Prognostic factors in cardiogenic shock. From bench to bedside - The CardShock Study

Cardiogenic shock (CS) is a state of hypotension and systemic hypoperfusion caused by cardiac dysfunction. CS is the most severe form of acute heart failure and the leading cause of death among patients hospitalized for acute coronary syndrome (ACS), which is the most common etiology of CS. Prolonged hypotension activates neurohormonal compensatory mechanisms and triggers inflammatory responses. CS often leads to multi-organ failure and has a poor prognosis (short-term mortality > 40%). The most important treatment strategy in ACS-related CS is immediate revascularization, usually with percutaneous coronary intervention. CS patients are typically managed in intensive care units and require vasoactive medication, ventilatory support, and sometimes mechanical circulatory support. Patient selection for the most aggressive therapies with possible complications and limited availability requires risk assessment in the initial stage of CS, before organ failure has become irreversible. The aim of this thesis was to evaluate easily available prognostic factors, including mental state evaluation and biomarkers of stress response and inflammation, in the early phase of CS. Data were from the CardShock study, a multinational, prospective, observational cohort of 219 CS patients with both ACS and non-ACS etiologies of CS. Patient recruitment was conducted between 2010 and 2012. Study I investigated baseline blood glucose levels and their relation to clinical picture and prognosis in CS. Hyperglycemia is a common phenomenon among critically ill patients. However, it is unclear whether hyperglycemia is fully adaptive and physiological or harmful during acute illness. In this CS population, blood glucose levels were distributed rather equally between the groups of normoglycemia (4.0-7.9 mmol/L), and mild (8.0-11.9 mmol/L), moderate (12.0-15.9 mmol/L) and severe (> 16 mmol/L) hyperglycemia. Hypoglycemia (< 4.0 mmol/L) was rare. Severe hyperglycemia was associated with acidosis and hyperlactatemia, reflecting profound hypoperfusion. Mortality was highest (60%) among CS patients with severe hyperglycemia or hypoglycemia, whereas patients with normoglycemia had the best prognosis (26% mortality). Moreover, severe hyperglycemia was independently associated with increased mortality. The prognostic value of baseline blood glucose level was less pronounced in patients with known diabetes. Study II evaluated the prevalence and prognostic significance of altered mental status (AMS) at the time of CS detection, and the associations of AMS to biochemistry and hemodynamic parameters. AMS is among the diagnostic criteria for CS as one of the clinical manifestations of end-organ hypoperfusion. Two-thirds of these CS patients presented with AMS at the time of shock detection as a sign of cerebral hypoperfusion. AMS was associated with lower systolic blood pressure and lower left ventricular ejection fraction, acidosis, hyperlactatemia, and hyperglycemia. Of these, acidosis was independently associated with AMS. Moreover, AMS was associated with more than two-fold short-term mortality compared with normal mental status. Study III examined the levels of growth differentiation factor 15 (GDF-15), a stress-responsive protein belonging to the transforming growth factor-β cytokine superfamily, in CS. The expression of GDF-15 is induced in many tissues and cell types in response to acute or chronic stressors. In this CS population, GDF-15 levels were very high already at the time of shock detection. High GDF-15 levels were associated with acidosis, hyperlactatemia, and biomarkers of cardiac, renal, and hepatic dysfunction. Moreover, high GDF-15 levels were independently associated with increased mortality. In addition, the kinetics of GDF-15 were different between survivors and non-survivors during the first days of shock. GDF-15 levels decreased among survivors as a positive response to treatment, whereas GDF-15 levels remained high or even increased among patients who subsequently died. For early risk stratification in CS, a GDF-1512h cut-off of 7000 ng/l was identified and found