Early implementation of continuous venovenous haemodiafiltration improves outcome in patients with heart failure complicated by acute kidney injury

Background: Acute kidney injury (AKI) is a serious complication of heart failure (HF). Continuous venovenous haemodiafiltration (CVVHDF) is a widely accepted method for treating this complication. However, the optimal time of its initiation has not been established. Aim: To compare the outcome of patients with HF treated with CVVHDF which was implemented late (the first two years of our experience) or early (the next two years of our experience). Methods: Thirty seven patients, mean age 65 years, were hospitalised between April 2006 and January 2010 with the diagnosis of HF complicated by AKI. The primary cardiovascular diseases were: valvular heart disease (30%), acute coronary syndrome (27%), dilated cardiomyopathy (16%), exacerbation of chronic HF (11%), and others (16%). The inclusion criteria for CVVHDF therapy were: symptoms of HF including cardiogenic shock with high levels of creatinine (≥ 300 μmol/L) and/or oliguria and/or symptoms of septic shock. The exclusion criteria were: serious coagulation disturbances or inability of placing a catheter in a central vein. Group A consisted of 12 patients treated from April 2006 to the end of 2007. In group B, there were 25 patients treated from the beginning of 2008 to January 2010. Before treatment, mean ejection fraction, left ventricular diastolic diameter and mean blood pressure in both groups were comparable. Renal replacement therapy in group B was started earlier than in group A (mean 2.0 ± 2.0 days vs 4.0 ± 4.3 days from the onset of symptoms of AKI; NS). Results: The day after the beginning of CVVHDF, renal failure parameters improved in both groups, but the improvement was much more significant in group B. In group A, 11 (92%) patients died. The mean CVVHDF duration was six days and all patients required mechanical ventilation. In group B, 17 (68%) patients died (NS). The mean CVVHDF duration was shortened to four days. Seventeen (68%) patients were ventilated mechanically and this parameter was significantly different between the groups (p = 0.03) Conclusions: An early introduction of CVVHDF significantly diminished the need to use mechanical ventilation and indicated a positive trend in the reduction of in-hospital mortality in patients with HF complicated by AKI. Kardiol Pol 2011; 69, 9: 891–896Wstęp i cel: Celem pracy była ocena rokowania u chorych z niewydolnością serca (HF) powikłaną ostrym uszkodzeniem nerek (AKI), leczonych za pomocą ciągłej żylno-żylnej hemodiafiltracji (CVVHDF). Badanych podzielono na 2 grupy. Do grupy A zaliczono pacjentów leczonych w pierwszych 2 latach od początku stosowania CVVHDF, a do grupy B — chorych poddanych terapii w późniejszym okresie. Metody: W okresie od kwietnia 2006 do stycznia 2010 r. w Klinice Intensywnej Terapii Kardiologicznej hospitalizowano 37 chorych z HF powikłaną AKI. Wada serca była przyczyną HF u 30% osób, ostry zespół wieńcowy — u 27% chorych, kardiomiopatię rozstrzerzeniową stwierdzono u 16% pacjentów, a zaostrzenie przewlekłej HF u 11%. U pozostałych 16% chorych rozpoznano inne przyczyny HF. Kryteriami włączenia do leczenia za pomocą CVVHDF były: objawy lewo- i/lub prawokomorowej HF, w tym wstrząs kardiogenny i stężenie kreatyniny we krwi ≥ 300 μmol/l i/lub skąpomocz, i/lub objawy wstrząsu septycznego. W przypadku istotnych zaburzeń krzepliwości krwi lub niemożności założenia dostępu żylnego do żyły centralnej nie stosowano CVVHDF. W grupie A było 12 chorych leczonych od kwietnia 2006 do końca 2007 r., a w grupie B — 25 osób leczonych od początku 2008 do stycznia 2010 r. Przed terapią badane grupy nie różniły się pod względem wartości frakcji wyrzutowej, wymiaru rozkurczowego lewej komory i średniego ciśnienia tętniczego krwi. U chorych z grupy B CVVHDF rozpoczęto wcześniej niż u pacjentów z grupy A (średnio 2,0 ± 2,0 v. 4,0 ± 4,3 dni; NS). Wyniki: W drugiej dobie leczenia za pomocą CVVHDF w obu grupach parametry niewydolności nerek poprawiły się, ale w istotnie większym stopniu w grupie B. W trakcie pobytu w szpitalu zmarło 11 (92%) chorych z grupy A; terapia za pomocą CVVHDF trwała średnio 6 dni, a 12 (100%) osób wymagało wentylacji mechanicznej. W grupie B zgony szpitalne wystąpiły u 17 (68%) chorych, a średni czas trwania CVVHDF wynosił 4 dni. W porównaniu z grupą A istotnie rzadziej zastosowano wentylację mechaniczną (17 chorych, 68%; p = 0,03). Wnioski: U chorych z HF powikłaną AKI wcześnie rozpoczęte leczenie nerkozastępcze za pomocą CVVHDF ogranicza konieczność stosowania wentylacji mechanicznej i pozytywnie wpływa na redukcję śmiertelności wewnątrzszpitalnej. Kardiol Pol 2011; 69, 9: 891–89

