendoza A 
Published: October 2024

Abstract

Background
Management of cardiogenic shock (CS) poses a formidable challenge in healthcare, necessitating innovative approaches and collaborative efforts, not only local, to improve outcomes.

Purpose
To demonstrate that CSWG international cooperation and research in CS can lower mortality, change practices, and improve outcomes.

Methods
From our institutional registry 28,054 patients, we selected 9,430 with CS in SCAI CWSG-score B-E 2022-23 CSWG incorporation (n=1112) against previous years (05-21, n=8318). The primary outcome was in-hospital mortality. Univariate and multivariate analyses were performed, and with PAC use as a a priori subgroup. Adjusted analysis was carried out with age, sex, DM, HTN, previous MI, PCI, CABG, or stroke; CKD, CS etiology, PAC, hemodialysis, number of vasoactives; the presence of MCS, use of mechanical ventilation, and SCAI-CSWG stage. Also, propensity score matching was used to explore differences using the a priori selected variables using K-nearest neighbors (K=2), radius of 1:2, caliper 0.2, and exact SCAI stage matching without replacement (Pre-CSWG n=2198, CSWG era n=1106).

Results
In the CSWG era, there's a increase in mean age (P=0.049) and a higher proportion of men (72.2 vs. 68%, p=0.005). Clinical risk factors show changes, including increased weight (P=0.037), higher smoking (53.3 vs. 48.6%, P=0.003), diabetes (40.1 vs. 34.8%, P=0.001), and hypertension (46.8 vs. 50%, p=0.043). Prior MI and CABG decreased significantly in the CSWG era. Therapeutic shifts are evident, with increased use of PAC (7.9 vs. 4.2%, P&lt;0.001) and significant changes in mechanical circulatory support (p&lt;0.001). Mortality substantially decreases in the CSWG era (15.3 vs. 22.3%, P&lt;0.001).
The unadjusted Cox Pre-CSWG era, the HR 1.41 (1.2-1.65, P&lt; 0.001) a restricted mean survival time (RSMT) of 1.73 days (0.92-2.54, P&lt;0.001). In PAC subgroup, the relationship between PAC use and outcomes appears to be consistent across the levels of the interacting variable (Pint=0.918), with a HR Pre-CSWG era 0.51 (0.44-0.59, P &lt;0.001) and CSWG era HR 0.48 (0.33-0.71,P &lt;0.001)(Fig1C)
The adjusted analysis, the Pre-CSWG era had a HR 1.21 (1.03-1.42, P=0.019). PAC outcomes were consistent across eras (Pint= 0.923). In the Pre-CSWG era HR 0.71 (0.59-0.84,P&lt;0.001), and similarly in the CSWG era 0.54 (0.34-0.87,P=0.01). (Fig1D)
The PS-cohort had a Pre-CSWG era HR 1.21 (1.01-1.45, P=0.034) of the Pre-CSWG era vs CSWG era and a RSMT at 30 days of 1.07 (0.14-2.01 P=0.025). (Fig2)

Conclusion
Shifts in patient demographics, clinical risk factors, hemodynamic parameters, and therapeutic strategies were observed. Notably, mortality significantly decreased with the CSWG incorporation, with consistent benefits of PAC use in both eras. The PS cohort underscored the impact of CSWG incorporation on outcomes. Overall, these findings highlight the transformative influence of CSWG on CS management, as international cooperation is key to improving outcomes.Figure 1.Mortality through erasFgure 2.Propensity score cohort