CANCARE RESEARCH
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An automated research-discovery feed. Summaries are based on published abstracts and are not clinical recommendations.
CS-MORT-6: A mortality score that refines risk within EHR-derived SCAI stages in cardiogenic shock.
Clinical takeaway CS-MORT-6 showed moderate external discrimination and differentiated mortality risk within EHR-derived SCAI stages. These findings support further prognostic evaluation, not score-directed treatment decisions.
Summary & abstract
Study summary
CS-MORT-6 was developed in adults with cardiogenic shock to predict subsequent in-hospital mortality at a 24-hour landmark; 892 deaths occurred among 2694 ICU survivors at that landmark. External validation included 1047 patients from 117 hospitals. The integer score had an external AUROC of 0.759 (95% CI, 0.729–0.790), but overpredicted mortality on average. Within EHR-derived SCAI stages, mortality differed by 20–47 percentage points between the lowest and highest score tertiles in MIMIC-IV, with a similar pattern in eICU, suggesting additional risk stratification beyond stage alone.
Study limitation: Predictions apply to patients alive in the ICU at 24 hours; repeated scoring and real-time performance require prospective evaluation.
Published abstract
BACKGROUND: Cardiogenic shock carries high in-hospital mortality, and the ordinal SCAI classification does not rank risk within a stage. Existing scores generally require imaging, procedural, or support-dependent data. METHODS: We identified 3103 adults with documented cardiogenic shock in MIMIC-IV. Six predictors (lactate, urine output, cardiac arrest, age, blood urea nitrogen, red cell distribution width) were selected by bootstrap LASSO screening and clinical review. CS-MORT-6 was derived as two continuous ridge logistic models (lactate or anion gap) fitted at a 24-h landmark and a 0-to-15-point integer score. The primary outcome was subsequent in-hospital death among patients alive in the ICU at the landmark (n = 2694; 892 deaths). The models were externally validated in 1047 patients from 117 eICU hospitals. RESULTS: The integer score's AUROC was 0.727 (95% CI, 0.706-0.747) on cross-validation and 0.759 (0.729-0.790) externally; corresponding values were 0.734 and 0.759 (lactate model) and 0.726 and 0.748 (anion-gap model). Externally, the integer score over-predicted on average (calibration-in-the-large -0.22, slope 1.15). Within EHR-derived SCAI stages, mortality differed by 20 to 47 percentage points between the lowest and highest score tertiles in MIMIC-IV, with a similar pattern in eICU. Adding the anion-gap model to stage increased apparent AUROC by 0.139 (0.116-0.162) in MIMIC-IV and 0.141 (0.101-0.178) in eICU. Compared with BOS,MA2 (654 eICU patients scorable by both), the anion-gap model's AUROC difference was 0.004 (-0.039 to 0.046). CONCLUSIONS: At 24 h, CS-MORT-6 distinguished mortality risk within EHR-derived SCAI stages and retained moderate discrimination externally. Repeated scoring and real-time performance require prospective evaluation.
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Temporary Right Ventricular Mechanical Circulatory Support Devices in Acute Right Ventricular Failure and Cardiogenic Shock: A Cross-Device Systematic Review and Single-Arm Meta-Analysis.
Clinical takeaway These pooled estimates describe outcomes and complication burden in selected patients receiving temporary RV support. They cannot establish benefit over alternative care or identify a superior device.
Summary & abstract
Study summary
This single-arm meta-analysis included 106 studies and 4653 adults receiving temporary mechanical support for acute right ventricular failure or RV-predominant cardiogenic shock. Pooled survival to discharge was 60.4% (95% CI 56.0–64.7), with a wide prediction interval of 34.4%–81.6%; separately pooled 30-day mortality was 30.1% (95% CI 24.1–36.9). Pooled bleeding, renal complications, and stroke rates were 36.5%, 46.6%, and 14.5%, respectively. Concurrent left-sided support was reported in 85.8% of patients with available data, limiting applicability to isolated primary RV shock; these descriptive findings do not establish treatment benefit or comparative device effectiveness.
Study limitation: Heterogeneous treated cohorts, frequent concurrent left-sided support, and inclusion of 57 conference-abstract studies limit certainty and generalizability.
