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Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

Background Intracranial aneurysms are reported in 6%-10% of patients with bicuspid aortic valve (BAV), and routine intracranial aneurysm surveillance has been advocated by some. We assessed the prevalence and features of the most important patient-outcome: aneurysmal sub-arachnoid hemorrhage (aSAH), as compared with controls without aSAH, and tricuspid aortic valve (TAV) with aSAH. Methods and Results Adult patients with accurate diagnosis of aSAH and at least one echocardiogram between 2000 and 2019 were identified from a consecutive prospectively maintained registry of aSAH admissions. Controls without a diagnosis of SAH were age- and sex-matched. BAV prevalence was confirmed echocardiographically. Severity of aSAH was categorized using modified Fisher and World Federation of Neurological Scale. Neurologic outcome was assessed using modified Rankin score. A total 488 aSAH cases and 990 controls were identified and BAV status was confirmed. Prevalence of BAV in patients with aSAH was 1.2% (6/488) versus 3.5% (35/990) in controls, P =0.01. BAV+aSAH were noted to be younger than TAV+aSAH (56±11 versus 68±14; P =0.03) with smaller aneurysms (5±2 versus 7±4; P =0.31). The severity of aSAH was lesser in BAV+aSAH than TAV (modified Fisher grade>2 50% versus 74%; P =0.19, World Federation of Neurological Scale grade>3 17% versus 36%; P =0.43). BAV+aSAH had less severe neurologic disability (modified Rankin score 3%-6 33% versus 49% in TAV; P =0.44) and comparable in-hospital mortality rates ( P =0.93). BAV had lower odds for aSAH on multivariate analysis (odds ratio 0.23[CI 0.08-0.65]; P =0.01). Conclusions Prevalence of BAV was 3 times lower in the aSAH registry than in controls without aSAH. BAV+aSAH had clinically smaller aneurysms, clinically smaller bleeds, and better neurologic outcome as compared with TAV+aSAH, which needs to be confirmed in larger studies. These findings argue against routine surveillance for intracranial aneurysms in patients with BAV without aortic coarctation.

Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000-2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age-, sex-, and race-stratified trends in CABG use; in-hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98-0.98]; P <0.001), in ST-segment-elevation myocardial infarction (10.2% [2000] to 5.2% [2017]; adjusted OR, 0.95 [95% CI, 0.95-0.95]; P <0.001) and non-ST-segment-elevation myocardial infarction (10.8% [2000] to 10.0% [2017]; adjusted OR, 0.99 [95% CI, 0.99-0.99]; P <0.001), with consistent age, sex, and race trends. In 2012 to 2017, compared with 2000 to 2005, admissions receiving emergent CABG were more likely to have non-ST-segment-elevation myocardial infarction (80.5% versus 56.1%), higher rates of noncardiac multiorgan failure (26.1% versus 8.4%), cardiogenic shock (11.5% versus 6.4%), and use of mechanical circulatory support (19.8% versus 18.7%). In-hospital mortality in CABG admissions decreased from 5.3% (2000) to 3.6% (2017) (adjusted OR, 0.89; 95% CI, 0.88-0.89 [ P <0.001]) in the overall cohort, with similar temporal trends in patients with ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction. An increase in lengths of hospital stay and hospitalization costs was seen over time. Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST-segment-elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in-hospital mortality consistently decreased in this population.

Background The role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood. Methods and Results This was a retrospective cohort study of adult admissions with AMI-CA from the National Inpatient Sample (2012-2017). Self-reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in-hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do-not-resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI-CA were more likely to be female, with more comorbidities, higher rates of non-ST-segment-elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race ( p <0.001). Admissions of patients with AMI-CA had significantly higher unadjusted mortality (47.4% and 47.4%) as compared with White patients admitted (40.9%). In adjusted analyses, Black race was associated with lower in-hospital mortality (odds ratio [OR], 0.95; 95% CI, 0.91-0.99; P =0.007) whereas other races had higher in-hospital mortality (OR, 1.11; 95% CI, 1.08-1.15; P <0.001) compared with White race. Admissions of Black patients with AMI-CA had longer length of hospital stay, higher rates of palliative care consultation, less frequent do-not-resuscitate status use, and fewer discharges to home (all P <0.001). Conclusions Racial and ethnic minorities received less frequent guideline-directed procedures and had higher in-hospital mortality and worse outcomes in AMI-CA.

Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in-hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in-hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively ( P =0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in-hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53-0.90, P =0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52-0.94, P =0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20-0.88, P =0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22-0.82, P =0.01) were also associated with a lower in-hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges ( P >0.05). Conclusions We found an association between lower in-hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.

Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST-segment-elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04-1.15]) and decreased in non-ST-segment-elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46-0.49]) admissions ( P <0.001). Compared with those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) ( P <0.001). The AIS cohort had higher in-hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72-1.78]; P <0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P <0.001). Among AMI-AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions.

