THE ASSOCIATION OF LIVER CIRRHOSIS WITH POOR OUTCOMES WITH INTERVENTIONAL MANAGEMENT FOR STEMI RELATED CARDIOGENIC SHOCK, A NATIONWIDE ANALYSIS

Abstract Background Remdesivir is a nucleotide analogue antiviral that was FDA approved for the treatment of hospitalized patients with coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Remdesivir has been associated with elevations in serum aminotransferase levels but most cases being mild to moderate and reversible upon discontinuation. Although national COVID-19 guidelines and the American Association for the Study of Liver Diseases (AASLD) currently recommend remdesivir for use in hospitalized patients requiring supplemental oxygen, data is limited using remdesivir in patients with chronic liver disease. Here, we describe our experience with remdesivir in patients with liver cirrhosis. Methods Patients with liver cirrhosis who received remdesivir were identified either prospectively or retrospectively by primary or secondary ICD-10 codes indicating liver disease. Data collected included patient demographics, underlying cause of cirrhosis, co-morbidities, Child-Pugh score, laboratory values (serum aminotransferase levels, serum creatinine) during and following remdesivir, adverse reactions attributed to remdesivir, and mortality (in-hospital, 30-day, and 90-day). Results A total of 4 patients with underlying liver cirrhosis completed a 5-day course of remdesivir treatment. On admission, Child-Pugh class was A for 1 patient, B for 2 patients, and C for 1 patient. Causes for cirrhosis were nonalcoholic steatohepatitis (NASH), hepatic amyloidosis, and chronic hepatitis B. There were no acute elevations in aminotransferase levels or adverse events attributed to remdesivir therapy. Mortality was high with 50% in-hospital mortality. Of the 2 other patients who survived to discharge, one was discharged to home hospice and the other was readmitted within 30 days and expired during that admission. Conclusion Since there is limited data available using remdesivir in patients with advanced liver disease, we did not identify any safety concerns related to remdesivir in our cirrhotic patients. Mortality was high illustrating the poor outcomes of patients with advanced liver disease and COVID-19. Patients with cirrhosis should be offered remdesivir if clinically appropriate. Disclosures All Authors: No reported disclosures

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Cardiogenic Shock: Protocols, Teams, Centers, and Networks

US Cardiology Review ◽

10.15420/usc.2021.10 ◽

2021 ◽

Vol 15 ◽

Author(s):

Alex F Warren ◽

Carolyn Rosner ◽

Raghav Gattani ◽

Alex G Truesdell ◽

Alastair G Proudfoot

Keyword(s):

Cardiogenic Shock ◽

Systems Of Care ◽

Team Approach ◽

Hub And Spoke ◽

Disease States ◽

Outcome Relationship ◽

Challenges And Opportunities ◽

Potential Benefits ◽

Volume Outcome ◽

Poor Outcomes

The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary ‘shock team’ approach to CS management. A volume–outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of ‘shock hubs’ as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke ‘shock network’ approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.

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Impact of Sarcopenia on Survival and Clinical Outcomes in Patients With Liver Cirrhosis

Frontiers in Nutrition ◽

10.3389/fnut.2021.766451 ◽

2021 ◽

Vol 8 ◽

Author(s):

Mirabela-Madalina Topan ◽

Ioan Sporea ◽

Mirela Dănilă ◽

Alina Popescu ◽

Ana-Maria Ghiuchici ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Liver Cirrhosis ◽

Portal Hypertension ◽

Handgrip Strength ◽

Survival Rates ◽

Infectious Complications ◽

Skeletal Muscle Index ◽

Class B ◽

Impact On Survival ◽

Poor Outcomes

Background: Sarcopenia is now recognized more and more as a biomarker with poor outcomes in cirrhotic patients.Aims: The purpose of this study was to investigate the prevalence of sarcopenia in patients with liver cirrhosis and prospectively investigate the association between sarcopenia and different complications and its impact on survival.Material and Methods: This prospective study included patients with liver cirrhosis admitted to our department from 2018 to 2020. Sarcopenia was assessed according to EWGSOP2 criteria, incorporating low Handgrip strength (<27 kg for men and <16 kg for women) with low skeletal muscle index evaluated by CT (<50 for men and <39 for women). Associations between sarcopenia and portal hypertension-related complications, infectious complications, and risk of hepatocellular carcinoma, the number of in-hospital days, 30-day readmission, and survival over the next 6 and 12 months were analyzed.Results: A total of 201 patients were enrolled in the study, 63.2% male, mean age 61.65 ± 9.49 years, 79.6% Child-Pugh class B and C. The primary etiology of liver cirrhosis was alcohol consumption (55.2%). The prevalence of sarcopenia was 57.2 %, with no significant differences between the male and female groups. Significant associations were found between sarcopenia and portal hypertension-related complications, infectious complications, and risk of hepatocellular carcinoma. In multivariate analysis, sarcopenia was assessed as a risk factor alone, increasing the risk for ascites 3.78 times, hepatocellular carcinoma by 9.23 times, urinary tract infection by 4.83 times, and spontaneous peritonitis 2.49 times. Sarcopenia was associated with more extended hospital stay and higher 30 days readmission. Six months and 1-year survival were reduced in the sarcopenia group than in the non-sarcopenia group (p < 0.0001).Conclusion: Sarcopenia is a common complication of liver cirrhosis and associates with adverse health-related outcomes and poor survival rates.