Published abstract
BACKGROUND: Evidence for temporary right ventricular assist devices (tRVADs) is fragmented. We characterized outcomes among adults receiving temporary support for acute right ventricular (RV) failure or RV-predominant cardiogenic shock. METHODS: MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched from inception to June 2026. Arm-level outcome proportions were pooled on the logit scale using three-level random-effects models, with arms nested within studies. Device-stratified estimates, meta-regression, and sensitivity analyses were examined. RESULTS: We included 106 studies (119 device arms; 4653 patients), including 57 conference-abstract studies (53.8%). Concurrent left-sided support was reported in 85.8% of patients with available data; post-LVAD RV failure predominated in 47.5% of arms. Separately pooled survival to discharge was 60.4% (95% CI 56.0-64.7; 63 arms), successful weaning 60.6% (54.8-66.2; 68 arms), and 30-day mortality 30.1% (24.1-36.9; 31 arms). The survival prediction interval was wide (34.4%-81.6%). Pooled bleeding, renal complications (acute kidney injury and/or renal replacement therapy, as reported), and stroke were 36.5%, 46.6%, and 14.5%, respectively. Device-stratified estimates were vulnerable to confounding. No meta-regression association remained significant after multiplicity correction. CONCLUSIONS: These descriptive estimates characterize selected, heterogeneous treated cohorts, predominantly receiving left-sided or biventricular support; they do not establish treatment benefit or comparative device effectiveness. Complication rates were high. Applicability to isolated primary RV shock is limited. Standardized prospective data are needed to inform patient selection, timing, and device strategy. TRIAL REGISTRATION: PROSPERO registration number: CRD420261406088.
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Beyond hemodynamic failure: a distinct inflammatory cytokine profile in cardiogenic shock complicating acute coronary syndrome.
Clinical takeaway ACS-related cardiogenic shock was associated with a distinct inflammatory profile, but these exploratory associations do not establish causality or demonstrate clinical utility for cytokine testing.
Summary & abstract
Study summary
This observational study compared 76 patients with acute coronary syndrome, including 38 with cardiogenic shock and 38 without shock. Patients with shock had lower blood pressure, reduced ejection fraction, and higher markers of myocardial injury and inflammation. Five cytokines were elevated in unadjusted analyses; IL-8, IL-18 and IL-1β remained significantly associated with shock after adjustment for age, sex and STEMI status. Mortality was numerically higher in the shock group. The authors characterized these inflammatory findings as exploratory and requiring confirmation in larger prospective studies.
Study limitation: The small observational cohort and limited adjustment leave residual confounding; mortality effect sizes and uncertainty were not reported.
Published abstract
OBJECTIVE: To compare the clinical, hemodynamic, metabolic and inflammatory profiles of patients with acute coronary syndrome (ACS) with and without cardiogenic shock (CS) and to identify biomarkers associated with disease severity. METHODS: In this observational study, 76 patients with ACS (38 with CS and 38 without CS) were enrolled. Clinical characteristics, laboratory parameters, cardiac biomarkers, lipid profile and 13 circulating cytokines were assessed. Continuous variables were compared using Welch's t-test or the Mann-Whitney U test and categorical variables using the chi-square or Fisher's exact test. Exploratory multivariable analyses adjusted for age, sex and STEMI status were performed for selected cytokines. RESULTS: Compared with patients without CS, those with CS had significantly lower blood pressure, higher shock index, reduced ejection fraction and higher CK-MB, troponin I, BNP, D-dimer, CRP, LDH, urea and liver enzyme levels. IL-8, IL-1β, IL-18, TNF-α and GM-CSF were significantly elevated in unadjusted analyses. After adjustment for age, sex and STEMI status, IL-8, IL-18 and IL-1β remained significantly associated with CS. Mortality was numerically higher in the CS group. CONCLUSION: ACS complicated by CS was associated with profound hemodynamic impairment, greater myocardial injury and an enhanced inflammatory response. These exploratory findings warrant confirmation in larger prospective studies.
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Prognostic implications of complications during VA-ECMO for cardiogenic shock.
Clinical takeaway Complication type and timing were associated with mortality during VA-ECMO for cardiogenic shock. These findings provide prognostic context but do not establish that complications caused the observed excess mortality.
Summary & abstract
Study summary
An ELSO Registry analysis included 22,547 adults receiving VA-ECMO for cardiogenic shock during 2017–2024; 54% died in hospital. Complications occurred in 74% of nonsurvivors versus 54% of survivors. Neurologic complications were associated with a mortality hazard ratio of 3.6 (95% confidence interval 3.4–3.8). Multistate analysis estimated 30-day mortality risk at 48.6% without complications and 93.1% with a neurologic complication. Among patients surviving to three weeks, those without complications during that period had the highest conditional survival. Neurologic and pulmonary complications were associated with the greatest mortality risk.
