CANCARE RESEARCH
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Hemoglobin trends and transfusion practices after cardiac arrest: a cohort study.
Clinical takeaway Anemia and transfusion were common after cardiac arrest. The mortality association is hypothesis-generating and does not establish that a higher transfusion target improves outcomes.
Summary & abstract
Study summary
This retrospective cohort included 958 adult cardiac arrest patients at three academic hospitals who survived initial resuscitation and had hemoglobin measured. Mean initial hemoglobin was 9.75 g/dL (SD 2.60), declining progressively over the first 20 days. Within 30 days, 369 patients (38.5%) received red cell transfusions; mean pre-transfusion hemoglobin was 6.96 g/dL (SD 1.06). In exploratory analysis, initial hemoglobin ≥9 g/dL was associated with lower in-hospital mortality (adjusted OR 0.62, 95% CI 0.46–0.84), but the study did not establish whether anemia caused worse outcomes.
Study limitation: Retrospective observational data cannot disentangle anemia as a marker versus a driver of mortality or establish transfusion benefit.
Published abstract
BACKGROUND: Hemoglobin targets are absent from post-cardiac arrest guidelines. New trials suggest that patients with brain and myocardial injury, injuries common post-arrest, may benefit from higher hemoglobin targets. Trends in post-arrest hemoglobin and real-world practices remain poorly characterized. METHODS: We performed a retrospective cohort study of consecutive adult cardiac arrests at three academic hospitals. We screened in-hospital and out-of-hospital arrests with resuscitation efforts ongoing at hospital arrival for inclusion. Patients who survived the initial resuscitation and had a hemoglobin value measured were included. All post-arrest hemoglobin values and red blood cell transfusions were collected through 30 days; descriptive statistics and graphical visualization were used to present hemoglobin trends and transfusion practices. Exploratory analyses evaluated the association between hemoglobin and in-hospital mortality. RESULTS: Of 2,634 cardiac arrests, 958 met inclusion criteria, with 152 (15.9%) out-of-hospital arrests and 806 (84.1%) in-hospital. The mean initial post-arrest hemoglobin was 9.75 g/dL (SD 2.60), with hemoglobin levels declining progressively over the first 20 days post-arrest. Red cell transfusions were delivered for 369 (38.5%) patients in the 30 days post-arrest, with 1,238 total transfusions. The mean pre-transfusion hemoglobin value was 6.96 g/dL (SD 1.06). Pre-transfusion hemoglobin levels were < 7 g/dL for 762 (61.6%) of transfusions, and ≥ 7 g/dL for 476 (38.4%) of transfusions. Over 30 days, the highest proportion of patients transfused was in the first 48 h. Patients with initial post-arrest hemoglobin ≥ 9 g/dL had lower in-hospital mortality (adjusted OR 0.62, 95% CI 0.46-0.84, p<0.01). In time-varying analysis, post-arrest hemoglobin through 30 days demonstrated an L-shaped association with mortality, with 95% of the total reduction in mortality hazard captured below 9.20 g/dL. CONCLUSIONS: Anemia is common after cardiac arrest, worsening in initial survivors. There is substantial variation in pre-transfusion hemoglobin levels, reflecting clinical equipoise. Clinical trials are needed to disentangle anemia as a driver versus a marker of outcomes, and test whether the risk is modifiable.
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Influencing factors analysis and prediction model development for ROSC in adult non-traumatic OHCA: a retrospective study based on pre-hospital emergency settings.
Clinical takeaway The model showed internal discrimination for sustained ROSC, not survival or neurological recovery. Its predictive associations do not establish treatment effects or justify care-limitation decisions.
Summary & abstract
Study summary
This retrospective study included 9,386 adults with non-traumatic out-of-hospital cardiac arrest treated through Tianjin Emergency Medical Center during 2023–2024. Sustained return of spontaneous circulation through emergency department arrival and handover occurred in 678 patients (7.2%). An initially shockable rhythm was associated with higher odds of ROSC (adjusted OR 2.850, 95% CI 2.390–3.397). A prediction nomogram developed using a random 7:3 training–test split achieved a test-set AUC of 0.775 (95% CI 0.745–0.805), with an optimism-corrected C-index of 0.7679 after bootstrap internal validation.
Study limitation: Retrospective data from one emergency medical centre and internal validation alone limit confidence in transportability to other resuscitation systems.
