Clinical Characteristics and Predictors of In-hospital Mortality in Patients with Cardiogenic Shock: Results from the RESCUE Registry

doi:10.21203/rs.3.rs-102981/v1

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Clinical Characteristics and Predictors of In-hospital Mortality in Patients with Cardiogenic Shock: Results from the RESCUE Registry

https://doi.org/10.21203/rs.3.rs-102981/v1

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published 01 Jun, 2021

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Background: In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean CS patients.

Methods: The RESCUE study is a multi-center, retrospective and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality.

Results: In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and non-ischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intra-aortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multi-variable analysis, age ≥70 years, cardiac arrest at presentation, vasoactive-inotrope score >80, continuous renal replacement therapy, and mechanical ventilator were independent predictors for in-hospital mortality.

Conclusions: The in-hospital mortality of CS patients remains high despite the high utilization of mechanical circulatory support. Age, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure were poor prognostic factors for in-hospital mortality.

Trial registration: RESCUE registry, Clinicaltrials.gov, NCT02985008, Registered 01 January 2014 - Retrospectively and Prospectively registered

https://clinicaltrials.gov/ct2/show/NCT02985008.

Critical Care & Emergency Medicine

Cardiac & Cardiovascular Systems

Cardiogenic shock

vasopressor

mechanical circulatory support

Cardiogenic shock (CS) is a circulatory failure related to insufficient supply of oxygen to tissues mainly driven by low cardiac output. Acute myocardial infarction (AMI) was reported to be the most common cause. In-hospital mortality of CS patients has decreased in recent years but remains high.(1) In particular, refractory CS, which refers to persistent shock despite appropriate volume resuscitation or use of inotropes or vasopressors, is lethal in more than half of hospitalized patients.(2) Recent advances of temporary mechanical hemodynamic support for patients with CS refractory to conventional medical therapy are expected to improve patient survival. However, a large-scale, randomized controlled trial showed that routine use of intra-aortic balloon pump (IABP) as the most popular mechanical circulatory support (MCS) did not improve survival in CS patients with complicating AMI.(3) However, advanced MCS devices such as Impella and extracorporeal membrane oxygenator (ECMO) showed favorable outcomes in several registries.(4, 5) Although several randomized controlled trials showed the benefit of early coronary intervention and some medication strategies,(6, 7) current therapeutic strategies remain empirical and not evidence-based in CS patients.(8) Therefore, we conducted the RESCUE registry to investigate overall characteristics and predictors of clinical outcomes regarding efficacy and safety of contemporary practices in CS patients.

Study Population

The RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock, NCT02985008 at www.clinicaltrials.gov) study is a multi-center registry of patients with CS aged over 19 years. A total of 1,247 patients from 12 tertiary centers between January 2014 and December 2018 was enrolled (Fig. 1). More detailed information regarding prospective and retrospective enrollments of each institute is shown in Supplementary Table 1. The inclusion criteria were as follows: 1) systolic blood pressure < 90 mmHg for 30 minutes or need for inotrope or vasopressor support to achieve a systolic blood pressure > 90 mmHg and 2) presence of pulmonary congestion and signs of impaired organ perfusion (altered mental status, cold periphery, oliguria < 0.5 mL/kg/h for the previous 6 h, or blood lactate > 2 mmol/L). Exclusion criteria were (1) out-of-hospital cardiac arrest and (2) evidence of septic or hypovolemic shock.

Data Collection and Outcomes

Data were collected using a web-based case record form. Additional information was obtained from medical records or by telephone contact, if necessary. The primary outcome was in-hospital mortality. The secondary outcome was altered neurological status upon discharge from the hospital, as assessed by the Glasgow-Pittsburgh Cerebral Performance Categories (CPC) scale (scores range from 1 to 5) (9). CPC scores of 1 and 2 were classified as favorable neurological outcomes, while CPC scores of 3, 4, and 5 were considered poor neurological outcomes. All-cause mortality was defined as death from any cause. The institutional review board of each hospital approved the study protocol and waived the requirement for written informed consent for patients enrolled in the retrospective registry. We obtained informed consent from the patients enrolled for prospective registry.

Statistical Analysis

Categorical variables were tested using the Chi-square test or Fisher’s exact test, as appropriate, and presented as number and relative frequency. Continuous variables were compared the using Student’s t-test and presented as mean ± standard deviation or median (25th – 75th percentile). A multi-variable Cox regression analysis was used to identify the predictors of in-hospital mortality in CS patients. For practical purpose, continuous variables were transformed into categorical variables, which were assessed by normal range or cut-off value as determined in previous studies. The covariates considered clinically relevant or that showed a univariate relationship with outcome (p ≤ 0.2) were entered into a multi-variable regression model. Clinically inter-correlated variables were excluded from the model. Statistical analyses were performed using R Statistical Software (version 3.2.5; R Foundation for Statistical Computing, Vienna, Austria) with p < 0.05 considered statistically significant.

