Burden and predictors of mortality related to cardiogenic shock in the South Bronx Population.

Am J Cardiovasc Dis 2024;14(6):355-367 www.AJCD.us /ISSN:2160-200X/AJCD0159635 Original Article Burden and predictors of mortality related to cardiogenic shock in the South Bronx Population Nismat Javed1, Vikram Itare2,3, Sai Vishnu Vardhan Allu1, Shalini Penikilapate1, Neelanjana Pandey4, Nisha Ali2,3, Preeti Jadhav3,5, Sridhar Chilimuri5, Jonathan N Bella3,5 Resident Physician, BronxCare Health System, Bronx, NY, USA; 2Cardiology Fellow, BronxCare Health System, Bronx, NY, USA; 3Mount Sinai Morningside-BronxCare Health System, Bronx, NY, USA; 4Medicine Attending, BronxCare Health System, Bronx, NY, USA; 5BronxCare Health System, Bronx, NY, USA 1 Received August 5, 2024; Accepted October 30, 2024; Epub December 15, 2024; Published December 30, 2024 Abstract: Objectives: Cardiogenic shock is a significant economic burden on healthcare facilities and patients. The prevalence and outcome of cardiogenic shock in the South Bronx are unknown. The aim of the study was to examine the burden of non-AMI CS in Hispanic and Black population in South Bronx and characterize their in-hospital outcomes. Methods: We reviewed patient charts between 1/1/2022 and 1/1/2023 to identify patients with a primary diagnosis of cardiogenic shock (ICD codes R57.0, R57, R57.8, R57.9) residing in the following zip codes: 1045159 and 10463. Student’s T-test was used to assess differences for continuous variables; chi-square statistic was used for categorical variables. A logistic regression analysis model was used to assess independent predictors of mortality. A P-value of < 0.05 was considered significant. Results: 87 patients were admitted with cardiogenic shock (60% African American, 67% male, mean age =62±15 years) of which 54 patients (62%) died. Those who died were older, had > 1 pressor, out-of-hospital arrest, arrested within 24 hours of admission, and had higher SCAI class, lactate, and ALT levels than those who were discharged. The logistic regression analysis model showed that older age ((RR=3.4 [95% CI: 3.3-3.45]), > 1 pressor (RR=3.4 [95% CI: 2.6-4.2]) and higher SCAI class (2.1 [95% CI: 1.52.1], all P < 0.05)) were independent predictors of mortality in patients with cardiogenic shock. Additionally, most of the patients had either Medicare or Medicaid insurance in predominantly African American study population. Conclusions: Cardiogenic shock carries a significant risk of death. Factors such as advanced age, the administration of more than one vasopressor, and a higher SCAI classification have been identified as independent predictors of mortality among inpatients with cardiogenic shock. Additionally, the progression and outcomes of the condition are influenced by variables like race (e.g., African American individuals in this study) and economic challenges, including the type of insurance coverage (e.g., Medicaid or Medicare). Further research is essential to explore strategies that could enhance survival rates in cardiogenic shock patients, with a particular focus on addressing economic and racial disparities. Keywords: Cardiogenic shock, outcomes, mortality, diagnosis, treatment Introduction Cardiogenic shock (CS) is a critical condition characterized by a significant reduction in cardiac output, leading to inadequate blood flow to vital organs. CS is experienced by approximately 5% to 7% of patients who present with acute myocardial infarction (AMI) [1]. It is more frequently seen in patients with ST-segmentelevation MI (STEMI) compared to those with non-STEMI [1]. Despite advancements in care, the acute mortality rate remains unacceptably high, around 60% [2-4]. However, recent years have seen a decline in mortality rates for AMI- CS. This has been attributed to the establishment of care goals, the introduction of quantitative diagnostic tools, and the rapid initiation of mechanical circulatory support (MCS) [5]. In this regard, diagnostic tools are focused on heart failure with respect to acute myocardial infarction. CS can be categorized based on which ventricle is affected. Left ventricle-dominant CS is characterized by high pulmonary capillary wedge pressure (PCWP) over 18 mmHg and normal or low central venous pressure (CVP) under 14 mmHg, due to reduced left ventricular (LV) contractility. Right ventricle-dominant CS is marked by elevated CVP over 14 https://doi.org/10.62347/HYCA6457 Cardiogenic shock in the population of South Bronx mmHg, with normal or low pulmonary artery pressure and PCWP under 18 mmHg, while maintaining normal LV function. Biventricular failure is identified by high CVP over 14 mmHg, normal or high PCWP over 18 mmHg, hypotension, and reduced LV function [6]. For patients with predominant left ventricular (LV) failure, mechanical circulatory support (MCS) options include intra-aortic balloon counterpulsation (IABP), Impella devices (LP/CP/5.0/5.5), and the TandemHeart percutaneous LV assist device. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can also be used for systemic circulatory support, but it requires careful monitoring for LV distension and pulmonary edema. In such cases, additional LV decompression or venting may be necessary, which can be achieved using IABP, a left-sided Impella device, pulmonary artery cannulation, or surgical LV venting. For patients with predominant right ventricular (RV) failure, MCS options include the Impella RP pump and the TandemHeart ProtekDuo percutaneous RV assist device. Patients with biventricular failure may benefit from bilateral Impella pumps or VA-ECMO combined with an LV venting mechanism [7]. 1 year was performed. The inclusion criteria were based on the following: 1. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and in-hospital admissions with ICD-10-CM codes R57.0, R57, R57.8, and R57.9. 2. Admission within the date range 1/1/2022 and 1/1/2023. 3. Patients with ages > 18 years. 4. Patients who were not pregnant. 5. Patients residing in zip codes of South and Central Bronx (1045159 and 10463). 6. Patients who had other causes of cardiogenic shock apart from acute myocardial infarction. Exclusion criteria were based on the following: 1. Patients under 18 years of age. 2. Patients who were pregnant. 3. Patients who had missing data with respect to variables for data inclusion. 4. Patients who did not have signs of tissue hypoperfusion and were therefore less likely to have cardiogenic shock. 5. Patients who presented with cardiogenic shock related to acute myocardial infarction. Materials and methods The data was cross-checked for accuracy and consistency by two other team members. The team members were blinded to each others’ decisions. Demographic characteristics, including age, gender, race, insurance, and housing zip codes, were collected. Cardiovascular outcomes, including biochemical and clinical parameters, were assessed at admission, shock onset, and discharge. The cardiovascular biochemical markers included lactate, troponin, (...truncated)