Published abstract
BACKGROUND: Cardiac arrest is a major global public health problem. This study aimed to explore factors influencing return of spontaneous circulation (ROSC) and develop a prediction model for out-of-hospital cardiac arrest (OHCA) patients. METHODS: We retrospectively collected electronic medical records of adult non-traumatic OHCA patients at Tianjin Emergency Medical Center from January 1, 2023 to December 31, 2024. The primary outcome was sustained ROSC up to emergency department arrival and handover to receiving-hospital staff. Multivariable mixed-effects logistic regression with clinician ID as random intercept adjusted clustering bias; predictors with p < 0.05 formed the nomogram. Patients were randomly split 7:3 for training and internal testing. Discrimination was assessed by ROC-AUC (acceptable threshold >0.7). We performed 1000 bootstrap resampling to correct C-index against overfitting. Calibration curves and decision curve analysis (DCA) further evaluated predictive consistency and net clinical benefit. RESULTS: Among 9,386 included cases, 678 (7.2%) achieved ROSC. Mixed-effects regression identified independent ROSC predictors: public location (aOR = 1.285, 95% CI:1.038-1.592), 06:00-12:00 onset (aOR = 1.308, 95% CI:1.018-1.682), prolonged emergency response time (aOR = 0.971, 95% CI:0.945-0.999), extended onset-to-ambulance intervals (5-10 min: aOR = 0.758;10-30 min: aOR = 0.578;>30 min:aOR = 0.498 vs ≤5 min), no OHCA occurred at emergency call (aOR = 1.540, 95% CI:1.048-2.262), male attending physicians (aOR = 1.255, 95% CI:1.077-1.464), longer physician practice years (aOR = 1.043, 95%CI: 1.022-1.065), intermediate physician title (aOR = 1.236, 95% CI:1.047-1.459), shockable initial rhythm (aOR = 2.850, 95% CI:2.390-3.397), endotracheal intubation (aOR = 2.294, 95% CI:1.936-2.718), epinephrine >5 mg (aOR = 0.765,95% CI:0.626-0.935). The nomogram AUC reached 0.775 (95% CI:0.756-0.794) in the training set and 0.775 (95% CI:0.745-0.805) in the test set; 1000 bootstrap internal validation gave an optimism-corrected C-index of 0.7679 with minimal optimism of 0.0071, showing negligible overfitting, good calibration and favorable net clinical benefit via DCA. CONCLUSION: This study identified multiple factors significantly associated with ROSC in OHCA patients; the constructed model showed good predictive value.
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Physiological Effects and Clinical Limitations of Impella-Bridge Strategy for Post-Infarction Ventricular Septal Rupture.
Clinical takeaway This small series documents achievement of scheduled repair in most patients, alongside improving haemodynamic measures but worsening SOFA-defined organ dysfunction. It does not establish comparative benefit for an Impella-bridge strategy.
Summary & abstract
Study summary
This retrospective study evaluated 10 consecutive patients with post-infarction ventricular septal rupture managed with Impella support; median age was 74 years. Four patients also received veno-arterial extracorporeal life support, and one underwent Impella upgrade. Scheduled repair was achieved in nine patients (90%), with a median interval from Impella initiation to repair of 8 (7, 10) days. Pulmonary artery and central venous pressures, B-type natriuretic peptide, and lactate decreased before repair, while non-CNS SOFA scores increased. Organ support requirements and device-related complications were also observed during bridging.
Study limitation: The retrospective, 10-patient series lacked a comparator, limiting causal interpretation and assessment of comparative clinical outcomes.
Published abstract
BACKGROUND: Post-infarction ventricular septal rupture (VSR) remains a life-threatening mechanical complication of acute myocardial infarction. We evaluated the feasibility of an Impella-bridge strategy for scheduled VSR repair. METHODS: We retrospectively analyzed 10 consecutive patients with post-infarction VSR who were transferred to our institution and managed with Impella support. Outcomes included achievement of scheduled repair and serial changes in hemodynamic parameters and organ dysfunction during the bridging period. RESULTS: The median age was 74 years. All patients received Impella 2.5 or CP support after transfer; veno-arterial extracorporeal life support was added in four patients, and Impella support was upgraded in one patient. The median duration from Impella initiation to VSR repair was 8 (7, 10) days. Scheduled repair was achieved in nine patients (90%). Mean pulmonary artery pressure, central venous pressure, plasma B-type natriuretic peptide levels, and lactate decreased over time before repair, whereas non-CNS SOFA scores increased during bridging. CONCLUSIONS: In patients with post-infarction VSR, an Impella-bridge strategy may help achieve scheduled VSR repair with improved hemodynamic stabilization; however, SOFA-defined abnormalities, organ support requirements, and device-related complications were observed during the bridging period. Further studies are needed to define patient selection, management strategies, and the optimal timing of repair for this strategy.
