Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis.

BACKGROUND: Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock. MAIN BODY: Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42). CONCLUSION: Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Effectiveness of specialised support surface modes in preventing pressure injuries in intensive care: A systematic review and meta-analysis.

BACKGROUND: Patients in intensive care units (ICU) are at an increased risk of pressure injuries. In ICUs, specialised support surfaces are an intervention often used to prevent pressure injuries. This systematic review and meta-analysis aimed to ascertain the effectiveness of different specialised support surface modes for preventing pressure injuries to adult ICU patients. METHODS: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, PEDro, Cochrane Library, Clinicaltrials.gov and eligible paper references were searched for appropriate studies. Studies were included if they investigated both dynamic support surface modes low-air-loss (LAL) and alternating pressure (AP), involved adult ICU patients (≥18 years old), and investigated pressure injury incidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Mixed Methods Appraisal Tool (MMAT) checklists were used for reporting and quality assessment. Risk ratios (RRs) with 95 % Confidence Intervals (CIs) were used to summarise pressure injury incidence. The pooled RR was calculated with the random-effects model using the Mantel-Haenszel method. Further secondary analysis examined length of stay (LoS) and severity of illness. RESULTS: The four included studies involved 3,308 patients. These studies were heterogeneous in design. When AP surface mode was compared with LAL surface mode, there was no significant difference in the occurrence of pressure injury (8.9 % versus 10.9 %, RR 0.64). Mattress mode also had no direct association with length of stay and severity of illness. CONCLUSION: This systematic review and meta-analysis found no significant difference in the effectiveness of LAL and AP support surface modes in preventing pressure injuries in adult ICU patients. IMPLICATIONS FOR CLINICAL PRACTICE: Clinicians should remember that mattresses are just one element within strategies to prevent pressure injuries in ICUs. The equivocal findings of this systematic review highlight the complexity of preventing pressure injuries and underscore the importance of holistic nursing care.

The management of heart failure cardiogenic shock: an international RAND appropriateness panel.

BACKGROUND: Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF. METHODS: A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1-3 as inappropriate, 4-6 as uncertain and as 7-9 appropriate). RESULTS: Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS. CONCLUSION: This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines.

The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review.

Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.

Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach.

BACKGROUND: Current practice in cardiogenic shock is guided by expert opinion in guidelines and scientific statements from professional societies with limited high quality randomized trial data to inform optimal patient management. An international panel conducted a modified Delphi process with the intent of identifying aspects of cardiogenic shock care where there was uncertainty regarding optimal patient management. METHODS: An 18-person multidisciplinary panel comprising international experts was convened. A modified RAND/University of California Los Angeles appropriateness methodology was used. A survey comprising 70 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9: 1 to 3 inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. A summary of the results was discussed as a group, and the survey was iterated and completed again before final analysis. RESULTS: There was broad alignment with current international guidelines and consensus statements. Overall, 44 statements were rated as appropriate, 19 as uncertain, and 7 as inappropriate. There was no disagreement with a disagreement index <1 for all statements. Routine fluid administration was deemed to be inappropriate. Areas of uncertainty focused panel on pre-PCI interventions, the use of right heart catheterization to guide management, routine use of left ventricular unloading strategies, and markers of futility when considering escalation to mechanical circulatory support. CONCLUSIONS: While there was broad alignment with current guidance, an expert panel found several aspects of care where there was clinical equipoise, further highlighting the need for randomized controlled trials to better guide patient management and decision making in cardiogenic shock.