Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure

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 < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 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 < 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.

Incidence and outcomes of acute kidney injury stratified by cardiogenic shock severity

“…This study was approved by the Institutional Review Board of Mayo Clinic (IRB # 16–000722) as posing minimal risk to patients and was performed under a waiver of informed consent. We retrospectively analyzed a previously‐constructed database, including data from the index CICU admission of consecutive unique adult patients aged ≥18 years admitted to the CICU at Mayo Clinic Hospital St. Mary's Campus between January 1, 2007, and December 31, 2015 2,6,7,13,15‐22 . To minimize bias associated with CICU readmissions, only data from the first CICU admission during the study period was analyzed.…”

“…Using the Multidisciplinary Epidemiology and Translational Research in Intensive Care Data Mart, we recorded demographic, vital signs, laboratory, clinical and outcome data, as well as procedures and therapies performed during the CICU and hospital stay 2,6,7,13,15‐23 . The admission vital signs, clinical measurements, and laboratory values were defined as either the first value recorded after or closest to the index CICU admission.…”

“…Acute kidney injury (AKI) is one of the most common manifestations of end‐organ dysfunction in critically ill patients 1,2 . The development of AKI portends a poor prognosis in patients with critical illness requiring intensive care unit (ICU) admission 2‐4 .…”

“…Acute kidney injury (AKI) is one of the most common manifestations of end‐organ dysfunction in critically ill patients 1,2 . The development of AKI portends a poor prognosis in patients with critical illness requiring intensive care unit (ICU) admission 2‐4 . AKI is common in patients presenting to the Cardiac Intensive Care Unit (CICU), and the co‐occurrence of acute cardiac dysfunction and AKI is termed acute cardiorenal syndrome (CRS) 3,5‐7 .…”

“…The Society for Cardiovascular Angiography and Interventions (SCAI) recently published a CS severity classification system to facilitate more accurate communication among clinicians by clearly defining CS severity 12 . This classification schema has aided in prognostication among CICU patients and in patients presenting with CS, and impaired kidney function was an important marker of hypoperfusion used to define CS 2,13,14 . Markers of kidney function on admission were progressively worse, and the need for dialysis more common, among patients with increasing SCAI shock stages 13 …”