Baseline Characteristics

Among the 1,293 patients enrolled in this study, 46 were excluded because of out-of-hospital cardiac arrest (n = 44) or withdrawal of consent (n = 2). Finally, 1,247 patients were analyzed for this study. Of them, 954 were enrolled retrospectively and 293 prospectively. A total of 419 patients (33.6%) died during index hospitalization. The characteristics of these patients are compared with those of other registries in Table 1.

Table 1

Clinical characteristics of patients hospitalized with cardiogenic shock in Korea compared with other registries
Variables	RESCUE	SHOCK Trial	CardShock	Cardiovascular Shock
Sample size	1,247	1,190	219	979
Region	Korea	USA	Europe	Japan
Time period	January 2014-December 2018	April 1993 - August 1997	October 2010-December 2012	May 2012-June2014
Demographics
Age (years)	65.6 ± 13.8	68.7 ± 11.8	68 ± 11	70.3 ± 14.2
Male (%)	860 (69.0)	710 (59.7)	162 (74.0)	645 (65.9)
Body mass index (kg/m²)	23.4 ± 3.6	–	26.5 (24.2–29.0)	–
Vital sign
Systolic blood pressure (mmHg)	73.5 ± 29.1	87.7 ± 22.3	78 ± 14	78.2 ± 15.7
Diastolic blood pressure (mmHg)	46.6 ± 19.9	52.3 ± 17.0	47 ± 10	–
Heart rate (beats/min)	82.8 ± 34.2	95.7 ± 26.2	90 ± 28	73.0 ± 48.7
Cardiac arrest as presentation	268 (21.5)	–	62 (28.3)	–
Comorbidities
Diabetes mellitus	443 (35.5)	388 (32.6)	62 (28.3)	252 (25.7)
Hypertension	660 (52.9)	632 (53.1)	132 (60.3)	545 (55.7)
Dyslipidemia	330 (26.5)	497 (41.8)	–	274 (28.0)
Current smoker	356 (28.5)	596 (50.1)	87 (39.7)	278 (28.4)
Chronic kidney disease	123 (9.9)	130 (10.9)	25 (11.4)	–
Peripheral arterial occlusive disease	52 (4.2)	213 (17.9)	–	–
Prior myocardial infarction	160 (12.8)	445 (37.4)	54 (24.7)	–
Prior cerebrovascular accident	119 (9.5)	–	20 (9.1)	–
Acute coronary syndrome	894 (75.1)	1190 (100)	177 (80.8)	499 (51.0)
Left ventricular ejection fraction, %	35.9 ± 16.3	32.6 ± 13.8	33 ± 14	45.0 (30.0–60.0)
Laboratory
Hemoglobin (g/dL)	12.7 ± 2.6	12.9 ± 2.5	12.8 ± 2.2	–
Serum creatinine (mg/dL)	1.6 ± 1.4	1.4 ± 1.4	1.0 (0.8–1.4)	–
Glucose (mg/dL)	223 ± 119	208 ± 105	250 ± 139	–
Lactate (mmol/L)	6.5 ± 4.7	5.4 ± 3.9	2.8 (1.7–5.8)	–
Managements
Vasopressor	1,081 (86.7)	–	–	–
Mechanical ventilator	709 (56.9)	–	–	–
Continuous renal replacement therapy	285 (22.9)	–	–	–
Intra-aortic balloon pump	314 (25.2)	–	–	–
Extracorporeal membrane oxygenator	496 (39.8)	–	–	–
In-hospital mortality, %	419 (33.6)	731 (61.4)	80 (36.5)
30-day mortality, %				336 (34.3)

The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and non-ischemic ventricular arrhythmia (2.5%). Baseline characteristics are shown in Table 2. Compared with survivors, non-survivors were older and had lower body mass index, systolic blood pressure, diastolic blood pressure, left ventricular ejection fraction, and hemoglobin but higher aspartate transaminase, serum creatinine, glucose, and lactate levels. Furthermore, non-survivors had a higher incidence of comorbidities such as diabetes mellitus, hypertension, chronic kidney disease, and prior MI and were more often female, showed cardiac arrest at presentation, and had an ischemic cause.