Background Abnormal circadian blood pressure (BP) variations during sleep, specifically the non-dipping (<10% fall in nocturnal BP) and reverse-dipping patterns (rise in nocturnal BP), have been associated with an increased risk of cardiovascular events and target organ damage. However, the relationship between abnormal sleep BP variations and cerebral small vessel disease markers is poorly established. This study aims to assess the association between non-dipping and reverse-dipping BP patterns with markers of silent cerebral small vessel disease. Methods and Results MEDLINE, Embase, and Cochrane Databases were searched from inception through November 2019. Studies that reported the odds ratios (ORs) for cerebral small vessel disease markers in patients with non-dipping or reverse-dipping BP patterns were included. Effect estimates from the individual studies were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird. Twelve observational studies composed of 3497 patients were included in this analysis. The reverse-dipping compared with normal dipping BP pattern was associated with a higher prevalence of white matter hyperintensity with a pooled adjusted OR of 2.00 (95% CI, 1.13-2.37; I 2 =36%). Non-dipping BP pattern compared with normal dipping BP pattern was associated with higher prevalence of white matter hyperintensity and asymptomatic lacunar infarction, with pooled ORs of 1.38 (95% CI, 0.95-2.02; I 2 =52%) and 2.33 (95% CI, 1.30-4.18; I 2 =73%), respectively. Limiting to only studies with confounder-adjusted analysis resulted in a pooled OR of 1.38 (95% CI, 0.95-2.02; I 2 =52%) for white matter hyperintensity and 1.44 (95% CI, 0.97-2.13; I 2 =0%) for asymptomatic lacunar infarction. Conclusions The non-dipping and reverse-dipping BP patterns are associated with neuroimaging cerebral small vessel disease markers.

Background This study sought to evaluate the 15-year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction-cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in-hospital mortality and resources utilization. Multivariable regression and propensity-matching analyses were used to control for confounding. In this 15-year period, there were 444 253 acute myocardial infarction-cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in-hospital mortality (odds ratio 6.59 [95% CI 6.37-6.83]; P<0.001). The cohort with PCS use had >2-fold higher in-hospital mortality, 12-fold higher use of do-not-resuscitate status, lesser in-hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity-matched cohort. Conclusions PCS use in patients with acute myocardial infarction-cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital-specific disparities in the utilization of PCS.

Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10-year period, 9753 admissions were identified with 40.6% requiring pre- LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non-intra-aortic balloon pump MCS devices. The cohort receiving MCS had greater in-hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in-hospital mortality. In 696 propensity-matched pairs, use of MCS was predictive of higher in-hospital mortality (odds ratio 1.4 [95% confidence interval 1.1-1.6]; P=0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in-hospital mortality and greater resource utilization.

Background There are limited data on the presentation of Takotsubo cardiomyopathy ( TTC ) in severe sepsis. Methods and Results This was a retrospective cohort study using the National Inpatient Sample database (2007-2013) of all adults with severe sepsis. TTC was identified in patients with severe sepsis using previously validated administrative codes. The primary outcome was in-hospital mortality, and secondary outcomes included resource utilization and discharge disposition. Regression analysis was performed for the entire cohort and a propensity-matched sample. An exploratory analysis was performed for predictors of TTC incidence and mortality in TTC . During this 7-year period, in 7.1-million hospitalizations for severe sepsis, TTC was diagnosed in 10 746 (0.15%) admissions. TTC was noted more commonly in whites, females, and among 65- to 79-year-old individuals. TTC was independently associated with lower in-hospital mortality in severe sepsis (odds ratio, 0.58; 95% confidence interval, 0.51-0.65). This association was more prominent in females (odds ratio, 0.51; 95% confidence interval, 0.44-0.59]) compared with males (odds ratio, 0.69; 95% confidence interval, 0.55-0.85]). Presentation in later years of the study period, middle-age, female sex, and white race were independent predictors for the diagnosis of TTC . Age ≥80 years, black race, greater comorbidity, and multiorgan dysfunction were independently associated with higher in-hospital mortality among TTC admissions. Conclusions TTC is observed with increasing frequency in severe sepsis and was associated with a significantly lower in-hospital mortality compared with patients without TTC . Presentation in later years of the study period, middle age, female sex, and white race were independent predictors for the diagnosis of TTC in severe sepsis.

Background: There are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA-ECMO., Methods and Results: We systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA-ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short-term and long-term mortality were included. Given the significant methodological and statistical differences between published studies, meta-analysis of the association of CPB/VA-ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA-ECMO. Common indications for CPB/VA-ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA-ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short-term mortality (in-hospital and 30-day) was 29.8%, and 1-year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients., Conclusions: CPB/VA-ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA-ECMO, and the characteristics of this population remain poorly defined., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Troponin-T elevation is seen commonly in sepsis and septic shock patients admitted to the intensive care unit. We sought to evaluate the role of admission and serial troponin-T testing in the prognostication of these patients., Methods and Results: This was a retrospective cohort study from 2007 to 2014 on patients admitted to the intensive care units at the Mayo Clinic with severe sepsis and septic shock. Elevated admission troponin-T and significant delta troponin-T were defined as ≥0.01 ng/mL and ≥0.03 ng/mL in 3 hours, respectively. The primary outcome was in-hospital mortality. Secondary outcomes included 1-year mortality and lengths of stay. During this 8-year period, 944 patients met the inclusion criteria with 845 (90%) having an admission troponin-T ≥0.01 ng/mL. Serial troponin-T values were available in 732 (78%) patients. Elevated admission troponin-T was associated with older age, higher baseline comorbidity, and severity of illness, whereas significant delta troponin-T was associated with higher severity of illness. Admission log 10 troponin-T was associated with unadjusted in-hospital (odds ratio 1.6; P =0.003) and 1-year mortality (odds ratio 1.3; P =0.04), but did not correlate with length of stay. Elevated delta troponin-T and log 10 delta troponin-T were not significantly associated with any of the primary or secondary outcomes. Admission log 10 troponin-T remained an independent predictor of in-hospital mortality (odds ratio 1.4; P =0.04) and 1-year survival (hazard ratio 1.3; P =0.008)., Conclusions: In patients with sepsis and septic shock, elevated admission troponin-T was associated with higher short- and long-term mortality. Routine serial troponin-T testing did not add incremental prognostic value in these patients., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)