Study limitation: Observational registry associations cannot establish causality; the three-week landmark findings apply only to patients surviving to that point.
Published abstract
PURPOSE: Veno-arterial extracorporeal oxygenation (VA-ECMO) provides comprehensive cardiopulmonary support in patients with cardiogenic shock (CS), but may result in complications. While complications rates are known, their impact on risk of death remains largely unknown. METHODS: Using the Extracorporeal Life Support Organization (ELSO) Registry to identify adults with a diagnosis of CS treated with VA-ECMO (2017-2024), we analyzed the association between timing and type of complication and in-hospital mortality using three methodologies: 1) Cox proportional hazards analysis, treating complications as time-dependent covariates; 2) Multi-State Model (MSM) analysis, treating complications as transient states and estimating the differential mortality rate from each of these states; and 3) landmark Kaplan Meier survival analysis, estimating conditional survival curves, given survival to 3 weeks, based on count and timing of complications. RESULTS: Among 22,547 patients (31.7% female), 12,094 (54%) died during index hospitalization. More non-survivors experienced complications than survivors (74% vs 54%), with all sub-types occurring more frequently. Neurologic complications increased the hazard of mortality by 3.6 (95% C.I 3.4 - 3.8). MSM analysis indicated that the absolute 30-day risk of mortality was greater if a patient had a complication, increasing from 48.6% (0 complications) to 93.1% with a neurologic complication. Landmark survival analysis demonstrated that patients without complications within the first 3 weeks had the highest conditional survival. CONCLUSION: Complications on VA-ECMO have a significant and cumulative effect on in-hospital mortality, with a higher number associated with increased risk of death. Neurologic and pulmonary complications were associated with the greatest mortality risk.
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Derivation and Validation of Operational Definitions From Claims Data for Identifying Cardiogenic Shock.
Clinical takeaway The algorithm may support cardiogenic-shock surveillance and long-term outcome research using Korean claims data. These findings concern case identification rather than treatment effectiveness.
Summary & abstract
Study summary
This diagnostic accuracy study evaluated a claims-based cardiogenic shock definition against clinically adjudicated standards in two Korean clinical cohorts. The algorithm combined diagnostic codes with treatment-based criteria reflecting haemodynamic support, including mechanical circulatory support or vasoactive therapy. Among 10,156 cardiac ICU registry patients, sensitivity was 0.89, specificity 0.90, and accuracy 0.90; sensitivity was 0.95 in the 1,247-patient RESCUE registry. Nationwide application identified 207,419 patients with cardiogenic shock, with cumulative mortality of 37.9% at 12 months, 49.9% at five years, and 61.7% at ten years.
Study limitation: The abstract reports neither uncertainty intervals for diagnostic performance nor specificity in the RESCUE validation cohort.
Published abstract
OBJECTIVES: To derive and validate a claims-based operational definition for cardiogenic shock (CS) using administrative data against clinically adjudicated reference standards. DESIGN: Diagnostic accuracy study. SETTING: Two independent clinical cohorts, a single-center cardiac ICU (CICU) registry and a multicenter CS registry (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock [RESCUE]), and a nationwide administrative database from the Korean National Health Insurance Service. PATIENTS: A total of 10,156 patients from the CICU registry and 1,247 patients from the RESCUE registry. For population-level application, 207,419 patients were identified from the national claims database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A claims-based algorithm defined CS using the International Classification of Diseases, 10th Revision code R57.0 or cardiac disease codes combined with treatment-based criteria reflecting hemodynamic support, including mechanical circulatory support or vasoactive therapy. In the CICU cohort, the algorithm demonstrated a sensitivity of 0.89 and specificity of 0.90, with an overall accuracy of 0.90. In the RESCUE cohort, sensitivity was 0.95. When applied to the nationwide database, 207,419 patients with CS were identified. The cumulative mortality rates were 37.9% at 12 months, 49.9% at 5 years, and 61.7% at 10 years. CONCLUSIONS: A claims-based definition combining diagnostic codes with treatment-based criteria demonstrated high diagnostic performance for identifying CS. This approach enables reliable large-scale epidemiologic studies and long-term outcome assessments using administrative data and may facilitate system-level evaluation of critical care delivery in patients with CS.
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Complexity of coronary artery disease in infarct-related cardiogenic shock and multivessel disease: a substudy of the DanGer Shock trial.