Clinical picture and risk prediction of short-term mortality in cardiogenic shock

AIMS: The aim of this study was to investigate the clinical picture and outcome of cardiogenic shock and to develop a risk prediction score for short-term mortality. METHODS AND RESULTS: The CardShock study was a multicentre, prospective, observational study conducted between 2010 and 2012. Patients with either acute coronary syndrome (ACS) or non-ACS aetiologies were enrolled within 6 h from detection of cardiogenic shock defined as severe hypotension with clinical signs of hypoperfusion and/or serum lactate >2 mmol/L despite fluid resuscitation (n = 219, mean age 67, 74% men). Data on clinical presentation, management, and biochemical variables were compared between different aetiologies of shock. Systolic blood pressure was on average 78 mmHg (standard deviation 14 mmHg) and mean arterial pressure 57 (11) mmHg. The most common cause (81%) was ACS (68% ST-elevation myocardial infarction and 8% mechanical complications); 94% underwent coronary angiography, of which 89% PCI. Main non-ACS aetiologies were severe chronic heart failure and valvular causes. In-hospital mortality was 37% (n = 80). ACS aetiology, age, previous myocardial infarction, prior coronary artery bypass, confusion, low LVEF, and blood lactate levels were independently associated with increased mortality. The CardShock risk Score including these variables and estimated glomerular filtration rate predicted in-hospital mortality well (area under the curve 0.85). CONCLUSION: Although most commonly due to ACS, other causes account for one-fifth of cases with shock. ACS is independently associated with in-hospital mortality. The CardShock risk Score, consisting of seven common variables, easily stratifies risk of short-term mortality. It might facilitate early decision-making in intensive care or guide patient selection in clinical trials

20-letnia pacjentka z mnogimi powikłaniami zakrzepowo-zatorowymi

We report a case of young female with remittent bilateral pulmonary embolism and thrombus in the right ventricle, who required highly specialized treatment. The coexistence of right heart thrombus with pulmonary thromboembolism is uncommon; however, significantly worsens patients prognosis. Treatment is still controversial.Przedstawiono przypadek młodej kobiety z nawracającą obustronną zatorowością płucną i skrzepliną w prawej komorze serca, która wymagała wysokospecjalistycznego leczenia. Współistnienie skrzepliny w prawym sercu i ostrej zatorowości płucnej jest rzadkością, jednak istotnie pogarsza rokowanie pacjentów. Leczenie nadal budzi kontrowersje

The association of admission blood glucose level with the clinical picture and prognosis in cardiogenic shock - Results from the CardShock Study

