Outcomes associated with respiratory failure for patients with cardiogenic shock and acute myocardial infarction: a substudy of the culprit-shock trial

Abstract

Background Respiratory insufficiency with the need for mechanical ventilation (MV) is one of the most common indications for admission to intensive care units. However, little is known about the clinical outcomes of patients with acute myocardial infraction (AMI) complicated by cardiogenic shock (CS) who require mechanical ventilation (MV). The aim of this study was to identify the characteristics, risk factors, and outcomes associated with the provision of MV in this specific high-risk population. Methods Patients with CS complicating AMI and multivessel coronary artery disease from the CULPRIT-SHOCK trial were included. We explored clinical outcome within 30 days in patients not requiring MV, those with MV on admission, and those in whom MV was initiated within the first day after admission. Results Among 683 randomized patients included in the analysis, 17.4% received no MV, 59.7% were ventilated at admission and 22.8% received MV within or after the first day after admission. Patients requiring MV were younger, more frequently non-smokers, had higher body mass indices, presented more often with clinical signs of impaired organ perfusion including worse renal function, higher burden of coronary artery disease, were more likely to have experienced resuscitation within 24h before admission, had worse left ventricular function, and presented more often with non-ST-segment elevation myocardial infarction. The primary endpoint of all-cause death or need for renal replacement therapy occurred in 21.8% of patients without MV, in 53.3% of patients with MV at admission (adjusted odds ratio [aOR] 6.03, 95% confidence interval (CI) 3.17–11.47, p=0.002, compared to patients without) and 65.4% of patients with MV initiated within the first day after admission (aOR 8.09 95% CI 4.32–15.16, p<0.001, compared to patients without). Factors independently associated with the provision of MV on admission included higher body weight, resuscitation within 24h before admission, elevated heart rate and evidence of triple vessel disease. Conclusions Requiring MV in patients with CS complicating AMI is common and independently associated with mortality after adjusting for covariates. Patients with delayed MV initiation appear to be at higher risk of adverse outcomes. Further research is necessary to identify the optimal timing of MV in this high-risk population. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): Swiss National Foundation

Trends in Therapy and Outcomes Associated With Respiratory Failure in Patients Admitted to the Cardiac Intensive Care Unit

“…As observed in the CCCTN database, mortality was higher in patients with respiratory failure associated with CA (especially non-VF), shock, and sepsis, which is likely explained by the multiorgan involvement frequently observed in these critically ill patients. 8,11 Patients resuscitated from CA are at risk of aspiration, pneumonia and other causes of lung injury that may require a different approach to management than CICU patients with respiratory failure from other causes. 31 Mortality was lower in patients with HF and ACS, whose respiratory failure was likely due to reversible conditions such as volume overload rather than underlying lung injury, which may respond more favorably to the hemodynamic effects of PPV.…”

“…2 Studies have reported a prevalence of respiratory failure ranging between 6-25% of CICU patients, with a need for PPV in up to 80% depending on the indication for CICU admission. 2 –11 Given the known effects of PPV on hemodynamics resulting from changes in intrathoracic pressures and the potential for complications from PPV itself, PPV should be used carefully and tailored to the underlying cardiac pathology. 12,13 For these reasons, respiratory failure has been identified as an important predictor of hospital mortality for CICU patients.…”

“…Previous studies on respiratory failure in critically-ill cardiac patients have focused on specific subpopulations or limited periods, without examining the entire CICU population or providing information on temporal changes. 1,3 –6,8 –11 Therefore, we aimed to investigate the prevalence, prevailing trends, and outcomes of patients admitted with respiratory failure in a large historical cohort of tertiary-care CICU patients spanning more than a decade. This epidemiological data on respiratory failure in the CICU population could be leveraged for planning future randomized clinical trials of respiratory support strategies in CICU patients.…”