Clinical takeaway Coronary complexity provided prognostic information, but no significant pump-effect interaction was detected by baseline SYNTAX category. The isolated left main subgroup signal remains exploratory.
Summary & abstract
Study summary
This DanGer Shock secondary analysis examined coronary complexity and 180-day mortality in infarct-related cardiogenic shock; 256 patients had multivessel disease. High baseline SYNTAX scores were associated with greater mortality odds than low/intermediate scores (adjusted OR 3.12, 95% CI 1.17-8.69); residual scores independently predicted mortality. Baseline SYNTAX category did not significantly modify the microaxial pump effect (interaction p=0.31). Among 35 patients with isolated left main culprit lesions, pump support versus standard care was associated with lower mortality odds (adjusted OR 0.17, 95% CI 0.03-0.99), a hypothesis-generating finding.
Study limitation: Baseline SYNTAX scores were available for only 211 patients; the isolated left main analysis involved just 35 patients.
Published abstract
BACKGROUND: The prognostic impact of multivessel coronary anatomy and complexity in infarct-related cardiogenic shock (CS) is insufficiently characterised. AIMS: We sought to investigate the prognostic value of baseline and residual SYNTAX scores and their influence on the effect of microaxial flow pump (mAFP) support in multivessel disease (MVD) and infarct-related CS. METHODS: In this secondary analysis of the DanGer Shock trial, MVD was defined as ≥1 non-culprit stenosis ≥70% or an isolated left main (LM) culprit lesion. Baseline SYNTAX scores were categorised as low (≤22), intermediate (23-32), or high (>32). Patients with an isolated LM culprit lesion were analysed separately. The primary outcome was 180-day all-cause mortality. RESULTS: Of 355 patients included in DanGer Shock, 256 patients had MVD; 211 had an available baseline SYNTAX score, with 26% of these in the low, 47% in the intermediate, and 27% in the high baseline SYNTAX groups. In all, 35 patients had an isolated LM culprit lesion. A high baseline SYNTAX score was associated with higher odds of 180-day all-cause mortality compared with low and intermediate baseline SYNTAX scores (adjusted odds ratio [OR] 3.12, 95% confidence interval [CI]: 1.17-8.69). A higher baseline SYNTAX score was associated with a higher residual SYNTAX score (p<0.001). The residual SYNTAX score independently predicted 180-day all-cause mortality. The mAFP effect was not modified by the baseline SYNTAX group (p for interaction=0.31). In patients with an isolated LM culprit lesion, mAFP use was associated with lower odds of 180-day all-cause mortality compared with standard care alone (adjusted OR 0.17, 95% CI: 0.03-0.99). CONCLUSIONS: Baseline and residual SYNTAX scores independently predicted 180-day mortality. The mAFP effect was not modified by SYNTAX measures. In the isolated left main subgroup, a hypothesis-generating signal towards a clinical benefit with mAFP use was observed.
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Inflammation, Infarct Size and 10-Year Mortality in STEMI Patients Stratified by the ORBI Risk Score: A DANAMI-3 Sub-study.
Clinical takeaway ORBI-defined shock risk also marked higher long-term mortality and greater infarct burden in STEMI patients initially without shock. Its weaker discrimination than age alone limits its appeal as a stand-alone long-term prognostic tool.
Summary & abstract
Study summary
This DANAMI-3 secondary analysis classified 1,574 STEMI patients without cardiogenic shock as high or low risk using the ORBI score. High-risk patients had greater inflammation and larger final infarcts, involving 15.7% versus 10.1% of left ventricular mass. Ten-year all-cause mortality was 41% versus 20%, with an adjusted hazard ratio of 1.47 (95% confidence interval 1.16–1.85). The adjusted mortality association was strongest within 30 days, while the score discriminated 10-year mortality less well than age alone, with areas under the curve of 0.67 versus 0.79.
Study limitation: These nonrandomized risk-group comparisons cannot establish causality or whether targeting inflammation improves outcomes.