Background: Critically ill patients often present with hyperglycemia, regardless of previous history of diabetes mellitus (DM). Hyperglycemia has been associated with adverse outcome in acute myocardial infarction and acute heart failure. We investigated the association of admission blood glucose level with the clinical picture and short-term mortality in cardiogenic shock (CS). Methods: Consecutively enrolled CS patients were divided into five categories according to plasma glucose level at the time of enrolment: hypoglycemia (glucose = 16.0 mmol/L) hyperglycemia. Clinical presentation, biochemistry, and short-term mortality were compared between the groups. Results: Plasma glucose level of 211 CS patients was recorded. Glucose levels were distributed equally between normoglycemia (26% of patients), mild (27%), moderate (19%) and severe (25%) hyperglycemia, while hypoglycemia (2%) was rare. Severe hyperglycemia was associated with higher blood leukocyte count (17.3 (5.8) E9/L), higher lactate level (4.4 (3.3-8.4) mmol/L) and lower arterial pH (7.23 (0.14)) compared with normoglycemia or mild to moderate hyperglycemia (p <0.001 for all). In-hospital mortality was highest among hypoglycemic (60%) and severely hyperglycemic (56%) patients, compared with 22% in normoglycemic group (p <0.01). Severe hyperglycemia was an independent predictor of in-hospital mortality (OR 3.7, 95% CI 1.19-11.7, p = 0.02), when adjusted for age, gender, LVEF, lactate, and DM. Conclusions: Admission blood glucose level has prognostic significance in CS. Mortality is highest among patients with severe hyperglycemia or hypoglycemia. Severe hyperglycemia is independently associated with high in-hospital mortality in CS. It is also associated with biomarkers of systemic hypoperfusion and stress response. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

Altered mental status predicts mortality in cardiogenic shock - results from the CardShock study

Background: Altered mental status is among the signs of hypoperfusion in cardiogenic shock, the most severe form of acute heart failure. The aim of this study was to investigate the prevalence of altered mental status, to identify factors associating with it, and to assess the prognostic significance of altered mental status in cardiogenic shock. Methods: Mental status was assessed at presentation of shock in 215 adult cardiogenic shock patients in a multinational, prospective, observational study. Clinical picture, biochemical variables, and short-term mortality were compared between patients presenting with altered and normal mental status. Results: Altered mental status was detected in 147 (68%) patients, whereas 68 (32%) patients had normal mental status. Patients with altered mental status were older (68 vs. 64 years, p=0.04) and more likely to have an acute coronary syndrome than those with normal mental status (85% vs. 74%, p=0.04). Altered mental status was associated with lower systolic blood pressure (76 vs. 80 mmHg, p=0.03) and lower arterial pH (7.27 vs. 7.35, p Conclusions: Altered mental status is a common clinical sign of systemic hypoperfusion in cardiogenic shock and is associated with poor outcome. It is also associated with several biochemical findings that reflect inadequate tissue perfusion, of which low arterial pH is independently associated with altered mental status.Peer reviewe

Prognostic impact of angiographic findings, procedural success, and timing of percutaneous coronary intervention in cardiogenic shock

Abstract Aims Urgent revascularization is the mainstay of treatment in acute coronary syndrome (ACS) related cardiogenic shock (CS). The aim was to investigate the association of angiographic results with 90-day mortality. Procedural complications of percutaneous coronary intervention (PCI) were also examined. Methods and results This CardShock (NCT01374867) substudy included 158 patients with ACS aetiology and data on coronary angiography and complications during PCI procedure. Survival analysis was conducted with Kaplan?Meier curves and Cox regression analysis. Median age was 67 ± 11 years, and 77% were men. During 90-day follow-up, 66 (42%) patients died. Patients with one-vessel disease (n = 49) had lower mortality than patients with two-vessel (n = 59) or three-vessel (n = 50) disease (25% vs. 48% vs. 52%, P = 0.011). Successful revascularization [Thrombolysis in Myocardial Infarction (TIMI) Flow 3 post-PCI) was achieved more often in survivors than non-survivors (81% vs. 60%, P = 0.019). The median symptom-to-balloon time was 340 (196?660) minutes, with no difference between survivors and non-survivors. In multivariable mortality analysis, multivessel disease (HR 2.59, CI95% 1.29?5.18) and TIMI flowPeer reviewe