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Between patterns and predictions: Interpretable latent EEG representations for clinical insights.
Clinical takeaway This EEG representation showed potentially useful outcome discrimination after cardiac arrest. The abstract does not establish its incremental clinical value or suitability for individual prognostic decisions.
Summary & abstract
Study summary
Researchers applied a pretrained EEG embedding framework without retraining to three independent cohorts, including 575 cardiac arrest patients, 100 patients with subarachnoid hemorrhage, and 141 routine EEG recordings. EEG segments were mapped into a 128-dimensional space anchored by expert-derived reference brain states. Favorable outcomes or physiological recordings lay closer to healthy reference states, whereas poor outcomes and pathological recordings shifted toward pathological regions. Trajectory-derived geometric and temporal features discriminated outcomes after cardiac arrest with ROC-AUC 0.83 and after subarachnoid hemorrhage with ROC-AUC 0.76.
Study limitation: The abstract does not specify outcome definitions, assessment timing, or uncertainty around discrimination estimates.
Published abstract
Electroencephalography (EEG) captures rich brain dynamics, yet in clinical practice this complexity is often reduced to simplified summaries or categorical labels, limiting its interpretability for decision-making. We tested the hypothesis that a pretrained latent embedding framework, the Universal Map of EEG (UM-EEG), can preserve clinically meaningful structure across heterogeneous datasets and provide a generalizable representation of brain states. We applied UM-EEG, without retraining, to three independent cohorts spanning distinct clinical contexts: long-term EEG recordings from cardiac arrest patients (n = 575), subarachnoid hemorrhage (n = 100), and routine clinical EEG recordings containing physiological and pathological patterns (n = 141). EEG segments were projected into a 128-dimensional space anchored by expert-derived reference states, including wakefulness, sleep stages, ictal-interictal continuum activity, and burst suppression. Across datasets, favorable outcome or physiological recordings were consistently located closer to healthy reference states, whereas poor outcome and pathological recordings shifted toward pathological regions of the embedding space. Trajectory-derived geometric and temporal features discriminated outcome in cardiac arrest (ROC-AUC 0.83) and subarachnoid hemorrhage (ROC-AUC 0.76), and distinguished physiological from pathological routine EEGs (ROC-AUC 0.93). In routine EEG, similarity relationships derived from embedding trajectories correlated with those derived from structured clinical reports, indicating that the latent space recapitulates clinically relevant organization. These findings show that a fixed, semantically structured EEG embedding generalizes across etiologies and recording settings, enabling prognostic stratification and contextual interpretation while preserving the relational structure of brain states.
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Bystander AED Effectiveness Despite Low Utilisation in OHCA.
Clinical takeaway Bystander AED application was associated with better survival and neurological outcomes, but estimates depended on the comparator definition. These observational findings also identify substantial underutilization in nonpublic settings.
Summary & abstract
Study summary
A retrospective Korean registry analysis included 23,918 adults with out-of-hospital cardiac arrest of presumed medical etiology, including 383 with bystander AED application. Compared with no prehospital defibrillation, bystander AED application was associated with higher survival to discharge (adjusted odds ratio 1.60, 95% CI 1.19–2.14) and good neurological outcome (2.31, 1.65–3.23). Pooling EMS-shocked and non-defibrillated patients as controls attenuated both associations to non-significance. AED application occurred in 8.5% of public-area versus 1.9% of nonpublic AED-opportunity cases, highlighting a utilization gap.
Study limitation: Nonrandomized comparisons remain vulnerable to residual confounding; changing the reference group materially altered the estimated associations.