Published abstract
BACKGROUND: The ORBI Risk Score predicts in-hospital cardiogenic shock after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Whether high-risk patients also have more systemic inflammation, larger infarcts and higher long-term mortality is not known. METHODS: In a DANAMI-3 sub-study, 1,574 STEMI patients without cardiogenic shock were classified as high (ORBI ≥8, n = 273) or low risk (n = 1,301). Inflammation was assessed by routine C-reactive protein (CRP), leukocyte count and neutrophil-to-lymphocyte ratio (NLR) within 72 hours of PCI, and admission mid-regional pro-adrenomedullin (MR-proADM). Infarct size was measured by cardiac magnetic resonance. Ten-year all-cause mortality was obtained from the Danish Civil Registration System. Cox models were adjusted for age, sex, comorbidity, kidney function and randomised allocation. RESULTS: High-risk patients had higher peak CRP (72 vs. 11 mg/L), leukocyte count (12.8 vs. 10.4 × 109/L), NLR (6.2 vs. 3.5) and MR-proADM (0.73 vs. 0.62 nmol/L; all p < 0.001), and larger infarcts (final infarct size 15.7% vs. 10.1% of left ventricular mass). Ten-year mortality was 41% vs. 20% (hazard ratio 2.56, 95% CI 2.05-3.20; adjusted 1.47, 1.16-1.85). The adjusted hazard ratio was 4.79 within 30 days and 1.27 after the first year. The score discriminated 10-year mortality less well than age alone (area under the curve 0.67 vs. 0.79). CONCLUSIONS: The ORBI Risk Score identifies STEMI patients with more inflammation, larger infarcts and higher mortality, especially in the first year. Beyond the first year the association was largely explained by age. Whether anti-inflammatory treatment benefits these patients is a question for randomised trials.
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Early Lower Pulmonary Arterial Diastolic Pressure Monitored With Pulmonary Arterial Catheters Is Associated With Improved Survival During VA ECMO for Patients With Acute Cardiogenic Shock: A Propensity-Matched Study.
Clinical takeaway Early on-support pulmonary artery diastolic pressure may provide prognostic information during VA ECMO. These observational findings do not establish that lowering pressure or using a catheter improves survival.
Summary & abstract
Study summary
This registry study examined 7,654 adults receiving VA ECMO for cardiogenic shock; 3,077 were managed with pulmonary arterial catheters. Haemodynamics were assessed at 24 hours, and the primary outcome was 30-day in-hospital mortality. Catheter use was not significantly associated with lower in-hospital mortality (adjusted OR 0.95, 95% CI 0.897–1.006). Among patients surviving 24 hours, pulmonary artery diastolic pressure above 18 mm Hg was associated with greater in-hospital mortality within 30 days (HR 1.29, 95% CI 1.13–1.46), with consistent associations in subgroups receiving left ventricular mechanical unloading.
Study limitation: Observational associations remain vulnerable to confounding; the pressure analysis was restricted to patients surviving 24 hours.
Published abstract
BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is used to support refractory cardiogenic shock (CS) but may increase peripheral afterload. Invasive hemodynamic measurement and cardiopulmonary congestion during VA ECMO may correlate with survival, but the precise mechanisms underlying this benefit are uncertain. OBJECTIVES: The aim of this study was to determine whether invasive hemodynamic monitoring with a pulmonary arterial catheter (PAC) and early on-support pulmonary artery diastolic pressure (PAD) are associated with survival during VA ECMO. METHODS: Adult patients with CS from the ELSO (Extracorporeal Life Support Organization) Registry from 2015 to 2020 were analyzed. Invasive hemodynamic status was assessed at 24 hours of ECMO. The primary outcome was 30-day in-hospital mortality. The association between the use of left ventricular mechanical unloading (LVMU) and both 24-hour on-support invasive hemodynamic status and in-hospital mortality was examined using landmark adjustment. RESULTS: In total, 7,654 patients treated with VA ECMO for CS were identified, of whom 3,077 were managed with PACs. PAC use during VA ECMO was not significantly associated with lower in-hospital mortality, with an adjusted OR of death of 0.95 (95% CI: 0.897-1.006; P = 0.077). Among patients who survived 24 hours, higher single early values of on-support PAD at 24 hours (>18 mm Hg) were associated with greater in-hospital mortality within 30 days (HR: 1.29; 95% CI: 1.13-1.46; P < 0.001), which remained consistent within subgroups receiving concomitant LVMU (peripherally inserted ventricular assist device or intra-aortic balloon pump). CONCLUSIONS: There is a significant, graded relationship between higher single measures of 24-hour on-support PAD and death. Patient survival is greatest when 24-hour PAD is <18 mm Hg. PAD decreased at 24 hours among all comers, but 47% of patients received LVMU devices to support this reduction.
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Initial V-A ECMO Flow-Index and Its Association With Inflammation, Organ Failure, and Outcomes.
