Study reports prevalence of different types of shock in COVID-19 patients
A new analysis of the database of critically ill patients with COVID-19-related pneumonia, published in the American Journal of Cardiology and conducted at Hackensack Meridian Hackensack University Medical Center (HUMC), is the first study to report the prevalence of different types of shock in patients with COVID-19. Defining these subgroups can help tailor therapy to the underlying causes of hemodynamic abnormalities.
The study showed that the incidence of cardiogenic shock in this population, characterized by a low ejection fraction and a low cardiac index, was 10%. This group can benefit from inotropic or mechanical support. Another group with preserved ejection fraction but low cardiac output may respond to volume expansion therapy. Thus, the study may provide better therapeutic approaches to the shock associated with COVID-19.
The study authors note that patients with COVID-19 and respiratory failure frequently develop shock, some of which is cardiogenic, a potentially fatal disease in which the heart cannot pump enough blood to meet the needs of the patient. body.
Potential mechanisms of myocardial injury in COVID-19 include direct injury due to viral infection, consequences of the immune response to COVID, ischemia, deregulation of the renin-angiotensin system, a hormonal system that regulates blood pressure, fluids and electrolytes; and dysfunctional coronary endothelium, a type of non-obstructive coronary artery disease.
HUMC has established a comprehensive prospective database of patients admitted with COVID-19 as of March 2, 2020, including demographics, clinical characteristics, laboratory values, and clinical outcomes (the RealWorld Database). From this database, patients in shock were identified.
Patients in shock who underwent echocardiograms were identified and examined, with ejection fraction measurement (EF, the percentage of blood that the heart ejects with each beat, with a normal value of 60-65%) and cardiac index (CI, the total flow pumped by the heart indexed to the size of the body).
Of 1,275 patients hospitalized at HUMC for COVID pneumonia between March 2 and May 31, 2020, 215 had shock requiring vasopressors, of which 156 had echocardiography to assess ventricular function and stroke volume. The mean age was 67, the mean ejection fraction was 59.5, and the mean cardiac index was 2.40. Patients were divided into 4 subgroups defined by EF and CI: 15 had low EF and low CI, 8 had low EF and normal CI, 55 had preserved EF and low CI, and 73 had preserved EF and normal CI. Overall hospital mortality was 73 percent. Mortality was highest in the group with a low cardiac index and a low 87 percent ejection fraction.
“Given the potential mechanisms by which COVID-19 may impact myocardial function, the presence of a low ejection fraction and a low cardiac index in this group of critically ill patients is not surprising.” said Steven M. Hollenberg, MD, cardiologist at Heart & Vascular Hospital, Hackensack University Medical Center, who performed the analysis and with his colleagues wrote the manuscript.
A low cardiac index despite the preservation of the ejection fraction suggests an underfilling of the left ventricle in these patients, who could benefit from additional blood volume. Hemodynamic assessment of COVID patients in shock by specific subgroups may help tailor treatment to the underlying causes of detected hemodynamic abnormalities. “
Steven M. Hollenberg, MD, Cardiologist, Heart and Vascular Hospital, Hackensack University Medical Center
Joseph E. Parrillo, MD, President, Heart & Vascular Hospital, HUMC, said: âThis study shows the ability of clinical research databases to answer important clinical questions about possible mechanisms and the best potential treatments for our patients with serious illnesses such as shock. due to COVID-19. “
âAt HUMC, we are always striving to innovate and find various treatment modalities, including for COVID, to serve our patients, our community and our team members,â said Lisa Tank, MD, Chief Medical Officer by HUMC. “This includes conducting important clinical research. I am proud of the efforts of Dr. Hollenberg and the team at Heart & Vascular Hospital to better understand how to treat patients with this virus.”
Hollenberg, SM, et al. (2021) Hemodynamic profiles of shock in patients with COVID-19. American Journal of Cardiology. doi.org/10.1016/j.amjcard.2021.05.029.