to provide incremental value to validated clinical risk scores. Study IV analyzed the levels and kinetics of inflammatory markers in CS, including C-reactive protein (CRP), interleukin 6 (IL-6), and procalcitonin (PCT). Inflammatory response with subsequent vasodilation is thought to play an important role in the complex pathophysiology of CS. Inflammatory marker levels were considerably elevated during the first days of shock. PCT peaked at 24 hours, while CRP continued to rise until 48 to 72 hours. High PCT and IL-6 levels were closely associated with acidosis, hyperlactatemia, and clinical findings of systemic hypoperfusion. In addition, high levels of PCT and IL-6 were associated with poor prognosis. During the first days of CS, high inflammatory marker levels seemed to reflect shock severity rather than infectious complications. In conclusion, patients in the early phase of CS present with various clinical and biochemical findings that reflect disturbed homeostasis, including hyperglycemia and AMS. In addition, high levels of GDF-15 and inflammatory markers are detected in CS, indicating organ dysfunction and profound circulatory failure. These should be regarded as warning signs of severe hypoperfusion and poor outcome and should be considered in early risk assessment.Sydänperäinen shokki on äkillisen sydämen vajaatoiminnan vaikein muoto, jossa sydämen pumppaustoiminnan häiriö johtaa voimakkaaseen verenpaineen laskuun ja verenkierron vajaukseen. Sydänperäisen shokin yleisin syy on sepelvaltimotautikohtaukseen liittyvä sydänlihasvaurio, joka aiheuttaa noin 80% tapauksista. Verenpaineen lasku johtaa elimistössä neurohormonaalisten järjestelmien sekä tulehdusvasteen aktivoitumiseen ja usein monielinvaurioon. Sydänperäisen shokin ennuste on huono, sillä jopa puolet potilaista menehtyy sairaalahoidon aikana. Sydänperäinen shokki onkin yleisin kuolinsyy sepelvaltimotautikohtauksen vuoksi sairaalahoitoon joutuneilla potilailla. Tärkein hoitomuoto sepelvaltimotautikohtaukseen liittyvässä shokissa on välitön ahtautuneen sepelvaltimon avaaminen, useimmiten pallolaajennuksella. Potilaat vaativat tyypillisesti tehohoitoa, verenkiertoa tukevaa lääkitystä sekä hengityksen ja toisinaan myös verenkierron tukemista koneellisesti. Edellä mainitut hoitomuodot ovat raskaita, sisältävät huomattavia komplikaatioriskejä ja kuluttavat paljon terveydenhuollon voimavaroja. Näin ollen intensiivisimmät hoidot tulisi rajata potilaille, jotka niistä todennäköisimmin hyötyvät, ja hoito aloittaa välittömästi ennen pysyvien elinvaurioiden kehittymistä. Tämän väitöskirjatyön tavoitteena oli tutkia sydänperäisen shokin alkuvaiheessa todettavia, helposti saatavilla olevia ennustetekijöitä kuten verikokeissa ja potilaan kliinisessä tutkimuksessa havaittavia poikkeavuuksia. Väitöskirjan aineisto on peräisin 219 potilaan CardShock-tutkimuksesta, joka on eurooppalainen etenevä, havainnoiva monikeskustutkimus. Potilasaineisto kerättiin vuosina 2010-2012. Osatyössä I tutkittiin sydänperäiseen shokkiin sairastuneiden potilaiden alkuvaiheen verensokeritasoja ja niiden yhteyttä ennusteeseen. Koholla oleva verensokeritaso eli hyperglykemia on yleinen ilmiö vaikeasti sairailla potilailla. On kuitenkin epäselvää, onko verensokeritason nousu pääosin tarkoituksenmukainen ja fysiologinen ilmiö vai onko se itsessään haitallista äkillisen sairastumisen yhteydessä. Tässä potilasaineistossa verensokeritasot olivat jakautuneet suhteellisen tasaisesti normaalin verensokerin (4.0-7.9 mmol/L) sekä lievän (8.0-11.9 mmol/L), keskivaikean (12.0-15.9 mmol/L) ja vaikean (> 16 mmol/L) hyperglykemian välillä, kun taas matala verensokeri (< 4.0 mmol/L) oli harvinaista. Vaikea hyperglykemia oli yhteydessä veren matalaan pH-arvoon sekä kohonneeseen laktaattipitoisuuteen kuvastaen kudosten hapenpuutetta ja verenkierron vajausta. Kuolleisuus oli suurinta (60%) niillä potilailla, joiden tulovaiheen verensokeri oli joko hyvin korkea tai poikkeuksellisen matala. Vaikea hyperglykemia oli itsenäinen kuolleisuuden riskitekijä. Sen sijaan aiemmin todettu diabetes vähensi verensokerin ennustearvoa sydänperäisessä shokissa. Osatyössä II tarkasteltiin sydänperäisen shokin alkuvaiheessa todetun poikkeavan