Clinical takeaway Higher initial ECMO flow-index was associated with organ failure and poorer outcomes, but these findings do not establish that higher flow causes harm or that reducing flow improves outcomes.
Summary & abstract
Study summary
This retrospective single-center study compared higher versus lower initial flow-index in 553 patients receiving V-A ECMO between 2014 and 2024. After excluding cerebral death, multi-organ failure occurred in 32.7% of the high-flow group versus 23.0% of the low-flow group. Initial flow-index remained associated with multi-organ failure after adjustment (OR 1.102 per 0.1 L/min/m2, 95% CI 1.001–1.214). High-flow patients had greater baseline haemodynamic compromise, and exploratory mediation analysis suggested an indirect association through early hemolysis. Higher flow-index was also associated with worse neurological outcome and reduced survival.
Study limitation: Retrospective single-center data and greater shock severity in high-flow patients limit causal interpretation; mediation findings remain exploratory.
Published abstract
BACKGROUND: Refractory cardiogenic shock remains associated with high mortality despite macrocirculatory stabilization with V-A ECMO. We investigated the association between initial ECMO flow-index, organ dysfunction, inflammatory activation, hemolysis, and clinical outcome. METHODS: In this retrospective single-center study, 553 patients receiving V-A ECMO between 2014 and 2024 were divided into low-flow (< 1.63 L/min/m2, n = 269) and high-flow (≥ 1.63 L/min/m2, n = 284) groups. Patients were additionally stratified according to eCPR status. Multivariable logistic regression was used to assess factors associated with multi-organ failure (MOF), and exploratory mediation analyses evaluated day-1 free hemoglobin and IL-6 as potential mediators. RESULTS: High-flow patients were more hemodynamically compromised, with higher lactate, vasoactive-inotropic support, inflammatory markers, and early hemolysis. After exclusion of cerebral death, MOF occurred more frequently in the high-flow group (32.7% vs. 23.0%, p = 0.028). Initial flow-index remained independently associated with MOF in the overall cohort (OR 1.102 per 0.1 L/min/m2, 95% CI 1.001-1.214, p = 0.048) and in the eCPR subgroup (OR 1.117, 95% CI 1.028-1.214, p = 0.008). Day-1 free hemoglobin was independently associated with MOF, and mediation analysis demonstrated a significant indirect effect through early hemolysis. No significant indirect effect through IL-6 was observed. Higher flow index was also associated with worse neurological outcome and reduced survival. CONCLUSIONS: Higher initial V-A ECMO flow-index is associated with greater shock severity and multi-organ failure. Early hemolysis may partly contribute to this association, particularly in eCPR patients. These findings support individualized flow management with close monitoring of hemolysis and evolving organ dysfunction.
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Efficacy and safety of nafamostat mesilate for anticoagulation during ECMO/CRRT: insight from the integrated meta-analysis and FAERS pharmacovigilance study.
Clinical takeaway The pooled bleeding association is relevant to extracorporeal-support care, but does not establish an ECMO-specific benefit. Nonsignificant filter-lifespan findings do not demonstrate equivalence.
Summary & abstract
Study summary
This meta-analysis included 17 studies involving 1,893 patients, comparing nafamostat with sodium citrate, unfractionated heparin, or no anticoagulation during ECMO/CRRT. Nafamostat was associated with fewer bleeding events (odds ratio 0.61; 95% confidence interval 0.43–0.86). Filter lifespan did not differ significantly between groups (mean difference 1.29 hours; 95% confidence interval −1.09 to 3.66). A separate FAERS analysis included 24,238 reports across the three anticoagulants and identified nafamostat reporting signals for disseminated intravascular coagulation, gastrointestinal hemorrhage, and decreased platelet count; these are reporting signals rather than comparative clinical risks.
Study limitation: The abstract does not separate ECMO from CRRT results or report mortality findings, limiting cardiac ICU interpretation.
