2998Contemporary and real-life picture of cardiogenic shock in France: a descriptive analysis of the FRENSHOCK multicenter prospective registry

Abstract

Background: Epidemiologic data about cardiogenic shock (CS) are still poor. Moreover, previous studies focused on ischemic CS, forgetting all part of the CS encountered in clinical practice. We conducted a large, prospective and multicentric registry of non-selected CS patients admitted in cardiac and general critical care units. Method(s): FRENSHOCK registry (Clinicaltrials.gov: NCT02703038) was a multicenter survey realized during a 6 month period (April to October 2016) in France. Patients were prospectively included regardless of the CS etiology if they met at least one criterion for each of the following three points: (1) a low cardiac output defined by a systolic blood pressure (SBP) <90mmHg and/or the need of amines to maintain SBP >90 mmHg, or a low cardiac output defined by cardiac index <2.2L/min/m2 on echocardiography or right heart catheterization; (2) an elevation of the left and/or right heart pressures defined by clinical or radiological, or biological (NtproBNP/BNP), or echocardiographical, or invasive hemodynamics overload signs; and (3) a clinical (oliguria, marbling, confusion) and/or biological hypoperfusion (lactates >2mmol/L, hepatic failure, renal failure). Result(s): 772 patients were included in 48 centers (male 71.5%, mean age of 65.7y +/-14.9). Comorbidities were classical: previous coronary revascularization 26.2%, history of extra cardiac arterial disease 14.8%, previous renal failure 21.3% and COPD 6.5%. Cardiovascular risk factors included diabetes (28.2%), active tobacco (27.8%), dyslipidemia (35.2%) and hypertension (47.2%). 56% were known for previous cardiomyopathy (especially 29.8% ischemic origin, 10.1% idiopathic, valvular 8.4%). CS etiology often associated several triggers but ischemic was retained for only 36.4% (n=281) of patients with type 1 infarction for 17.4% (n=134). Non-ischemic trigger factors were predominant (n=491; 63.9%): supra ventricular (13.2%) and ventricular arrythmia (12.6%), infection (11.9%), iatrogenic (6.1%), conductive disorders (2.3%), non-observance (3.5%), and others (13.7%). At admission median SBP was 101.2 mmHg +/-25.2. Sinusal rhythm was present in only 52.1%. Right heart failure signs were present in 49.2% and left signs in 71.9% (Killip IV for 48.7%). Biological analysis found signs of hypoperfusion with high lactate (3.0 95% CI [2.0-4.8]), renal (eGFR 49.6+/-26.8 ml/min/m2) and hepatic alteration (ASAT 90.0 UI/ml, 95% IC [39-300]; Prothrombin time 57.1+/-25.4%). Biventricular failure was frequent (LVEF was 26.3% +/-13.4; TAPSE 13.4mm +/-5). When realized (n=399; 51.7%) coronarography was pathological in 81.3% (n=321) (monotroncular 31.1%, bitroncular 35% and tritroncular 33.9%). A culprit lesion was found in 78.8% and concern LVA in 48.4%, RCA in 22.6% and left main in 15.3%. Conclusion(s): This large multicentric and prospective registry confirmed the heterogeneity of CS in terms of etiology, presentation and prognosis with a predominance of non-ischemic CS in practice.