Predictive value of plasma proenkephalin and neutrophil gelatinase-associated lipocalin in acute kidney injury and mortality in cardiogenic shock

Background: Acute kidney injury (AKI) is a frequent form of organ injury in cardiogenic shock. However, data on AKI markers such as plasma proenkephalin (P-PENK) and neutrophil gelatinase-associated lipocalin (P-NGAL) in cardiogenic shock populations are lacking. The objective of this study was to assess the ability of P-PENK and P-NGAL to predict acute kidney injury and mortality in cardiogenic shock. Results: P-PENK and P-NGAL were measured at different time points between baseline and 48 h in 154 patients from the prospective CardShock study. The outcomes assessed were AKI defined by an increase in creatinine within 48 h and all-cause 90-day mortality. Mean age was 66 years and 26% were women. Baseline levels of P-PENK and P-NGAL (median [interquartile range]) were 99 (71-150) pmol/mL and 138 (84-214) ng/mL. P-PENK > 84.8 pmol/mL and P-NGAL > 104 ng/mL at baseline were identified as optimal cut-offs for AKI prediction and independently associated with AKI (adjusted HRs 2.2 [95% CI 1.1-4.4, p = 0.03] and 2.8 [95% CI 1.2-6.5, p = 0.01], respectively). P-PENK and P-NGAL levels at baseline were also associated with 90-day mortality. For patients with oliguria 6 h before study enrollment, 90-day mortality differed significantly between patients with low and high P-PENK/P-NGAL at baseline (5% vs. 68%, p 105.7 pmol/L and P-NGAL(24h) > 151 ng/mL had unadjusted hazard ratios of 5.6 (95% CI 3.1-10.7, p <0.001) and 5.2 (95% CI 2.8-9.8, p <0.001) for 90-day mortality. The association remained significant despite adjustments with AKI and two risk scores for mortality in cardiogenic shock. Conclusions: High levels of P-PENK and P-NGAL at baseline were independently associated with AKI in cardiogenic shock patients. Furthermore, oliguria before study inclusion was associated with worse outcomes only if combined with high baseline levels of P-PENK or P-NGAL. High levels of both P-PENK and P-NGAL at 24 h were found to be strong and independent predictors of 90-day mortality.Peer reviewe

Predictive value of plasma proenkephalin and neutrophil gelatinase-associated lipocalin in acute kidney injury and mortality in cardiogenic shock

Background: Acute kidney injury (AKI) is a frequent form of organ injury in cardiogenic shock. However, data on AKI markers such as plasma proenkephalin (P-PENK) and neutrophil gelatinase-associated lipocalin (P-NGAL) in cardiogenic shock populations are lacking. The objective of this study was to assess the ability of P-PENK and P-NGAL to predict acute kidney injury and mortality in cardiogenic shock. Results: P-PENK and P-NGAL were measured at different time points between baseline and 48 h in 154 patients from the prospective CardShock study. The outcomes assessed were AKI defined by an increase in creatinine within 48 h and all-cause 90-day mortality. Mean age was 66 years and 26% were women. Baseline levels of P-PENK and P-NGAL (median [interquartile range]) were 99 (71-150) pmol/mL and 138 (84-214) ng/mL. P-PENK > 84.8 pmol/mL and P-NGAL > 104 ng/mL at baseline were identified as optimal cut-offs for AKI prediction and independently associated with AKI (adjusted HRs 2.2 [95% CI 1.1-4.4, p = 0.03] and 2.8 [95% CI 1.2-6.5, p = 0.01], respectively). P-PENK and P-NGAL levels at baseline were also associated with 90-day mortality. For patients with oliguria 6 h before study enrollment, 90-day mortality differed significantly between patients with low and high P-PENK/P-NGAL at baseline (5% vs. 68%, p 105.7 pmol/L and P-NGAL(24h) > 151 ng/mL had unadjusted hazard ratios of 5.6 (95% CI 3.1-10.7, p <0.001) and 5.2 (95% CI 2.8-9.8, p <0.001) for 90-day mortality. The association remained significant despite adjustments with AKI and two risk scores for mortality in cardiogenic shock. Conclusions: High levels of P-PENK and P-NGAL at baseline were independently associated with AKI in cardiogenic shock patients. Furthermore, oliguria before study inclusion was associated with worse outcomes only if combined with high baseline levels of P-PENK or P-NGAL. High levels of both P-PENK and P-NGAL at 24 h were found to be strong and independent predictors of 90-day mortality.Peer reviewe