Published abstract
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) require a balance between maintaining circuit patency and minimizing bleeding risk. Nafamostat mesilate (NM) is a short-acting anticoagulant with distinctive pharmacokinetic properties, including rapid metabolism and a short half-life, which may reduce prolonged systemic anticoagulant exposure. These characteristics make NM a potential alternative to conventional anticoagulation strategies, particularly for patients at high risk of bleeding. This study aimed to systematically evaluate the efficacy and safety of NM as an anticoagulant for ECMO/CRRT. METHODS: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for randomized controlled trials and cohort studies comparing NM with sodium citrate, unfractionated heparin (UFH), or no anticoagulation. A meta-analysis was conducted to evaluate filter lifespan, bleeding events, thromboembolic events, and 28-day/intensive care unit (ICU) mortality. Reporting characteristics and potential safety signals for the three anticoagulants were also compared using data from the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS). RESULTS: The meta-analysis included 17 studies involving 1,893 patients. Filter lifespan did not differ significantly between the NM and control groups (mean difference [MD] = 1.29 h; 95% confidence interval [CI], -1.09-3.66), whereas the risk of bleeding events was significantly lower in the NM group (odds ratio [OR] = 0.61; 95% CI, 0.43-0.86). Subgroup analyses showed that NM was associated with a significantly lower risk of bleeding than sodium citrate (OR = 0.53; 95% CI, 0.31-0.90) and no anticoagulation (OR = 0.41; 95% CI, 0.19-0.90); sensitivity analyses supported the robustness of this finding. The FAERS analysis included 24,238 reports, comprising 233 for NM, 1,612 for sodium citrate, and 22,393 for UFH, with distinct reporting profiles observed among the three anticoagulants. Representative signals for NM included disseminated intravascular coagulation (n = 17; ROR = 112.68, 95% CI: 69.69-182.19), gastrointestinal hemorrhage (n = 12; ROR = 15.44, 95% CI: 8.74-27.29), and decreased platelet count (n = 13; ROR = 7.52, 95% CI: 4.35-13.00). CONCLUSION: NM may reduce bleeding risk while maintaining a filter lifespan comparable to that achieved with other anticoagulation strategies, potentially providing an individualized anticoagulation option for patients at high risk of bleeding. In clinical practice, coagulation abnormalities, changes in platelet counts, and bleeding-related events should be closely monitored.
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Intra-aortic balloon support for myocardial infarction with cardiogenic shock: insights from the Swedish Coronary Angiography and Angioplasty Registry.
Clinical takeaway This registry analysis found no clear mortality advantage associated with IABP and a signal for increased in-hospital complications. Wide mortality confidence intervals leave substantial uncertainty about benefit or harm.
Summary & abstract
Study summary
This prospective Swedish registry study included 2991 patients with myocardial infarction complicated by cardiogenic shock undergoing PCI; 737 received IABP. Investigators used hospital treatment preference as an instrumental variable to account for baseline differences. Overall 30-day mortality was 52%, and IABP was not associated with reduced 30-day mortality compared with no IABP (risk reduction −1.1%, 95% confidence interval −15.7 to 13.5). IABP use was associated with more in-hospital complications (reported increase 26.1%, 95% confidence interval 15.2–36.8), although the observational design limits causal interpretation.
Study limitation: Instrumental-variable adjustment cannot establish randomization, and the wide mortality confidence interval limits precision.
Published abstract
BACKGROUND: Cardiogenic shock remains the leading cause of in-hospital death in patients with acute myocardial infarction (MI). The intra-aortic balloon pump (IABP), once widely used, was downgraded in European guidelines after a major randomized trial showed no mortality benefit. This prospective observational study evaluated the impact of IABP on 30-day mortality and in-hospital complications in real-world patients with MI complicated by cardiogenic shock. METHODS: Data were obtained from the Swedish Coronary Angiography and Angioplasty Registry, including all percutaneous coronary intervention procedures performed across 31 hospitals in Sweden between 2005 and 2018. A total of 2991 patients with cardiogenic shock were included, of whom 737 (25%) received IABP. To account for baseline differences, instrumental variable analysis was applied using hospital treatment preference as the instrument. RESULTS: At 30 days, 52% of patients had died, and by 1 year, mortality reached 63.2%. In-hospital complications occurred in 13.4% of patients. IABP treatment was not associated with reduced mortality at 30 days [risk reduction: -1.1%, 95% confidence interval (CI): -15.7 to 13.5; P = 0.881] or at 1 year (risk reduction: -0.8%, 95% CI: -23.2 to 0.06; P = 0.258). However, IABP use was associated with a significantly higher risk of in-hospital complications (increase of 26.1%, 95% CI: 15.2-36.8; P < 0.001). CONCLUSION: IABP did not improve short- or long-term survival in patients with MI-related cardiogenic shock but was linked to increased complications, supporting current guideline recommendations against its routine use.
