Jentzer, J C

Abstract Background Cardiogenic shock (CS) is characterized by critically low cardiac output and impaired myocardial energy transfer to cardiac work. Left-ventricular (LV) cardiac mechanical efficiency (CE), defined as the fraction of total pressure-volume area (PVA) converted to external work (EW), captures how effectively the LV converts energy into stroke work. Because CE integrates load, chamber volumes, and pump performance into a single physiologic construct, it may directly reflect the energy-work mismatch that characterizes CS. The prognostic value of transthoracic echocardiography (TTE)-derived CE for in-hospital outcomes in CS remains uncertain. Purpose To determine whether TTE-derived CE measured within 24 hours of admission predicts in-hospital mortality in patients with CS, and to compare its discriminatory performance with LV ejection fraction (LVEF). Methods Data from CS patients admitted between 2007 and 2018 were analyzed. First LV end-systolic pressure (LVESP=0.9×systolic blood pressure), stroke volume (SV), and LV end-diastolic pressure (LVEDP, estimated using the Nagueh formula) was estimated. CE was then estimated based on EW (EW=(LVESP×SV)−(SV×LVEDP)), potential energy (PE=0.5×LVESP×LV end-systolic volume) and PVA (EW+PE) as CE=EW/PVA×100. We assessed CE and LVEF by TTE performed within 24 hours of admission. Patients were separated into tertiles of CE: high (>47%), moderate (36% < CE ≤47%), and low (CE ≤36%). The primary endpoint was in-hospital mortality. A key secondary endpoint was cardiac intensive care unit (CICU) mortality. Associations were tested with multivariable logistic regression (pre-specified covariates including LVEF). Results A total of 577 patients were included. Median age was 69 (IQR: 59-78) years, 38% were females and 65% had acute coronary syndrome. CICU mortality was 20% and total in-hospital mortality was 29%. Patients with low CE had a lower LVEF compared with patients with moderate or high CE (21% (IQR:19-24%) vs 31% (IQR: 28-33%) and 45% (39-51%) respectively). Median CE was 40.5% (IQR 31.8–51.0%) and was lower for in-hospital deaths (37.1% vs 42.1%, P<0.001). Patients with lower CE exhibited significantly higher CICU (P=0.003) and in-hospital mortality (P<0.001; Figure 1). Patients with CE in the lowest tertile had significantly increased risk of CICU and in-hospital death (Figure 2) compared with moderate or high CE tertiles. In multivariate analysis, every 1% decrease in CE corresponded to an 10% increased risk of CICU death and an 8% increased risk of in-hospital death. When both CE and LVEF were included in the same multivariate model, both were significant predictors of CICU death, while only CE remained a significant predictor of in-hospital death. Conclusion In patients with CS, TTE-derived CE measured within 24 hours of admission predicts early risk of death, underscoring the prognostic importance of LV energy-work coupling as a marker of disease severity beyond LVEF measurement.Figure 1: Figure 2:

