Cardiac Arrest in de Novo Heart Failure and Cardiogenic Shock

Patients with de novo heart failure and related cardiogenic shock (DNHF-CS) have a greater incidence of in-hospital cardiac arrest and death vs patients with acute-on-chronic (AC) HF-CS, according to findings published in the Journal of the American College of Cardiology: Heart Failure.

Investigators sought to characterize patients with HF-CS while focused on the practical application of the Society of Cardiovascular Angiography and Cardiovascular Interventions (SCAI) stages to define baseline and maximal shock severity, clinical outcomes, and in-hospital management with acute mechanical circulatory support (AMCS).

They initiated the CSWG (Cardiogenic Shock Working Group; ClinicalTrials.gov Identifier: NCT04682483) registry, which included 1767 patients (aged ≥18 years) with HF-CS, regardless of etiology, from 17 clinical sites (community, secondary, and tertiary care hospitals) between 2016 and 2020. Patients with postcardiotomy shock, ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, unknown causes of CS, or unknown outcome status at hospital discharge were excluded.

Overall, 19.8% of the 1767 consecutively enrolled patients (mean age, 62 years; 27.6% women) had DNHF-CS. The investigators found that patients were most likely to present in SCAI stage C or D with a maximum of SCAI stage D achieved, and almost as many patients presented in stage E as stage C. Overall, there were 441 patients who died in-hospital, and 400 who received left ventricular assist device or heart transplantation (HRT).

Compared with patients with ACHF-CS, patients with DNHF-CS were more likely to experience in-hospital death and in- and out-of-hospital cardiac arrest. They also escalated more rapidly to a maximum achieved SCAI stage than patients with ACHF-CS. Regardless of clinical presentation, in-hospital cardiac arrest was associated with greater in-hospital death (DNHF-CS: 63% vs 21%; ACHF-CS: 65% vs 17%; both P <.001).

Patients with ACHF-CS were more likely to receive HRT. There were 45% of HF-CS patients exposed to at least 1 acute mechanical circulatory support (AMCS) device throughout hospitalization, although few patients with DNHF-CS received any AMCS device within 24 hours of admission. The most commonly used device among patients receiving HRT was an intra-aortic balloon pump. A significant number of HF-CS patients deteriorated clinically after the first 24 hours of hospitalization.

There was increased lactate levels (hypoperfusion marker) and reduced systolic blood pressure (hypotension marker) among patients with DNHF-CS associated with higher in-hospital mortality.

A significant limitation of this study is the unknown factors, including order of use, concomitant use, flows, and dosages among patients receiving inotropes, vasoactive agents, or AMCS devices. Additional limitations include incomplete registry data derived from electronic health records, and survival bias among patients never hospitalized with HF who experienced death at home.

“…patients with DNHF-CS were a high-risk subgroup with greater in-hospital death or cardiac arrest and more rapid escalation to maximum disease severity,” the study authors wrote.

Disclosure: This research was supported by Abiomed Inc, Boston Scientific Inc, Abbott Laboratories, Getinge Inc, and LivaNova Inc. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.