Right Ventricular Dysfunction Is Common and Identifies Patients at Risk of Dying in Cardiogenic Shock

Pankaj Jain, Katherine L. THAYER, Jacob ABRAHAM, Kay D. EVERETT, Mohit PAHUJA, Evan H. WHITEHEAD, Benjamin P. SCHWARTZ, Anuradha LALA, Shashank S. SINHA, Manreet K. KANWAR, A. Reshad GARAN, Jaime A. HERNANDEZ-MONFORT, Claudius MAHR, Esther VOROVICH, Detlef WENCKER, James M. MCCABE, Tara JONES, Maithri GOUD, Paulina BACA, Neil HARWANIDaniel BURKHOFF, NAVIN K. KAPUR

Research output: Contribution to journalArticlepeer-review

28 Scopus citations

Abstract

Background: Understanding the prognostic impact of right ventricular dysfunction (RVD) in cardiogenic shock (CS) is a key step toward rational diagnostic and treatment algorithms and improved outcomes. Using a large multicenter registry, we assessed (1) the association between hemodynamic markers of RVD and in-hospital mortality, (2) the predictive value of invasive hemodynamic assessment incorporating RV evaluation, and (3) the impact of RVD severity on survival in CS. Methods and Results: Inpatients with CS owing to acute myocardial infarction (AMI) or heart failure (HF) between 2016 and 2019 were included. RV parameters (right atrial pressure, right atrial/pulmonary capillary wedge pressure [RA/PCWP], pulmonary artery pulsatility index [PAPI], and right ventricular stroke work index [RVSWI]) were assessed between survivors and nonsurvivors, and between etiology and SCAI stage subcohorts. Multivariable logistic regression analysis determined hemodynamic predictors of in-hospital mortality; the resulting models were compared with SCAI staging alone. Nonsurvivors had a significantly higher right atrial pressure and RA/PCWP and lower PAPI and RVSWI than survivors, consistent with more severe RVD. Compared with AMI, patients with HF had a significantly lower RA/PCWP (0.58 vs 0.66, P = .001) and a higher PAPI (2.71 vs 1.78, P < .001) and RVSWI (5.70 g-m/m2 vs 4.66 g-m/m2, P < .001), reflecting relatively preserved RV function. Paradoxically, multiple RVD parameters (PAPI, RVSWI) were associated with mortality in the HF but not the AMI cohort. RVD was more severe with advanced SCAI stage, although its prognostic value was progressively diluted in stages D and E. Multivariable modelling incorporating the RA/PCWP improved the predictive value of SCAI staging (area under the curve [AUC] 0.78 vs 0.73, P < .001), largely driven by patients with HF (AUC 0.82 vs 0.71, P < .001). Conclusions: RVD is associated with poor outcomes in CS, with key differences across etiology and shock severity. Further studies are needed to assess the usefulness of RVD assessment in guiding therapy.

Original languageEnglish
Pages (from-to)1061-1072
Number of pages12
JournalJournal of Cardiac Failure
Volume27
Issue number10
DOIs
StatePublished - Oct 2021

Keywords

  • Acute Myocardial Infarction
  • Cardiogenic shock
  • Right ventricular dysfunction
  • heart failure
  • hemodynamics
  • mortality

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