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P0591AKI TREATMENT WITH CVVH IN THE ICU: A FIFTEEN MONTH SINGLE-CENTER EXPERIENCE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0591 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Bernardo Lucca ◽

Silvia Perletti ◽

Gabriele Mortari ◽

Paola Gaggia ◽

Roberto Zubani ◽

...

Keyword(s):

Septic Shock ◽

Liver Cirrhosis ◽

Mortality Rate ◽

Cardiogenic Shock ◽

Heart Surgery ◽

Femoral Vein ◽

Chronic Dialysis ◽

Single Center ◽

Dialysis Dose ◽

General Icus

Abstract Background and Aims AKI (Acute Kidney Injury) is a condition associated with elevated morbility and mortality. It determines prolonged hospitalization and severe long-term complications. AKI often complicates the course of patients’ stay in ICU (Intensive Care Units) sometimes requiring CRRT (Continuous Renal Replacement Therapy). Our aim was to prospectively analyze and report our experience on CRRT carried out in our hospital’s ICUs, and to compare it with guideline recommendations and with other international experiences. Method This is a single-center prospective observational study. We collected epidemiologic, clinical and technical data regarding all CRRT treatments performed in the four ICUs (two general ICUs and two cardiological ICUs) at the ASST Spedali Civili of Brescia Italy, between 02/01/2018 and 05/31/2019. AKI was defined according to KDIGO guidelines. Exclusion criteria were: age less than 16 years, chronic dialysis treatment, functioning kidney transplantation. All CRRT were provided in the CVVH (Continuous Veno-Venous Hemofiltration) mode. Results We included 146 incident patients (M: 103; 70%), mean age 71 ± 15 years. Most treatments were performed in the cardiological ICUs (58%) as opposed to the general ICUs (42%). AKI was present at the moment of admission to the ICU in 67% of patients. 53% of patients had previous CKD. The most frequent comorbidities were: hypertension (73%), diabetes (45%), ischemic heart disease (38%). The most frequent reasons for starting CVVH were: severe oliguria (88%) and fluid overload (68%). 57% of patients had stage 3 AKI. At the time of treatment initiation 55% of patients also had congestive heart failure, 52% metabolic acidosis, and 51% sepsis. 23% were recovering from heart surgery and 10% from general surgery. Mechanic ventilation was performed in 40% of patients, non-invasive ventilation in 28%. 82% of patients required vasoactive treatment. The average SOFA score was 10 ± 2,9. Technical details of CVVH prescription are reported in Fig 1. The most common vascular access was a dual lumen femoral vein catheter in 96% of cases. Citrate anticoagulation was used in 32% of treatments, heparin in 27%. Circuit coagulation was the most frequent cause for set substitution (45%). Treatments using citrate had fewer set coagulations compared to heparin (18% vs 32%). The average dialysis dose was 31,2 ml/kg/h. Median treatment duration was 7,6 days, median stay in the ICU was 14,3 days, median global hospitalization lasted 30,9 days. Mortality rate was 47% in the ICU and 64% 90 days after discharge. The most frequent causes of death were MOF (33%), septic shock (20%) and cardiogenic shock (14%). As illustrated in figure 2, multivariate analysis showed that mortality was negatively influenced by the presence of liver cirrhosis, septic shock, cardiogenic shock and rhabdomyolysis. After hospital discharge, 14 patients continued to require chronic dialysis. Conclusion Our experience shows that in patients with AKI requiring CVVH, mortality rate is negatively influenced by the presence of septic and cardiogenic shock, liver cirrhosis and rhabdomyolysis. Treatment prescription respected clinical and technical guideline recommendations, and is mostly comparable to the related international literature.