tajunnantason merkitystä ja ennustevaikutusta. Kahdella kolmasosalla potilaista oli shokin toteamisvaiheessa poikkeava tajunnantaso oireena merkittävästä verenkierron vajauksesta. Poikkeava tajunnantaso oli yhteydessä matalaan verenpaineeseen, voimakkaasti alentuneeseen sydämen pumppaustoimintaan, veren matalaan pH-arvoon sekä kohonneisiin laktaatti- ja verensokeripitoisuuksiin. Näistä tekijöistä poikkeavaan tajunnantasoon oli itsenäisesti yhteydessä vain matala pH. Poikkeavaan tajunnantasoon liittyi yli kaksinkertainen kuolemanriski verrattuna niihin potilaisiin, joiden tajunnantaso säilyi normaalina shokista huolimatta. Osatyössä III määritettiin GDF-15-nimisen proteiinin pitoisuuksia veressä sydänperäisen shokin ensipäivinä ja niiden yhteyttä ennusteeseen. GDF-15:n tarkat vaikutukset elimistössä ovat vielä osittain epäselviä, mutta sen eritys lisääntyy monissa kudoksissa vasteena äkillisiin ja pitkäaikaisiin sairauksiin. Tutkimus osoitti, että GDF-15-tasot ovat hyvin korkeita jo sydänperäisen shokin toteamishetkellä. Korkeaan GDF-15-pitoisuuteen liittyi veren matala pH-arvo, kohonnut laktaattiarvo sekä sydämen, munuaisten ja maksan toimintahäiriöitä kuvastavia muutoksia verikokeissa. Korkea GDF-15-pitoisuus oli yhteydessä lisääntyneeseen kuolleisuuteen, ja erityisen suuri kuolemanriski oli potilailla, joiden GDF-15-pitoisuus nousi hoidosta huolimatta. Sen sijaan GDF-15-tason lasku kuvasti suotuisaa vastetta hoitoon ja hyvää ennustetta. Osatyössä IV tutkittiin tulehdusvastetta kuvastavien biomerkkiaineiden pitoisuuksia veressä sydänperäisen shokin alkuvaiheessa. Elimistön voimakkaan tulehdusreaktion ajatellaan olevan tärkeä tekijä sydänperäisen shokin kehittymisessä. Tutkimuksessa havaittiin, että tulehdusmerkkiaineet olivat selvästi koholla shokin ensipäivinä. Prokalsitoniini (PCT) saavutti huippuarvonsa 24 tunnin kohdalla, kun taas C-reaktiivinen proteiini (CRP) nousi 48-72 tuntiin asti. Korkeat PCT- ja interleukiini 6 (IL-6) -pitoisuudet liittyivät tiiviisti veren matalaan pH-arvoon ja kohonneeseen laktaattiarvoon sekä verenkierron vajausta kuvastaviin kliinisiin löydöksiin. Sen lisäksi korkeat PCT- ja IL-6-pitoisuudet ennustivat kuolleisuutta. Kokonaisuudessaan kohonneet tulehdusmerkkiaineet kuvastivat enemmänkin shokin vaikeusastetta kuin infektioita. Yhteenvetona voidaan todeta, että sydänperäiseen shokkiin sairastuneilla potilailla on monia elimistön tasapainotilan vakavaa häiriintymistä kuvaavia löydöksiä, kuten muutoksia verensokeritasossa tai tajunnassa. Voimakkaasti koholla olevat GDF-15- sekä tulehdusmerkkiainepitoisuudet kuvastavat vaikeaa verenkierron vajausta ja suurta kuolemanriskiä. Näitä löydöksiä voidaan hyödyntää riskiarviossa jo sydänperäisen shokin alkuvaiheessa

HYVÄNLAATUISEN ASENTOHUIMAUKSEN HOIDON VAIKUTUS LUKIHÄIRIÖISTEN LASTEN TEKNISEEN LUKUTAITOON – SATUNNAISTETTU HOITOKOKEILU

Tutkimuksen tavoitteena oli arvioida hyvänlaatuisen asentohoidon vaikutustaalakouluikäisten lukihäiriöisten lasten teknisen lukutaidon sujuvuuteen.Koeryhmä koostui 36 hoidetusta lukihäiriöisestä lapsesta. Lisäksitutkimuksessa oli kaksi vertailuryhmää: 18 lukihäiriöistä oppilasta, jotkasaivat laaja-alaista erityisopetusta, ja 18 normaalisti lukevaa lasta. Oppilaatlukivat ääneen ennen ja jälkeen hoidon saman tekstin, ja lukemiseen kulunutaika mitattiin.Tulosten mukaan kaikkien lasten lukeminen nopeutui tilastollisestimerkitsevästi. Asentohoitoa saanut lukihäiriöisten ryhmä ei eronnutvertailuryhmänä toimineesta lukihäiriöisten lasten ryhmästä. Lukihäiriöistenlasten ryhmästä erottui kuitenkin kuusi lasta, joiden lukemisen nopeusoli parantunut huomattavan paljon (vähintään 30 sekuntia). Kaikki nämälapset olivat saaneet asentohoidon. Tulosten perusteella näyttäisi, ettähyvänlaatuinen asentohoito voi auttaa niitä lapsia, joilla etenkin tekninenlukeminen on vaikeutunut. Lisätutkimuksia kuitenkin tarvitaan, jottatutkimusasetelmasta johtuvat virhetekijät saadaan eliminoitua.Asiasanat: Lukihäiriö, tekninen lukutaito, hyvänlaatuinen asentohuimaus, OCI, hoitokokeilu, satunnaistaminenKeywords: Dyslexia, technical reading, bening position vertigo, OCI, clinical trial, randomizatio

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