Padkins, Mitchell

Introduction: The Mayo Clinic Cardiac Intensive Care Unit Admission Risk Score (M-CARS) has been shown to predict hospital mortality in the CICU population better than conventional critical care scoring models. We tested the hypothesis that M-CARS could similarly be used to predict one-year mortality. Methods: We retrospectively reviewed adult CICU patients admitted from 2007 to 2018. M-CARS was calculated using admission data. Groups were compared using Wilcoxon test for continuous variables and chi-squared test for categorical variables. Results: This study included 12428 unique patients with a mean age of 67 ± 15 years (37% females), of whom 11279 (90.8%) survived hospitalization and 2839 patients (22.8%) died within 1 year of admission. The 1-year survival decreased incrementally as a function of increasing M-CARS ( Figure 1A , p<0.0001), and all components of M-CARS were significant predictors of 1-year mortality (p<0.001). 1690 hospital survivors (15.0%) died within 1 year. The 1-year survival decreased incrementally as a function of increasing M-CARS for scores <3 (all p<0.001); however, there was no further adverse 1-year survival for patients with M-CARS ≥3 ( Figure 1B, p=0.99). M-CARS components associated with 1-year mortality among hospital survivors included blood urea nitrogen, red blood cell distribution width, Braden score, and respiratory failure (all p<0.001), while cardiac arrest, cardiogenic shock, and anion gap were not. Conclusions: M-CARS accurately predicts 1-year mortality among CICU admissions, with a plateau effects at high M-CARS scores ≥3. Significant predictors of 1-year mortality among CICU survivors include frailty markers rather than admission severity.

Introduction: Acute kidney injury (AKI) is a highly prevalent risk factor for mortality among patients with cardiogenic shock (CS). We sought to assess the incidence and prognostic relevance of AKI as a function of shock severity in unselected Cardiac Intensive Care Unit (CICU) patients, as measured by the Society for the Cardiovascular Angiography and Interventions (SCAI) shock stage. Methods: We retrospectively reviewed admissions to the Mayo Clinic from 2007 to 2015 and stratified patients by the SCAI shock stage. AKI was defined and staged based on changes in serum creatinine during hospitalization as per KDIGO guidelines. Predictors of in-hospital mortality were analyzed using Kaplan-Meier survival analysis, and one-year mortality was analyzed using Cox proportional-hazards analysis. Results: The final study population included 10,004 unique patients with a mean age of 67 years and 37% females. The percentage of patients with SCAI shock stages A, B, C, D, and E were 47%, 30%, 15%, 7%, and 1%, respectively. AKI of any severity occurred in 51% of patients during hospitalization, including severe (stage 2/3) AKI in 16%. The incidence of AKI and severe AKI increased with the SCAI shock stage. Hospital mortality occurred in 8% of patients and increased as a function of the AKI stage and SCAI shock stage. AKI was associated with increased hospital mortality after multivariable adjustment (adjusted OR per AKI stage 1.17, 95% CI 1.05-1.30, p=0.005). Twenty-one percent of patients died within one year of CICU admission, and worse AKI was associated with increased one-year mortality (adjusted HR per AKI stage 1.11, 95% CI 1.05-1.18, p=<0.001). Hospital survivors with AKI of any severity had higher mortality compared with patients who did not have AKI (p<0.001). Conclusions: AKI was increasingly common in CICU patients with higher shock severity. In-hospital and one-year mortality risk increased as a function of the severity of AKI and the SCAI shock stage. This analysis emphasizes the importance of AKI as a complication of shock and as a predictor of adverse outcomes in CICU patients.

AbstractBackgroundAcute kidney injury (AKI) is common among patients with cardiogenic shock (CS) and it is independently associated with mortality. We sought to assess the prevalence, severity, and prognosis of AKI as a function of cardiogenic shock severity in unselected Cardiac Intensive Care Unit (CICU) patients.MethodsWe retrospectively reviewed admissions to the Mayo Clinic between 2007 to 2015 and stratified patients by the AKI stage (based on modified Kidney Disease: Improving Global Outcomes criteria) and Society for cardiovascular angiography and interventions (SCAI) shock stage. The association with in‐hospital mortality was analyzed using multivariable logistic regression.ResultsWe included 9,311 unique patients with a mean age of 67 years and 37% females. SCAI shock stages A, B, C, D, and E were present in 47%, 30%, 15%, 7%, and 1% of patients. The incidence of AKI of any severity was 39% in the CICU and 51% during the hospitalization. Hospital mortality occurred in 8% of all patients, and the risk increased as a function of the rising AKI and SCAI shock stage. Worsening AKI stage was associated with increased adjusted hospital mortality (adjusted OR per AKI stage 1.22, 95% CI 1.10–1.36, p < .001). Higher AKI stages were associated with increased adjusted hospital mortality in SCAI stage A/B (p < .001), but not in SCAI stage C, D, or E (all p > .05).ConclusionsHigher AKI stages were independently associated with mortality in CICU patients after accounting for shock severity and may add incremental prognostic utility in patients with lower SCAI stages.

Purpose: To study the effect of hypoalbuminemia on short- and long-term mortality in Cardiac Intensive Care Unit (CICU) patients. Methods: We reviewed 12,418 unique CICU patients from 2007 to 2018. Hypoalbuminemia was defined as an admission albumin level <3.5 g/dL. Predictors of hospital mortality were identified using multivariable logistic regression. Results: We included 2,680 patients (22%) with a measured admission albumin level. The median age was 68 (39% females). Admission diagnoses included acute coronary syndrome, heart failure, cardiac arrest, and cardiogenic shock. The median albumin level was 3.4 g/dL and 55% of patients had hypoalbuminemia. Hospital mortality occurred in 16%, and patients with hypoalbuminemia had higher hospital mortality (21% vs. 9%, adjusted OR 2.64, 95% CI 2.09-3.34, p < 0.001). Albumin level was inversely associated with hospital mortality (adjusted OR 0.60 per 1 g/dL higher albumin level, 95% CI 0.47-0.75, p <0.001), with a stepwise increase in the hospital mortality at lower albumin levels. Post-discharge mortality was higher in hospital survivors with hypoalbuminemia, and increased as a function of lower albumin levels. Conclusion: Hypoalbuminemia is common in CICU patients and associated with higher short- and long-term mortality. Progressively lower serum albumin was incrementally associated with higher hospital and post-discharge mortality.

Abstract Aims Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF. Methods and results We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007–2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2–1.4, P &lt; 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2–1.3, P &lt; 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P &lt; 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage. Conclusions Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.