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Abstract 17185: Burden and Prognostic Significance of Thrombocytopenia in the Cardiac Intensive Care Unit: Insights From the Critical Care Cardiology Trials Network (CCCTN) Registry

Circulation ◽

10.1161/circ.142.suppl_3.17185 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Orly Leiva ◽

Danuzia S Silva ◽

David Berg ◽

Jianping Guo ◽

Vivian Baird-Zars ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Cardiogenic Shock ◽

Prognostic Significance ◽

Laboratory Data ◽

Circulatory Support ◽

Platelet Counts ◽

Normal Platelet ◽

Poor Outcomes

Introduction: Thrombocytopenia is associated with poor outcomes in general medical intensive care unit (ICU) populations; however, the burden and prognostic significance of thrombocytopenia in cardiac ICU (CICU) populations have not been rigorously studied. Methods: The Critical Care Cardiology Trials Network (CCCTN) is an investigator-initiated multicenter network of CICUs (n=25) in North America. Consecutive admissions to the CICU during annual snapshots (mostly 2 months) were submitted to the coordinating center (TIMI Study Group, Boston, MA) between September 2017 and September 2019. Patients were stratified by platelet counts on admission to the CICU and nadir platelet counts. Thrombocytopenia was classified as mild (100-149 K/uL), moderate (50-99 K/uL), or severe (<50 K/uL). Results: Of 8206 CICU admissions with complete laboratory data, 21.7% had thrombocytopenia (platelets <150 K/uL) on admission and 38.4% had thrombocytopenia at any point during their CICU course ( Fig-left ). Among those with normal platelet counts on admission (n=6423), 21.3% developed thrombocytopenia during their CICU course. Patients with thrombocytopenia on admission were more likely to have active cancer, underlying liver disease, and CKD as compared to those who did not (each p<0.001). Among patients with cardiogenic shock (n=1478), 56.8% had thrombocytopenia (mild: 28.6%; moderate: 19.4%; severe: 8.9%). Among patients managed with mechanical circulatory support (MCS) (n=926), 65.0% had thrombocytopenia (mild: 27.0%; moderate: 24.3%; severe: 13.7%). There were stepwise gradients of increasing CICU and in-hospital mortality associated with lower nadir platelet counts (p-trend <0.001) ( Fig-right ). Conclusions: Thrombocytopenia is common in CICU patients, including more than half of patients with cardiogenic shock and those managed with MCS. Thrombocytopenia is an adverse prognostic marker in CICU patients.

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Cardiogenic shock associated with verapamil in a patient with liver cirrhosis

The Lancet ◽

10.1016/0140-6736(90)92561-u ◽

1990 ◽

Vol 336 (8722) ◽

pp. 1079 ◽

Cited By ~ 3

Author(s):

G STEHLE

Keyword(s):

Liver Cirrhosis ◽

Cardiogenic Shock

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Impact of Age on Outcomes in Patients With Cardiogenic Shock

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.688098 ◽

2021 ◽

Vol 8 ◽

Author(s):

Manreet Kanwar ◽

Katherine L. Thayer ◽

Arthur Reshad Garan ◽

Jaime Hernandez-Montfort ◽

Evan Whitehead ◽

...

Keyword(s):

Cardiogenic Shock ◽

Older Patients ◽

Work Group ◽

Hospital Survival ◽

Comorbidity Burden ◽

Selection For ◽

Artery Disease ◽

Poor Outcomes ◽

Support Devices ◽

Stage D

Background: Advanced age is associated with poor outcomes in cardiovascular emergencies. We sought to determine the association of age, use of support devices and shock severity on mortality in cardiogenic shock (CS).Methods: Characteristics and outcomes in CS patients included in the Cardiogenic Shock Work Group (CSWG) registry from 8 US sites between 2016 and 2019 were retrospectively reviewed. Patients were subdivided by age into quintiles and Society for Cardiovascular Angiography & Interventions (SCAI) shock severity.Results: We reviewed 1,412 CS patients with a mean age of 59.9 ± 14.8 years, including 273 patients > 73 years of age. Older patients had significantly higher comorbidity burden including diabetes, hypertension and coronary artery disease. Veno-arterial extracorporeal membrane oxygenation was used in 332 (23%) patients, Impella in 410 (29%) and intra-aortic balloon pump in 770 (54%) patients. Overall in-hospital survival was 69%, which incrementally decreased with advancing age (p < 0.001). Higher age was associated with higher mortality across all SCAI stages (p = 0.003 for SCAI stage C; p < 0.001 for SCAI stage D; p = 0.005 for SCAI stage E), regardless of etiology (p < 0.001).Conclusion: Increasing age is associated with higher in-hospital mortality in CS across all stages of shock severity. Hence, in addition to other comorbidities, increasing age should be prioritized during patient selection for device support in CS.

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Abstract P278: Association of Alcohol Use With Poor Outcomes in Takotsubo Cardiomyopathy

Circulation ◽

10.1161/circ.141.suppl_1.p278 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Temidayo Abe ◽

Samuel Ogbuchi ◽

Taiwo Ajose ◽

Ajibola Babatunde ◽

Chinonyelum Nwagbara ◽

...