Published abstract
OBJECTIVES: Observational estimates of bystander automated external defibrillator (AED) effectiveness are inconsistent in settings with mature public-access defibrillation infrastructure but low utilization, partly because the conventional reference group pools emergency medical services (EMS)-shocked with non-defibrillated patients. We estimated bystander AED effectiveness against a partitioned no-defibrillation reference, tested effect modification by location, and quantified the deployment-utilization gap. METHODS: Retrospective analysis of a prospectively collected multicenter out-of-hospital cardiac arrest (OHCA) registry (Korea, October 2015-June 2025; 23,918 adults of presumed medical etiology). A three-tier prehospital defibrillation-provider variable was defined: bystander AED applied (n = 383); EMS-delivered shock without preceding bystander AED (n = 5,975); and no prehospital defibrillation (reference; n = 17,560). Primary outcomes were survival to discharge and good neurological outcome (Cerebral Performance Category 1-2), analyzed by multivariable logistic regression with propensity-score, inverse-probability-weighting and location-stratified secondary analyses. RESULTS: Bystander AED application was associated with improved survival (adjusted odds ratio [aOR] 1.60; 95% CI 1.19-2.14) and good neurological outcome (2.31; 1.65-3.23), comparable to that of EMS-delivered shock; the pooled-control specification attenuated estimates to non-significance (survival 1.09; neurological 1.14). Shock-delivered applications significantly exceeded EMS-delivered shock for neurological outcome (aOR 1.43; p = 0.03). Effectiveness did not differ by location (interaction p ≥ 0.15). Bystander AED was applied in 8.5% of Public-area versus 1.9% of Nonpublic AED-opportunity cases-a 4.5-fold gap. CONCLUSIONS: Bystander AED was associated with improved outcomes when applied, comparable to or exceeding EMS-delivered shock; the dominant constraint was the deployment-utilization gap, greatest in residential settings. Residential rapid-activation infrastructure warrants policy priority alongside, not instead of, continued device placement.
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Forty-Eight Hour Lactate Normalization Predicts Favorable Neurologic Recovery and Survival in Venoarterial ECMO for Cardiogenic Shock.
Clinical takeaway Lactate normalization at 48 hours was associated with better neurologic discharge outcomes and 12-month survival during VA-ECMO. These findings support prognostic relevance, not a causal benefit of targeting lactate normalization.
Summary & abstract
Study summary
A retrospective multicenter registry analysis included 662 patients with cardiogenic shock who remained on VA-ECMO for at least 48 hours. Patients with 48-hour lactate below 2.0 mmol/L had more favorable neurologic discharge, defined as Cerebral Performance Category 1–2, than those with persistent elevation (71.4% versus 41.9%). Normalization remained independently associated with favorable neurologic discharge (odds ratio 3.12, 95% confidence interval 2.21–4.41). It was also associated with lower all-cause mortality at 12 months (hazard ratio 0.49, 95% confidence interval 0.38–0.64).
Study limitation: Retrospective analysis restricted to patients remaining on ECMO for at least 48 hours; baseline severity differences leave potential residual confounding.
Published abstract
Extracorporeal membrane oxygenation (ECMO) for cardiogenic shock (CS) is associated with high mortality and poor neurological outcomes. Dynamic assessment of metabolic recovery, reflected by lactate normalization, may offer additional prognostic value compared with static severity indices. We retrospectively analyzed 662 consecutive patients from the multicenter RESCUE II registry who remained on venoarterial ECMO for at least 48 hours. Patients were stratified by 48 hour lactate level: 48 hour lactate normalization group (< 2.0 mmol/L, n = 371) and persistent lactate elevation group (≥ 2.0 mmol/L, n = 291). The primary outcome was favorable neurologic discharge (FND), defined as discharge with a Cerebral Performance Category score of 1 or 2. The persistent lactate elevation group had a higher SOFA score (9.8 ± 3.2 vs. 8.5 ± 3.4, p < 0.001) and initial serum lactate (7.9 ± 4.8 mmol/L vs. 6.0 ± 4.3 mmol/L, p < 0.001). Lactate normalization was associated with a higher rate of FND (71.4% vs. 41.9%, p < 0.001), remained an independent predictor of FND (odds ratio [OR]: 3.12, 95% confidence interval [CI]: 2.21-4.41, p < 0.001), and was associated with lower risks of all-cause death (hazard ratio [HR]: 0.49, 95% CI: 0.38-0.64, p < 0.001) at 12 months. In conclusion, lactate normalization within 48 hours of ECMO initiation is associated with favorable neurologic status and 12 month survival.
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Enhanced Early Risk Stratification in Cardiogenic Shock Using Machine Learning: A Hierarchical Clustering Analysis.