Soluble urokinase-type plasminogen activator receptor improves early risk stratification in cardiogenic shock

Aims Soluble urokinase-type plasminogen activator receptor (suPAR) is a biomarker reflecting the level of immune activation. It has been shown to have prognostic value in acute coronary syndrome and heart failure as well as in critical illness. Considering the complex pathophysiology of cardiogenic shock (CS), we hypothesized suPAR might have prognostic properties in CS as well. The aim of this study was to assess the kinetics and prognostic utility of suPAR in CS. Methods and results SuPAR levels were determined in serial plasma samples (0-96 h) from 161 CS patients in the prospective, observational, multicentre CardShock study. Kinetics of suPAR, its association with 90-day mortality, and additional value in risk-stratification were investigated. The median suPAR-level at baseline was 4.4 [interquartile range (IQR) 3.2-6.6)] ng/mL. SuPAR levels above median were associated with underlying comorbidities, biomarkers reflecting renal and cardiac dysfunction, and higher 90-day mortality (49% vs. 31%; P = 0.02). Serial measurements showed that survivors had significantly lower suPAR levels at all time points compared with nonsurvivors. For risk stratification, suPAR at 12 h (suPAR(12h)) with a cut-off of 4.4 ng/mL was strongly associated with mortality independently of established risk factors in CS: OR 5.6 (95% CI 2.0-15.5); P = 0.001) for death by 90 days. Adding suPAR(12h) > 4.4 ng/mL to the CardShock risk score improved discrimination identifying high-risk patients originally categorized in the intermediate-risk category. Conclusion SuPAR associates with mortality and improves risk stratification independently of other previously known risk factors in CS patients.Peer reviewe

Mortality risk prediction in elderly patients with cardiogenic shock : results from the CardShock study

Aims This study aimed to assess the utility of contemporary clinical risk scores and explore the ability of two biomarkers [growth differentiation factor-15 (GDF-15) and soluble ST2 (sST2)] to improve risk prediction in elderly patients with cardiogenic shock. Methods and results Patients (n = 219) from the multicentre CardShock study were grouped according to age (elderly >= 75 years and younger). Characteristics, management, and outcome between the groups were compared. The ability of the CardShock risk score and the IABP-SHOCK II score to predict in-hospital mortality and the additional value of GDF-15 and sST2 to improve risk prediction in the elderly was evaluated. The elderly constituted 26% of the patients (n = 56), with a higher proportion of women (41% vs. 21%, P <0.05) and more co-morbidities compared with the younger. The primary aetiology of shock in the elderly was acute coronary syndrome (84%), with high rates of percutaneous coronary intervention (87%). Compared with the younger, the elderly had higher in-hospital mortality (46% vs. 33%; P = 0.08), but 1 year post-discharge survival was excellent in both age groups (90% in the elderly vs. 88% in the younger). In the elderly, the risk prediction models demonstrated an area under the curve of 0.75 for the CardShock risk score and 0.71 for the IABP-SHOCK II score. Incorporating GDF-15 and sST2 improved discrimination for both risk scores with areas under the curve ranging from 0.78 to 0.84. Conclusions Elderly patients with cardiogenic shock have higher in-hospital mortality compared with the younger, but post-discharge outcomes are similar. Contemporary risk scores proved useful for early mortality risk prediction also in the elderly, and risk stratification could be further improved with biomarkers such as GDF-15 or sST2.Peer reviewe