Citations

AbstractAimsCardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS.Methods and resultsPatients with a diagnosis of CS from Mayo Clinic (2007–15) and University Clinic Hamburg (2009–17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years.ConclusionOlder patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.

Abstract Complicated grief (CG), severe, prolonged (>12 months) grieving, disproportionately affects older adults. A prospective two-group, waitlisted RCT examined whether four sessions of Accelerated Resolution Therapy (ART) was effective in informal caregivers by comparing pre-to-post ART changes and investigating variation in treatment response by baseline CG levels. Inclusion: ≥60 years, Inventory of Complicated Grief >25. Paired t-tests of mean (SD) differences compared pre- to post-ART; pre-ART to 8-week follow-up, and post-ART to 8-week follow-up; then stratified by median baseline level of CG. Mean (SD) age of 54 participants was 68.7 (7.2) years, 85% female, and 93% white. Significantly greater CG reduction (-22.8 (10.3)) vs. waitlist (-4.3 (6.0)) was found. Within-participant effect sizes from baseline to 8-weeks post treatment were 1.96 (95% CI: 1.45, 2.47; p<0.0001). Treatment effects did not substantially differ by baseline levels. Lesson learned was that it was possible to successfully recruit and treat CG in the community.

Biomarkers may serve as objective measures in complicated grief (CG) potentially capturing responses to stress reduction treatment. This paper reports challenges in obtaining and assessing salivary cortisol and α-amylase (sAA) for a recent randomized clinical trial. Within-session changes in salivary cortisol and sAA for 54 older adults with CG who received Accelerated Resolution Therapy were compared with perceived stress measured by Subjective Units of Distress Scale. Bivariate correlations and multiple regressions examined changes in biomarkers. Protocols, study logs, and audit reports identified challenges. Challenges included obtaining unstimulated passive drool salivary samples and their analyses. Our sample of older females on multiple medications may have resulted in a perfect storm of moderating and intervening variables which affected the stress response. This paper contributes to the discussion on designing clinical trials for older adults which must account for physiologic changes, multimorbidity, and polypharmacy common in this population and makes recommendations moving forward.

Background: There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults. Methods: A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay. Results: A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P <0.001). Compared with men, women with AMI-CS were more frequently of Black race, from a lower socioeconomic status, with higher comorbidity, and admitted to rural and small hospitals (all P <0.001). Women had lower rates of ST-segment elevation presentation (73.0% versus 78.7%), acute noncardiac organ failure, cardiac arrest (34.3% versus 35.7%), and received less-frequent coronary angiography (78.3% versus 81.4%), early coronary angiography (49.2% versus 54.1%), percutaneous coronary intervention (59.2% versus 64.0%), and mechanical circulatory support (50.3% versus 59.2%; all P <0.001). Female sex was an independent predictor of in-hospital mortality (23.0% versus 21.7%; adjusted odds ratio, 1.11 [95% CI, 1.07–1.16]; P <0.001). Women had lower hospitalization costs ($156 372±$198 452 versus $167 669±$208 577; P <0.001) but comparable lengths of stay compared with men. Conclusions: In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.

Background: Although extracorporeal membrane oxygenation (ECMO) is used for hemodynamic support for in-hospital cardiac arrest (IHCA) complicating acute myocardial infarction (AMI), there are limited data on the outcomes stratified by the timing of initiation of this strategy. Methods: Adult (>18 years) AMI admissions with IHCA were identified using the National Inpatient Sample (2000–2017) and the timing of ECMO with relation to IHCA was identified. Same-day vs. non-simultaneous ECMO support for IHCA were compared. Outcomes of interest included in-hospital mortality, temporal trends, hospitalization costs, and length of stay. Results: Of the 11.6 million AMI admissions, IHCA was noted in 1.5% with 914 (<0.01%) receiving ECMO support. The cohort receiving same-day ECMO (N = 795) was on average female, with lower comorbidity, higher rates of ST-segment-elevation AMI, shockable rhythm, and higher rates of complications. Compared to non-simultaneous ECMO, the same-day ECMO cohort had higher rates of coronary angiography (67.5% vs. 51.3%; p = 0.001) and comparable rates of percutaneous coronary intervention (58.9% vs. 63.9%; p = 0.32). The same-day ECMO cohort had higher in-hospital mortality (63.1% vs. 44.5%; adjusted odds ratio 3.98 (95% confidence interval 2.34–6.77); p < 0.001), shorter length of stay, and lower hospitalization costs. Older age, minority race, non-ST-segment elevation AMI, multiorgan failure, and complications independently predicted higher in-hospital mortality in IHCA complicating AMI. Conclusions: Same-day ECMO support for IHCA was associated with higher in-hospital mortality compared to those receiving non-simultaneous ECMO support. Though ECMO-assisted CPR is being increasingly used, careful candidate selection is key to improving outcomes in this population.