Clinical takeaway Early clinical phenotypes may provide additional mortality stratification within SCAI stages in cardiogenic shock. These retrospective findings support further validation, not established clinical use.
Summary & abstract
Study summary
This multicenter retrospective registry included 2,906 adults with cardiogenic shock admitted to ICUs between 2016 and 2022. Hierarchical clustering was applied independently to clinical variables from ICU days 1, 2, and 3. Day-1 Cardiac, Cardio-Renal, and Cardio-Metabolic phenotypes had reported mortality of 15%, 27%, and 55%, respectively. Similar phenotypes persisted through days 2 and 3, and phenotype classification enhanced mortality stratification within each SCAI stage across the first three ICU days. The authors concluded that prospective validation is required before clinical implementation.
Study limitation: The retrospective design limits inference; the abstract does not specify the mortality timepoint or quantify incremental predictive performance.
Published abstract
BACKGROUND: Cardiogenic shock (CS) exhibits marked clinical heterogeneity, limiting the performance of conventional risk stratification tools like the Society for Cardiovascular Angiography and Interventions (SCAI) staging system. Machine learning (ML) has identified reproducible CS phenotypes that improve risk prediction, but their temporal consistency across the progression of shock remains incompletely described. OBJECTIVES: The purpose of this study was to evaluate the temporal evolution of ML-derived CS phenotypes across the first 3 intensive care unit (ICU) days and determine whether phenotype trajectories enhance mortality stratification beyond SCAI staging. METHODS: In a multicenter retrospective registry of 2,906 adults with CS admitted to ICUs between 2016 and 2022, hierarchical agglomerative clustering was applied independently to clinical variables on ICU days 1, 2, and 3. RESULTS: On day 1, 3 phenotypes emerged: Cardiac (younger, acute myocardial infarction-predominant, preserved renal function; 15% mortality), Cardio-Renal (older, non-acute myocardial infarction-predominant, isolated renal extracardiac impairment, predominantly SCAI A and B on admission; 27% mortality), and Cardio-Metabolic (severe renal and tissue malperfusion, predominantly SCAI D and E on admission; 55% mortality). Similar phenotypes persisted on day 2 and day 3. These ML-derived phenotypes enhanced mortality stratification within each SCAI stage across days 1 to 3. CONCLUSIONS: Hierarchical clustering reproduced previously identified CS phenotypes that were consistent across the first 3 days of ICU stay, providing an enhanced framework for early risk stratification. Prospective validation is required for clinical implementation.
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Sex Differences in Vasopressor De-escalation With Arginine Vasopressin in Mixed Cardiogenic-Vasodilatory Shock Under VA-ECMO.
Clinical takeaway Sex was associated with vasopressor de-escalation after vasopressin initiation in this VA-ECMO cohort. These hypothesis-generating findings do not establish sex-specific treatment effects or a survival benefit.
Summary & abstract
Study summary
A multicentre retrospective cohort assessed sex differences in vasopressor de-escalation after arginine vasopressin initiation in 193 patients with cardiogenic shock supported by VA-ECMO. Successful de-escalation at 48 hours, defined as norepinephrine equivalent dose below 0.25 µg/kg/min, occurred in 32% of women versus 49% of men (p=0.023). Male sex was independently associated with success (adjusted odds ratio 2.08, 95% confidence interval 1.07–4.15). In subgroup findings, excess failure risk was confined to postmenopausal women aged 55 years or older (adjusted odds ratio 2.75, 95% confidence interval 1.32–5.93).
Study limitation: Retrospective associations remain vulnerable to confounding; the menopause subgroup is exploratory, and vasopressor de-escalation is a surrogate endpoint.