Keyword(s):

Atrial Fibrillation ◽

Alcohol Use ◽

Cardiogenic Shock ◽

Takotsubo Cardiomyopathy ◽

Female Patients ◽

Significant Difference ◽

Poor Outcomes ◽

Stratified Analysis ◽

The Impact ◽

Overall Mortality

Introduction: Recent studies have demonstrated poor outcomes in patients with takotsubo cardiomyopathy (TCM). It is important to determine the predictors of these outcomes for appropriate risk stratification and to decrease the overall disease burden. Physical stressors and preexisting heart failure have been associated with poorer outcomes, however, the impact of alcohol use (ETOH) has not been discussed. Aim: To determine if underlying alcohol use is associated with poorer outcomes in patients with TCM. Methods: We recruited 6750 patients from 2011, 2012 National Inpatient Sample, 6325 had TCM alone while 425 had TCM and ETOH use. Our outcomes of interest were overall mortality, mechanical hemodynamic support (MHS) acute respiratory failure(ARF), cardiac arrest (SCA), cardiogenic shock, and atrial fibrillation. All clinical characteristics were defined as per the International Classification of Diseases 9th revision (ICD-9) codes. Logistic regression was used to estimate the odds ratio of the outcomes in the study compared to the control group while stratified analysis was used to adjust for age and sex both accounting for underlying comorbidities. Results: There was no significant difference between the two groups in the rates of atrial fibrillation (11.1% vs 10.4%; P= 0.656), cardiogenic shock (6.2% vs 4.7%; P= 0.201), MHS (2.3% vs 1.4%; P= 0.221) and overall mortality (4.1% vs 3.8%; p=0.702). Rates of ARF (29.9%, vs 18.2%; P< 0.0001) and SCA (4.9% vs 3.0%; P=0.025) were higher in patients with TCM+ETOH compared to TCM alone. Table 1 displays the adjusted odds ratios for the outcomes. Compared to the participants with TCM alone, odd ratios of ARF was significantly higher in patients with TCM+ETOH. Table 2 displays the stratified analysis based sex. Compared with TCM alone, female patients with TCM+ETOH are more likely to develop ARF, cardiogenic shock and SCA. Conclusion: Preexisting alcohol use is associated with poorer outcomes in female patients with TCM.

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Abstract P158: USING CHA 2 DS 2 - VASC SCORE TO PREDICT CLINICAL OUTCOMES IN PATIENTS WITH INFECTIVE ENDOCARDITIS

Circulation ◽

10.1161/circ.141.suppl_1.p158 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Temidayo Abe ◽

Paul J Mather ◽

Banjo Olowu

Keyword(s):

Infective Endocarditis ◽

Cardiogenic Shock ◽

Valve Replacement ◽

Linear Models ◽

Assessment Tool ◽

Replacement Surgery ◽

Risk Stratification Tool ◽

The Mean ◽

Poor Outcomes ◽

Overall Mortality

Background: The CHA 2 DS 2 - VASC score is a well-validated stroke risk stratification tool in patients with non-valvular atrial fibrillation. Most of the clinical variables used have been associated with poor outcomes in patients with infective endocarditis (IE). We aim to determine its usefulness in predicting outcomes in patients with IE. Methods: We included 35,570 patients with IE from the national inpatient sample (2009 - 2012). CHA 2 DS 2 - VASC score was calculated for each patient. Hierarchical two-level logistic and linear models were used to estimate outcomes for CHA 2 DS 2 - VASC scores 1 to 8, using score 0 as the referent score. Outcomes of interest were overall in-hospital mortality, cardiogenic shock, atrioventricular block (AVB) and valve replacement. All clinical characteristics were defined per the ICD-9-CM codes. Results: The mean age of the sample was 59.81 +/- 18 years. Of the 35570 patients with IE, overall mortality rate was 11.4% (n= 4038/35570), cardiogenic shock 2.6 % (n=912/35570), AVB 4% (n=1426/35570) and 10.3% (n=3652/35570) required valve replacement. Higher CHA2DS2-VASc score were associated with increased mortality from 8.1 % for a score of 0 to 21.7 % for score of 8. Cardiogenic shock increased from 5.2% for a score of 0 to 24 % for a score of 3. AVB increased from 5.5% for score of 0 to 17.5% for score of 4. While valve replacement surgery increased from 1.3% for score of 0 to 3.8% for score of 5. Figure, 1 revealed the adjusted odds ratios for outcomes per CHA 2 DS 2 - VASC score 1 to 8, using 0 as the referent score, a higher score was significantly associated with increased odds for overall mortality, cardiogenic shock, AVB, and valve replacement. Conclusion: In patients with infective endocarditis, CHA2DS2-VASc score can serve as a risk assessment tool to predict outcomes.

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