Rapid Classification and Treatment Algorithm of Cardiogenic Shock Complicating Acute Coronary Syndromes: The SAVE ACS Classification

Introduction. We aimed to identify the independent “frontline” predictors of 30-day mortality in patients with acute coronary syndromes (ACS) and propose a rapid cardiogenic shock (CS) classification and management pathway. Materials and Methods. From 2011 to 2019, a total of 11439 incident ACS patients were treated in our institution. Forward conditional logistic regression analysis was performed to determine the “frontline” predictors of 30 day mortality. The C-statistic assessed the discriminatory power of the model. As a validation cohort, we used 431 incident ACS patients admitted from January 1, 2020, to July 20, 2020. Results. Independent predictors of 30-day mortality included age (OR 1.05; 95% CI 1.04 to 1.07, p < 0.001 ), intubation (OR 7.4; 95% CI 4.3 to 12.74, p < 0.001 ), LV systolic impairment (OR severe_vs_normal 1.98; 95% CI 1.14 to 3.42, p = 0.015 , OR moderate_vs_normal 1.84; 95% CI 1.09 to 3.1, p = 0.022 ), serum lactate (OR 1.25; 95% CI 1.12 to 1.41, p < 0.001 ), base excess (OR 1.1; 95% CI 1.04 to 1.07, p < 0.001 ), and systolic blood pressure (OR 0.99; 95% CI 0.982 to 0.999, p = 0.024 ). The model discrimination was excellent with an area under the curve (AUC) of 0.879 (0.851 to 0.908) ( p < 0.001 ). Based on these predictors, we created the SAVE (SBP, Arterial blood gas, and left Ventricular Ejection fraction) ACS classification, which showed good discrimination for 30-day AUC 0.814 (0.782 to 0.845) and long-term mortality p log − rank < 0.001 . A similar AUC was demonstrated in the validation cohort (AUC 0.815). Conclusions. In the current study, we introduce a rapid way of classifying CS using frontline parameters. The SAVE ACS classification could allow for future randomized studies to explore the benefit of mechanical circulatory support in different CS stages in ACS patients.

Evaluate the results of veno-arterial extracorporeal membrane oxygenation for cardiogenic shock patient

Background: Although there are many advances in the diagnosis and resuscitation of patients with cardiogenic shock, the mortality rate is still high, especially for patients with cardiogenic shock due to complications of acute myocardial infarction, the mortality rate can be up to 50 - 70%. Objective: "Evaluate the effectiveness of clinical, subclinical and complications of V-A ECMO in patients with cardiogenic shock". Method: Retrospective analysis of patients diagnosed with cardiogenic shock supported by V-A ECMO revascularization from October 2018 and June 2020; Analyze the significance of V-A ECMO with the clinical outcome prognosis and and complications of V-A ECMO. Results: There were 23 patients hospitalized for cardiogenic shock, they have used the V-A ECMO. The mean age was 53,5±17,6, the minimum age was 13, the oldest was 76. The shortest hospital stay time was 3.5 day and the longest treatment time is 32 days. There were 15 patients alive, accounting for 65.2%, 8 patients died, accounting for 35.8%. The percentage of patients living in the group of myocarditis reached the highest rate. Common complications in patients supported by V-A ECMO are left ventricular volume overload and infection. Conclusion: V-A ECMO is a treatment option for life-threatening cardiogenic shock that has not responded to other therapies.

Successful Use of Extracorporeal Life Support and Continuous Renal Replacement Therapy in the Treatment of Cardiogenic Shock Induced by Tumor Lysis Syndrome in a Pediatric Patient With Lymphoma: A Case Report

The use of extracorporeal membrane oxygenation (ECMO) in the treatment of cardiopulmonary failure in children with malignant tumors is controversial. There are few reports on the use of ECMO in the treatment of children with tumor lysis syndrome. This article reports a case of a 9-year-old girl who presented with hyperkalemia and cardiogenic shock. The discovery of an abdominal mass with critical ultrasound provided key evidence for the initial diagnosis of tumor lysis syndrome. Cardiopulmonary resuscitation was performed for 1 h. Veno-arterial ECMO was installed at the bedside to provide cardiopulmonary support for the patient and was combined with continuous renal replacement therapy (CRRT) to improve her internal environment. The patient was ultimately diagnosed with mature B-cell lymphoma with tumor lysis syndrome. A severe electrolyte disorder led to cardiogenic shock. After the electrolyte imbalance was corrected, the patient's heart function gradually improved, ECMO was successfully weaned, and chemotherapy was continued with the support of CRRT. One month after ECMO weaning, the organ function of the patient had recovered and there were no serious complications. In this case report, we paid attention to the rapid diagnosis of the etiology behind a patient's shock with critical ultrasound as well as the initiation and management of extracorporeal cardiopulmonary resuscitation (ECPR), which provided us with valuable experience using VA-ECMO on critically ill children with tumors. It is also important evidence for the use of ECMO in the treatment of children with cardiopulmonary arrest secondary to malignancy.

Low-dose corticosteroid therapy for cardiogenic shock in adults (COCCA): study protocol for a randomized controlled trial

Background Cardiogenic shock (CS) is a life-threatening condition characterized by circulatory insufficiency caused by an acute dysfunction of the heart pump. The pathophysiological approach to CS has recently been enriched by the tissue consequences of low flow, including inflammation, endothelial dysfunction, and alteration of the hypothalamic-pituitary-adrenal axis. The aim of the present trial is to evaluate the impact of early low-dose corticosteroid therapy on shock reversal in adults with CS. Method/design This is a multicentered randomized, double-blind, placebo-controlled trial with two parallel arms in adult patients with CS recruited from medical, cardiac, and polyvalent intensive care units (ICU) in France. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 380 patients (190 per group). For the treatment group, hydrocortisone (50 mg intravenous bolus every 6 h) and fludrocortisone (50 μg once a day enterally) will be administered for 7 days or until discharge from the ICU. The primary endpoint is catecholamine-free days at day 7. Secondary endpoints include morbidity and all-cause mortality at 28 and 90 days post-randomization. Pre-defined subgroups analyses are planned, including: postcardiotomy, myocardial infarction, etomidate use, vasopressor use, and adrenal profiles according the short corticotropin stimulation test. Each patient will be followed for 90 days. All analyses will be conducted on an intention-to-treat basis. Discussion This trial will provide valuable evidence about the effectiveness of low dose of corticosteroid therapy for CS. If effective, this therapy might improve outcome and become a therapeutic adjunct for patients with CS. Trial registration ClinicalTrials.gov, NCT03773822. Registered on 12 December 2018