Published abstract
BACKGROUNDS: Women with cardiogenic shock (CS) under VA-ECMO face excess mortality, yet the pharmacological basis of this disparity remains poorly understood. Arginine vasopressin (AVP) is increasingly used as a non-adrenergic vasopressor in this setting, but whether sex modifies the hemodynamic response to AVP is unknown. METHODS: In this multicenter retrospective cohort of VA-ECMO-supported CS patients, we assessed whether sex was independently associated with successful vasopressor de-escalation at 48 hours (norepinephrine equivalent dose [NEE] <0.25 µg/kg/min) after AVP initiation. Multivariable logistic regression and linear mixed-effects models were used to evaluate sex differences in treatment response and NEE trajectories over time. RESULTS: Among 193 eligible patients, 32% of women achieved successful de-escalation versus 49% of men (p = 0.023). Male sex was independently associated with treatment success (aOR 2.08, 95% CI 1.07-4.15, p = 0.033). A significant sex-by-time interaction was observed in NEE trajectories (p = 0.041), with divergence emerging at 48 hours (NEE 0.24 vs. 0.01 µg/kg/min, p = 0.008). The excess failure risk was confined to postmenopausal women aged ≥55 years (aOR 2.75, 95% CI 1.32-5.93, p = 0.008). CONCLUSION: Female sex, particularly in a postmenopausal context, was independently associated with impaired vasopressor de-escalation following AVP in CS on VA-ECMO. These hypothesis-generating findings suggest that hormonal status may modulate vascular responsiveness to AVP and support the need for prospective studies incorporating hormonal profiling.
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Development and Validation of an Adult Medical Urgency Score for US Donor Heart Allocation.
Clinical takeaway The score improved short-term risk stratification and simulated prioritization of higher-risk transplant candidates. Whether implementation improves patient outcomes remains unestablished.
Summary & abstract
Study summary
This US registry study developed and validated a heart transplant urgency score estimating 6-week mortality without transplant in adult candidates. The score incorporated five laboratory values and four therapeutic devices, including mechanical circulatory support. In test data, mean discrimination was higher than the current six-status system (AUC 0.807 versus 0.693). In allocation simulations, observed 6-week transplant-censored mortality among first-ranked candidates was 15.7% (95% CI, 13.9%-17.6%) with score-based allocation versus 11.2% (95% CI, 10.1%-12.5%) under the current system, indicating prioritization of higher-risk candidates rather than a demonstrated survival benefit.
Study limitation: Registry-based prediction and simulated allocation do not establish the effects of implementing this policy on survival.
Published abstract
IMPORTANCE: One in 5 heart transplant candidates in the US die or are delisted without transplant. Donor hearts are currently allocated by a 6-status therapy-based system criticized for limited risk stratification and susceptibility to gaming. OBJECTIVE: To develop a new heart allocation policy based on an objective medical urgency score that ranks candidates based on the interaction between physiology and mechanical circulatory support. DESIGN, SETTING, AND PARTICIPANTS: Registry-based observational study using data from the US organ transplant system. All adult (aged ≥18 years) heart transplant candidates from January 2019 to August 2025 were included, split into training (2019-2023), validation (2023-2024), and test (2024-2025) datasets. MAIN OUTCOMES AND MEASURES: A marginal structural model of 6-week mortality without transplant was estimated (the US Candidate Risk Score [US-CRS]). Eight models were compared in held-out data by weighted time-dependent area under the curve (AUC) and calibration by status. Finally, US-CRS was converted into an allocation policy and a match-run simulation of waitlist reordering was performed compared with the current 6-status system. RESULTS: Adult heart transplant candidates were partitioned into consecutive training (n = 21 859), validation (n = 7897), and test (n = 8256) datasets (mean [SD] age, 53 [13] years; 74% male). The chosen US-CRS model included 5 laboratory values and 4 therapeutic devices (durable left ventricular assist device, intra-aortic balloon pump, microaxial flow pump, and advanced mechanical circulatory support). In test-set cross-sections of candidates actively waiting on the same calendar date, US-CRS had similar or significantly higher time-dependent AUC than the current 6-status system (mean AUC, 0.807 vs 0.693, respectively) and acceptable calibration by status, especially for candidates who received their status by exception. In match-run analysis (n = 45 530 donor hearts), a US-CRS-based system led to 67% of transplant recipients moving down in rank order and increased observed 6-week transplant-censored mortality for the first candidate on the match run from 11.2% (95% CI, 10.1%-12.5%) under the current system to 15.7% (95% CI, 13.9%-17.6%) under the US-CRS-based system. CONCLUSIONS AND RELEVANCE: In this registry-based study of US heart transplant candidates, a US-CRS-based allocation system prioritized sicker candidates with higher mortality without transplant compared with the current medical urgency statuses.
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Clinical Validation of the Nursing Diagnosis "Risk for Shock" in Patients with Acute Myocardial Infarction Admitted to the ICU.
