Women with cardiogenic shock: risk factors and management in a tertiary center
Authors: Diaz-Arroyo B , Gonzalez-Pacheco H , Villalobos-Pedroza M , Ortega-Hernandez J A , Gopar-Nieto R , Briseno-De La Cruz J L , Araiza-Garaygordobil D , Sierra Lara-Martinez D , Mendoza-Garcia S , Altamirano-Castillo A , Ontiveros-Mercado H , Aguilar-Montano K M , Arias-Mendoza A 
Published: October 2022

Abstract

Background
Cardiogenic shock (CS) mortality is about 50–60%; acute myocardial infarction (AMI) remains the most common cause, representing the 81%. There are related risk factors for the occurrence of CS in this vulnerable population, yet, data in these patients is scarce and compels us to identify specific risk factors and treatments to improve their prognosis.

Purpose
To identify the differences in clinical and laboratory characteristics, management strategies and outcomes, by evaluating etiology and risk factors, in order to predict mortality in this setting.

Methods
255 women were included, CS was defined by: systolic blood pressure &lt;90 mmHg, need of vasopressors, cardiac index &lt;2.2 L/min/m2, or blood lactate ≥2 mmol/L. Categorical variables were analyzed using X2; continuum data with U-Mann-Whitney; logistic regression for in-hospital mortality was constructed and KM curves were performed against SCAI and CARDSHOCK scores.

Results
In the current cohort, we found that classic risk factors are associated with AMI-CS such as age (68 vs 60, p&lt;0.001), BMI (26 vs 24, p=0.007), diabetes (65.58 vs 25%, p&lt;0.001), smoking (20.78 vs 2%, p=0.015), dyslipidemia (29 vs 10.89%, p=0.001), hypertension (66.88 vs 41.58%, p&lt;0.001) and previous stroke (3.9 vs 11.8, p&lt;0.001). Interestingly, AF occurred more frequently in non-AMI-CS (48.51 vs 3.25, p&lt;0.001). Initial SBP, DBP, and MAP were lower in this group (p&lt;0.001), and LVEF was higher (45 vs 35%, p=0.015). At lab data, AMI-CS had higher glucose, leukocytes, sodium, AST, ALT, and eGFR and lower creatinine.
Regarding the management strategy, AMI-CS was associated with the simultaneous use of more vasoactive agents (p&lt;0.001), norepinephrine (p=0.001), dobutamine (p&lt;0.001) and levosimendan (p=0.019), as well as IABP (31.17. vs 1.98, p&lt;0.001). No difference among groups was seen in global mortality (74.68 vs 73.27, p=0.802).
When analyzed by logistic regression, SCAI stages D and E had higher odds ratio (OR) of mortality compared to C stage. CARDSHOCK had significant differences along the tertiles, these 2 scores had substantial differences in the Kaplan-Meier curves with the 30-day mortality (p&lt;0.001, Fig. 1A, B, and C). The number of vasoactive agents had an incremental risk when using 2 (OR=2.66) or ≥3 (OR=2.32) drugs. Mechanical ventilation was associated with an increased mortality (OR=1.86). Gasometrical derived data had significant differences in lactate (OR=1.1), pH decrease (OR=1.33), and base excess (BE, OR=1.07) (Fig. 1A)

Conclusions
Herein, we identified specific risk factors related to mortality in women, AMI-CS patients had similar risk factors than the ones seen in men populations. But some specifics factors in women management differ compared to historical mixed cohorts.
In conclusion, women-derived data must be specifically analyzed focusing in the involved risk factors and management strategies, which differ from those reported in mixed cohorts.

Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Mexico City