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Published on: June 12, 2021
Clinical presentation, shock severity and mortality in patients with de novo versus acute-on-chronic heart
Jonas Sundermeyer1,2, Caroline Kellner1,3, Benedikt N Beer1,2
1Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
Insights
Patients with acute-on-chronic heart failure-related cardiogenic shock (HF-CS) face higher mortality than those with de novo HF-CS. This study reveals HF chronicity as a key factor in CS severity and outcomes.
Area of Science:
- Cardiology
- Critical Care Medicine
- Heart Failure Research
Background:
- Heart failure-related cardiogenic shock (HF-CS) is a critical condition with significant mortality.
- The clinical characteristics and outcomes of de novo versus acute-on-chronic HF-CS patients are not well-defined.
Purpose of the Study:
- To compare the clinical presentation and 30-day mortality between patients with de novo HF-CS and acute-on-chronic HF-CS.
Main Methods:
- An international observational study included 1030 patients with HF-CS from 16 centers (2010-2021).
- Adjusted logistic/Cox regression models were used to analyze differences in clinical presentation and 30-day mortality.
Main Results:
- Of 1030 patients, 47.2% had de novo HF-CS and 52.8% had acute-on-chronic HF-CS.
- Traditional markers of shock severity and treatment use were similar between groups.
- Acute-on-chronic HF-CS was associated with higher CS severity and a significantly increased 30-day mortality risk (adjusted HR 1.38, p=0.005).
Conclusions:
- Acute-on-chronic HF-CS is linked to greater severity and higher mortality compared to de novo HF-CS.
- Heart failure chronicity is a crucial factor modifying CS presentation and prognosis.
- Future clinical trials in HF-CS should stratify patients based on HF chronicity.
Aims:
Heart failure-related cardiogenic shock (HF-CS) accounts for a significant proportion of CS cases. Whether patients with de novo HF and those with acute-on-chronic HF in CS differ in clinical characteristics and outcome remains unclear. The aim of this study was to evaluate differences in clinical presentation and mortality between patients with de novo and acute-on-chronic HF-CS.
Methods And Results:
In this international observational study, patients with HF-CS from 16 tertiary care centres in five countries were enrolled between 2010 and 2021. To investigate differences in clinical presentation and 30-day mortality, adjusted logistic/Cox regression models were fitted. Patients (n = 1030) with HF-CS were analysed, of whom 486 (47.2%) presented with de novo HF-CS and 544 (52.8%) with acute-on-chronic HF-CS. Traditional markers of CS severity (e.g. blood pressure, heart rate and lactate) as well as use of treatments were comparable between groups. However, patients with acute-on-chronic HF-CS were more likely to have a higher CS severity and also a higher mortality risk, after adjusting for relevant confounders (de novo HF 45.5%, acute-on-chronic HF 55.9%, adjusted hazard ratio 1.38, 95% confidence interval 1.10-1.72, p = 0.005).
Conclusion:
In this large HF-CS cohort, acute-on-chronic HF-CS was associated with more severe CS and higher mortality risk compared to de novo HF-CS, although traditional markers of CS severity and use of treatments were comparable. These findings highlight the vast heterogeneity of patients with HF-CS, emphasize that HF chronicity is a relevant disease modifier in CS, and indicate that future clinical trials should account for this.
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