Clinical takeaway These findings identify bedside indicators associated with cardiogenic shock in ICU patients with myocardial infarction. They do not establish prospective prediction of deterioration or improved outcomes from indicator-guided monitoring.
Summary & abstract
Study summary
This Brazilian retrospective case-control study evaluated nursing indicators in 116 adult ICU patients with acute myocardial infarction, including 58 with cardiogenic shock and 58 without. Unstable blood pressure had 85.0% sensitivity (95% CI 76.2–93.8) and 83.6% specificity (95% CI 74.4–92.8) for distinguishing the groups. In adjusted analysis, unstable blood pressure was associated with shock (adjusted odds ratio 7.80; 95% CI 3.10–19.60), alongside hypoxia, hypoxemia, and inadequate fluid volume. Thermal and hemorrhagic indicators were no longer significant after adjustment.
Study limitation: The single-centre retrospective case-control design does not establish whether these indicators preceded shock or predict future deterioration.
Published abstract
ObjectiveTo clinically validate the nursing diagnosis "Risk for shock" in patients with acute myocardial infarction (AMI) admitted to an Intensive Care Unit (ICU).MethodA retrospective case-control study conducted at a high-complexity university hospital in Brazil. The sample consisted of 116 medical records of adult patients with AMI, equally distributed between the case group (with cardiogenic shock; n = 58) and the control group (without cardiogenic shock; n = 58). Diagnostic accuracy measures (sensitivity, specificity, predictive values, and likelihood ratios) were calculated, and multivariate binary logistic regression using the Stepwise Forward method was applied to identify independent predictors and control for confounders.ResultsIn the accuracy analysis, the indicator "Unstable blood pressure" showed the best clinical balance, with a sensitivity of 85.0% (95% CI: 76.2-93.8) and a specificity of 83.6% (95% CI: 74.4-92.8). "Hyperthermia" and "Inadequate fluid volume" showed the highest individual specificities (90.1% and 80.3%, respectively). After adjusting the logistic regression model (Nagelkerke R2 = 0.614; Hosmer-Lemeshow p = 0.782), only four factors remained significant as independent predictors of the outcome: unstable blood pressure (aOR = 7.80; 95% CI: 3.10-19.60; p < 0.001), hypoxia (aOR = 3.70; 95% CI: 1.50-9.20; p = 0.006), hypoxemia (aOR = 2.90; 95% CI: 1.40-6.10; p = 0.004), and inadequate fluid volume (aOR = 2.10; 95% CI: 1.00-4.50; p = 0.048). Thermal and hemorrhagic indicators lost significance after adjustment.ConclusionThe study clinically validated the diagnosis and confirmed a robust predictive model composed of four indicators. Prioritizing the monitoring of these risk factors enables critical care nurses to anticipate hemodynamic collapse, support targeted care protocols, and optimize multiprofessional decision-making at the bedside.
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Acute Effects of Impella 5.5 on Biventricular Filling and Pressure-Volume Area in Patients With Heart Failure Associated Cardiogenic Shock.
Clinical takeaway This small study documents acute haemodynamic changes after Impella 5.5 activation in refractory heart failure-associated shock. These physiological findings do not establish patient-centred benefit.
Summary & abstract
Study summary
Nine patients with medically refractory decompensated heart failure-associated cardiogenic shock underwent Impella 5.5 placement with invasive biventricular pressure-volume assessment. Acutely after activation, cardiac output increased from 3.4 ± 0.5 to 5.0 ± 0.7 L/min versus baseline (p = 0.0011). Left ventricular end-diastolic pressure decreased from 24.1 ± 6.7 to 16.8 ± 5.4 mm Hg (p = 0.0027), alongside reductions in end-diastolic volume and pressure-volume area. Right ventricular end-diastolic and end-systolic pressures and pressure-volume area also decreased, suggesting acute biventricular physiological effects of left ventricular unloading.
Study limitation: Only nine patients were studied using acute before-and-after measurements, without a separate control group or reported patient-centred outcomes.