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The red blood cell distribution width-to-albumin ratio and 28-day mortality in patients with severe cardiogenic shock: a retrospective cohort study based on MIMIC-IV with single-center external validation.
Clinical takeaway RAR was associated with short-term mortality in cardiogenic shock, but prospective validation is needed before its added value for clinical risk stratification is established.
Summary & abstract
Study summary
This retrospective study included 1,314 cardiogenic-shock patients across MIMIC-IV and a single-center external validation cohort. Higher red cell distribution width-to-albumin ratio (RAR) was associated with 28-day ICU mortality after adjustment (HR per unit 1.134, 95% CI 1.076–1.197). The association persisted in external validation (HR 1.359, 95% CI 1.177–1.568). For 28-day in-hospital mortality, the adjusted HR per unit was 1.085 (95% CI 1.031–1.141). A model incorporating RAR and five other clinical features showed moderate discrimination, with AUCs of 0.71, 0.70, and 0.75 in training, test, and external validation sets.
Study limitation: Retrospective observational data remain vulnerable to residual confounding; external validation came from only one center.
Published abstract
BACKGROUND: Cardiogenic shock (CS) is a critical syndrome with a very high fatality rate, and in-hospital mortality ranges from 27% to 51%. Among the various prognostic approaches, serum biomarkers have attracted considerable attention because they are easy to measure, inexpensive, and can be monitored dynamically. The red cell distribution width-to-albumin ratio (RAR) is a novel composite marker that integrates red blood cell heterogeneity (reflecting inflammation and oxidative stress) with albumin levels (indicating nutritional and anti-inflammatory capacity). It has shown initial promise for risk stratification in critically ill patients. However, the independent prognostic value of RAR specifically in CS remains unclear. Therefore, this study aims to systematically evaluate the ability of RAR to predict 28-day mortality in these patients. MATERIALS AND METHODS: This study used a two-cohort retrospective design. The internal training cohort was derived from CS patients in the MIMIC-IV v2.2 database, and the external validation cohort came from the medical record system of the Affiliated Hospital of Guizhou Medical University. To explore the association between RAR and short-term poor outcomes in severe CS, we applied multivariable Cox regression, restricted cubic spline (RCS) regression, subgroup analysis, and Kaplan-Meier survival curves. To develop a simple prediction model, the internal cohort was randomly split into a training set and a test set in a 7:3 ratio. In the training set, we used five methods-Boruta algorithm, LASSO-Cox regression, random forest (RF), gradient boosting (GBDT), and support vector machine (SVM)-to select key features associated with poor CS prognosis, covering laboratory indicators, comorbidities, demographic characteristics, and vital signs. Based on the selected feature variables, we built prognostic prediction models using multivariable Cox regression in each of the three cohorts. The discriminative ability of the model was compared with that of traditional disease severity scores using receiver operating characteristic (ROC) curves, with the area under the curve (AUC) as the measure of predictive performance. RESULT: A total of 1,314 CS patients were included in this study. In the fully adjusted model (Model 3), both continuous RAR and RAR quartiles were independently associated with 28-day adverse outcomes. For 28-day ICU mortality, each unit increase in RAR was associated with a 13.4% higher risk (HR 1.134, 95% CI 1.076-1.197, p < 0.001); compared with the lowest quartile (Q1), the highest quartile (Q4) had a significantly increased risk of 51.7% (HR 1.517, 95% CI 1.123-2.049, p = 0.007). For 28-day in-hospital mortality, the HR for continuous RAR was 1.085 (95% CI 1.031-1.141, p = 0.002), and the HR for Q4 vs. Q1 was 1.576 (95% CI 1.196-2.076, p = 0.001). Restricted cubic spline analysis further confirmed a significant positive dose-response relationship between RAR and mortality (overall p < 0.05). In the external validation cohort, the predictive value of RAR for 28-day ICU mortality remained consistent and was even stronger (HR for continuous RAR: 1.359, 95% CI 1.177-1.568, p < 0.001). the RAR-based risk prediction model showed moderate but consistent discriminative performance, with areas under the receiver operating characteristic curve of 0.71, 0.70, and 0.75 in the training, test, and external validation sets, respectively, all of which were higher than those of traditional severity scores (all DeLong tests p < 0.05). CONCLUSION: This study demonstrated in both cohorts that RAR is an independent associated with 28-day mortality risk in CS patients. The prediction model built on RAR and five other clinical features exhibited good clinical performance. With further prospective validation, this model may become a valuable exploratory tool for risk stratification in CS patients.
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