Cardiogenic shock doubles in-hospital mortality risk for children with worsening HF
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Key takeaways:
- Cardiogenic shock is a strong independent predictor of in-hospital mortality in children with acute decompensated HF.
- Most children with cardiogenic shock received mechanical ventilation or circulatory support.
Data show about one in four children admitted with acute decompensated HF develops cardiogenic shock with 24 hours, with high risk for in-hospital mortality that increases with escalating cardiogenic shock stage.
“Cardiogenic shock is a common presentation for children in acute decompensated HF, carries high morbidity, and has an extremely high mortality rate of 28%,” Kriti Puri, MBBS, assistant professor, pediatric critical care medicine and cardiology, Baylor College of Medicine and Texas Children's Hospital, told Healio. “To place in perspective, this is five times as high as pediatric septic shock and three times as high as the mortality of a STAT 5 congenital heart surgery at our center. Further, mortality is higher if the shock is more severe.”
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Assessing shock cases in children with HF
In a retrospective study, Puri and colleagues analyzed data from 591 children with 803 hospitalizations for acute decompensated HF admitted to Texas Children’s Hospital from 2004 to 2018, with a median age of 8 years. For patients who presented with cardiogenic shock, the researchers assessed risk factors for cardiogenic shock and for the primary outcome of in-hospital mortality. Children with alternative etiologies for decompensation or shock, such as sepsis or hypovolemia, were excluded. The researchers also created a modified shock classification, using Society for Cardiovascular Angiography and Interventions guidelines, and staged patients accordingly.
The findings were published in the Journal of the American College of Cardiology.
Within the cohort, 26% developed cardiogenic shock within 24 hours of presentation. The most common etiology of HF overall was cardiomyopathy (52%). Using the modified staging system, early escalation of shock stage within 24 hours of admission was seen among 16% of patients.
Those patients with cardiogenic shock had worse systolic function (P = .04), higher B-type natriuretic peptide concentration (P = .032) and more frequent early severe renal injury (P = .023) and liver injury (P < .001) compared with children without cardiogenic shock.
Compared with children without cardiogenic shock, children who presented with cardiogenic shock we more likely to receive mechanical ventilation (87% vs. 26%) and mechanical circulatory support (45% vs. 16%; P < .001 for both).
Looking at each patient’s most recent hospitalization for acute decompensated HF, the children experiencing cardiogenic shock were nearly twice as likely to die in-hospital vs. those without cardiogenic shock (OR = 1.91; 95% CI, 1.05-3.45; P = .033). Additionally, using the modified shock staging classification system, children with each higher stage of shock were more than twice as likely to die in-hospital (OR = 2.4-8.9; P < .001 for all).
“This is the first study describing in detail the epidemiology, clinical presentation and outcomes of children in cardiogenic shock,” Puri told Healio. “The high morbidity and mortality rate of pediatric cardiogenic shock are a reminder to the field to rigorously study this condition. We report the first use of an objective definition of pediatric cardiogenic shock as well as the modified SCAI criteria for risk-stratification in this population. This study is a key first step toward a uniform definition and risk stratification system for pediatric cardiogenic shock so that we can study outcomes across centers and work collaboratively toward improving them.”
Puri said risk stratification for pediatric cardiogenic shock needs to be validated at a multicenter level.
“The significant impact of early renal injury on outcomes of shock needs to be elucidated further,” Puri told Healio. “What we really need is a set of guidelines, just like we have ‘surviving sepsis’ guidelines. Finally, the field of pediatric cardiogenic shock is ripe for studies on the impact of early utilization of mechanical circulatory support, advanced hemodynamic monitoring, as well as shock phenotypes.”
Early recognition of shock key
In a related editorial published in the Journal of the American College of Cardiology, Kurt R. Schumacher, MD, MS, and Carolyn Vitale, MD, both of the Congenital Heart Center, C.S. Mott Children’s Hospital, University of Michigan, wrote that evidence already shows how simple interventions in the pediatric cardiac critical care field can significantly improve outcomes. They cited data from the Pediatric Cardiac Critical Care Consortium’s cardiac arrest prevention project, reported by Healio in 2022, that demonstrated how a low-technology prevention practice “bundle” significantly decreased rates of in-hospital cardiac arrest in pediatric ICUs over 18 months.
“Early recognition of cardiogenic shock could be addressed through a similar strategy,” Schumacher and Vitale wrote. “Also important, early consideration should be given to the ideal timing of mechanical circulatory support to rescue this population, given that there is a relatively high survival rate of medical patients with cardiogenic shock who receive mechanical circulatory support. With advances in temporary support, perhaps earlier consideration of mechanical circulatory support should occur to minimize further end-organ damage. Whatever approach is chosen, this extremely high-risk group demands the attention of our field, but it also may become an area for our biggest successes with changes in future practice.”
Reference:
For more information:
Kriti Puri, MBBS, can be reached at kriti.puri@bcm.edu; X (Twitter): @PuriKriti.
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