Published abstract
Use of Impella 5.5 in patients with decompensated heart failure-associated cardiogenic shock (ADHF-CS) is increasing as a bridge to advanced therapies. The effects of maximal trans-valvular unloading on biventricular filling and pressure-volume area (PVA) in ADHF-CS are poorly understood. Nine patients with medically refractory ADHF-CS underwent Impella 5.5 placement with simultaneous invasive arterial, venous, and biventricular pressure-volume loop analysis. Acutely after Impella 5.5 activation, cardiac output (3.4 ± 0.5 vs. 5.0 ± 0.7 L/min, p = 0.0011), diastolic (67.2 ± 8.0 vs. 80.7 ± 9.7 mm Hg, p = 0.0044) and mean arterial pressures (77.9 ± 7.1 vs. 86.9 ± 10.4 mm Hg, p = 0.029) increased, compared to baseline. Left ventricular end-diastolic pressure (24.1 ± 6.7 vs. 16.8 ± 5.4 mm Hg, p = 0.0027), volume (262.1 ± 103.9 vs. 231.5 ± 104.3 ml, p = 0.0036), and PVA (21,913 ± 7,055 vs. 18,357 ± 7,758 mmHg·ml, p = 0.013) decreased. Right ventricular end-diastolic (12.4 ± 4.6 vs. 9.1 ± 3.8 mm Hg, p = 3.8E-5) and end-systolic pressure (42.1 ± 11.9 vs. 34.4 ± 11.1 mm Hg, p = 0.030) and PVA (6,303 ± 3,851 vs. 4,437 ± 2,473 mm Hg·ml, p = 0.027) also decreased. These findings suggest that maximal left ventricular unloading can acutely reduce biventricular filling pressures and PVA in patients with ADHF-CS.
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Intraprocedural Cardiac Arrest in Patients Undergoing Percutaneous Coronary Interventions in the United States: An Analysis of the NCDR CathPCI Registry.
Clinical takeaway Intraprocedural cardiac arrest was uncommon but associated with substantial in-hospital mortality. Rising risk-adjusted arrest incidence alongside slightly declining mortality provides a contemporary benchmark, not evidence for any particular prevention or resuscitation strategy.
Summary & abstract
Study summary
This CathPCI registry study examined intraprocedural cardiac arrest and in-hospital mortality during PCI from 2018 to 2023. Arrest occurred during 36,755 of 3,956,840 procedures (0.93%), including 0.24% of elective procedures and 1.28% of acute coronary syndrome interventions. In-hospital mortality among patients with arrest was 40.5%; among those who died, 45.4% died in the catheterization laboratory. Over time, risk-adjusted arrest incidence increased from 0.79% to 0.95% (P = 0.042), while risk-adjusted mortality declined slightly from 45.1% to 43.6% (P = 0.027).
Study limitation: The observational registry design cannot establish causality or explain the divergent trends in arrest incidence and mortality.
Published abstract
BACKGROUND: Cardiac arrest (CA) during percutaneous coronary interventions (PCI) is a catastrophic procedural complication. Contemporary rates of CA during PCI are unknown. OBJECTIVES: This study sought to understand contemporary rates of CA, associated mortality, and identify predictors of CA during PCI. METHODS: Patients with CA during PCI from 2018 to 2023 were identified from the National Cardiovascular Data Registry CathPCI Registry. Trends in intraprocedural CA (IPCA) incidence and in-hospital death were evaluated. Predictors of IPCA and risk-adjusted mortality were identified. RESULTS: A total of 36,755 IPCA occurred during 3,956,840 PCIs (0.93%), including in 0.24% of elective PCIs, 0.32% of PCIs for stable coronary artery disease, and 1.28% of acute coronary syndrome interventions. The incidence of IPCA increased over time (0.62% in 2018 to 1.07% in 2023; P < 0.0001). In-hospital death occurred in 40.5% of patients with IPCA, 45.4% of whom died in the cardiac catheterization laboratory. Notably, although risk-adjusted IPCA increased (0.79% to 0.95%; P = 0.042), slight declines in risk-adjusted mortality (45.1% to 43.6%; P = 0.027) were observed over time. PCI for ST-segment elevation myocardial infarction, non-ST-segment acute coronary syndromes, increasing age, ventricular arrhythmias, severe aortic stenosis, vasopressors or inotrope use, mechanical circulatory support, coronary perforation, coronary dissection, cardiac tamponade, intraprocedural heart failure or myocardial infarction, and temporary cardiac pacemaker implantation were associated with increased adjusted odds of IPCA. CONCLUSIONS: IPCA complicates 0.93% of contemporary PCI. Despite an increasing incidence of risk-adjusted IPCA, there were slight declines in risk-adjusted in-hospital mortality in the study period. Several patient and procedural characteristics were independently associated with intraprocedural CA.
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