Abstract Background Diuretic resistance (DR) is the failure to achieve adequate natriuresis despite high diuretic doses, reflecting a state of low diuretic efficiency (DE). In heart failure (HF) and general intensive care cohorts, low DE and the presence of DR have been associated with adverse outcomes, including increased risk of rehospitalization and mortality (1-3). Quantitative data, however, remains limited in patients admitted to the cardiac intensive care unit (CICU) – a population characterized by cardiac critical illnesses and substantial cardiorenal interactions. Purpose The aim of this study is to investigate and characterize the association between DR and associated mortality outcomes in CICU patients. Methods This retrospective cohort study included adult CICU patients (2007-2018) who received loop diuretics on day 1 of admission. Patients with a stay <1 day or oliguria [<400mL urine output (UOP) total] were excluded. DR was defined as <500mL of UOP per 40mg oral furosemide equivalent (FSE). Acute kidney injury (AKI) was defined per KDIGO guidelines. Primary outcome was all-cause in-hospital mortality (including CICU deaths), and secondary outcome was all-cause 1-year mortality. In-hospital mortality predictors were evaluated using logistic regression and 1-year mortality predictors by Cox proportional-hazards models. 1-year survival was assessed using Kaplan-Meier curves. Multivariable models were adjusted for known confounders. Results 3,229 total patients were included. Median age was 71.2 (61.2, 80.7) years and 41.3% were female. Admission diagnoses included HF exacerbation (79.9%), acute coronary syndrome (34.5%), and respiratory failure (38.9%), among others. 1,098 (34.0%) patients met DR criterion; they had higher severity of illness scores, more comorbidities (including HF, diabetes mellitus, lung disease, and chronic kidney disease, p<0.001), and greater laboratory derangements. On admission, 23.6% patients had AKI, of which 54.3% patients met DR criterion. During hospitalization, 56.0% patients had AKI; those with DR had higher prevalence and severity of AKI (unadjusted OR 3.55 [3.02-4.17], p<0.001). Overall in-hospital mortality was 9.8% (including 5.2% in the CICU). In patients with DR, in-hospital mortality was 17.0% (9.7% in the CICU). Notably, 59.4% of all in-hospital deaths occurred in patients with DR. DR was independently associated with higher in-hospital (adjusted OR 2.00 [1.51-2.64], p<0.001) and 1-year (adjusted HR 1.64 [1.44-1.88], p<0.001) mortality. Patients with DR had higher mortality in each AKI stage (Figure 1), and patients with concomitant DR and AKI had the highest risk of 1-year mortality (Figure 2). Conclusion DR, defined by our easily applicable threshold, emerged as a powerful, independent predictor of adverse outcomes and was associated with substantially higher mortality, demonstrating potential as a valuable risk stratifying tool.

Abstract Background Hypotension is a recognized predictor of mortality in the cardiac intensive care unit (CICU) (1-3). Although prior studies link lower mean/averaged mean arterial pressure (MAP) to adverse outcomes, they highlight the need for dedicated research on the minimum MAP (mMAP), as mean data may fail to capture the clinical significance of brief, severe hypotensive episodes. Purpose This study aims to investigate the mortality outcomes associated with the mMAP within the first 24 hours of CICU admission and further stratified according to admission diagnoses. Methods This retrospective cohort study included adult CICU patients with available mMAP data (2007-2018). Patient data were extracted including admission diagnoses, critical care therapies (hemodynamic/ventilatory support, continuous renal replacement therapy), comorbidities, vital signs, lab values, and mortality outcomes. MAP was measured either invasively (arterial catheter) or non-invasively (blood pressure cuff). Primary exposure was mMAP, defined as the lowest recorded MAP in first 24 hours of CICU admission. Primary outcome was in-hospital mortality analyzed using logistic regression, before and after multivariable adjustment. Mortality outcomes were analyzed according to mMAP and stratified by admission diagnoses (not mutually exclusive). Results 11,930 patients were included. Median age was 69.4 (58.1, 79.2) years and 37.7% were female. Admission diagnoses included heart failure (48.7%), acute coronary syndrome (42.7%), shock (14.9%), and cardiac arrest (11.8%). Critical care therapies were used in 58.5%. Median mMAP was 54 (47, 62) mmHg. 1080 (9.1%) patients died during hospitalization, including 672 (5.6%) in the CICU. Median mMAP was lower in patients who died in the CICU (46 vs. 55 mmHg, p<0.001) and during the hospitalization (47 vs. 55 mmHg, p<0.001). In the overall cohort, the lowest mortality was at mMAP of 71-75 mmHg. Patients with lower mMAP had higher mortality across admission diagnosis subgroups (Fig1). The mMAP associated with the nadir mortality was slightly higher for acute coronary syndrome or cardiac arrest patients (66-70 mmHg) than for heart failure or cardiogenic shock patients (61-65 mmHg) (Fig2). Each 5 mmHg increase in mMAP was associated with lower in-hospital mortality in patients with (unadj OR 0.81 [0.79-0.84], AUC 0.64) and without (unadj OR 0.76 [0.71-0.82], AUC 0.67) critical care therapies. Conclusion Our findings re-affirm that hypotension is a significant predictor of mortality, consistent across all admission diagnoses. Notably, the mMAP range associated with the lowest in-hospital mortality was slightly lower for patients with circulatory failure (heart failure or cardiogenic shock) compared to those with acute coronary syndromes or cardiac arrest. This difference may represent an optimal balance between maintaining perfusion and preventing excessive afterload in the setting of circulatory failure, but further investigation is required.1) Mortality Per mMAP & Admission Diag 2) Nadir Mortality Point