Table 2

Baseline patient characteristics
Variables	Overall (n = 1247)	Survivors (n = 828)	Non-survivors (n = 419)	p-value
Age (years)	65.6 ± 13.8	64.0 ± 13.7	68.8 ± 13.6	< 0.001
Male	860 (69.0)	588 (71.0)	272 (64.9)	0.028
Body mass index (kg/m²)	23.4 ± 3.6	23.6 ± 3.6	23.1 ± 3.4	0.038
Systolic blood pressure (mmHg)	73.5 ± 29.1	76.6 ± 27.2	67.1 ± 31.7	< 0.001
Diastolic blood pressure (mmHg)	46.6 ± 19.9	48.6 ± 19.0	42.6 ± 21.1	< 0.001
Heart rate (beats/min)	82.8 ± 34.2	82.8 ± 32.0	82.8 ± 38.3	0.992
Cardiac arrest as presentation	268 (21.5)	102 (12.3)	166 (39.6)	< 0.001
Clinical presentation
Ischemic cause	1006 (80.7)	666 (80.4)	340 (81.1)	0.764
ST-segment elevation MI	355 (42.9)	355 (42.9)	202 (48.2)	0.073
Comorbidities
Diabetes mellitus	443 (35.5)	270 (32.6)	173 (41.3)	0.002
Hypertension	660 (52.9)	419 (50.6)	241 (57.5)	0.021
Dyslipidemia	330 (26.5)	227 (27.4)	103 (24.6)	0.284
Current smoker	356 (28.5)	262 (31.6)	94 (22.4)	0.001
Chronic kidney disease	123 (9.9)	58 (7.0)	65 (15.5)	< 0.001
Peripheral arterial occlusive disease	52 (4.2)	30 (3.6)	22 (5.3)	0.174
Prior MI	160 (12.8)	95 (11.5)	65 (15.5)	0.044
Prior cerebrovascular accident	119 (9.5)	70 (8.5)	49 (11.7)	0.066
Left ventricular ejection fraction, %	35.9 ± 16.3	39.2 ± 15.8	28.3 ± 14.8	< 0.001
Laboratory
Hemoglobin (g/dL)	12.7 ± 2.6	12.9 ± 2.5	12.2 ± 2.7	< 0.001
Platelets (x10³/µL)	211.0 ± 81.5	217.6 ± 80.4	197.9 ± 82.2	< 0.001
Total bilirubin (mg/dL)	1.0 ± 1.8	1.0 ± 1.9	1.1 ± 1.6	0.501
Aspartate transaminase (U/L)	257 ± 990	210 ± 891	348 ± 1154	0.022
Alanine transaminase (U/L)	144 ± 462	128 ± 464	177 ± 456	0.080
Serum creatinine (mg/dL)	1.6 ± 1.4	1.4 ± 1.4	1.8 ± 1.4	< 0.001
Glucose (mg/dL)	223 ± 119	208 ± 105	250 ± 139	< 0.001
Lactate (mmol/L)	6.5 ± 4.7	5.4 ± 3.9	8.4 ± 5.2	< 0.001
Values are mean ± standard deviation or n (%).
MI, myocardial infarction; NT-proBNP, N-terminal pro b-type natriuretic peptide

In-hospital Management and Outcomes

In-hospital management procedures are shown in Table 3. Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). MCS was used in 745 patients (59.7%), while IABP was used in 314 patients (25.2%) and ECMO in 496 patients (39.8%). Combined implementation of IABP and ECMO was performed in 29 patients (2.3%). Compared with survivors, non-survivors received more extracorporeal CPR and had higher of use of dopamine, epinephrine, norepinephrine, mechanical ventilator, continuous renal replacement therapy, IABP, and ECMO. Vasoactive-inotropic score was also higher in non-survivors. Kaplan-Meier curves showed favorable survival in non-arrest patients (vs. arrest patients) and those with vasoactive inotrope score < 80 (vs. ≥ 80), BMI < 25 kg/m² (vs. ≥ 25 kg/m²), and lactate < 8 mmol/L (vs. ≥ 8 mmol/L) (Fig. 2).

Table 3

In-hospital management methods
Variables	Overall (n = 1247)	Survivors (n = 828)	Non-survivors (n = 419)	p-value
Dopamine	790 (63.4)	496 (59.9)	294 (70.2)	< 0.001
Epinephrine	86 (6.9)	30 (3.6)	56 (13.4)	< 0.001
Norepinephrine	715 (57.3)	405 (48.9)	310 (74.0)	< 0.001
Vasoactive-Inotropic Score	73.4 ± 136.5	46.0 ± 124.3	127.5 ± 143.4	< 0.001
Mechanical ventilator	709 (56.9)	347 (41.9)	362 (86.4)	< 0.001
Continuous renal replacement therapy	285 (22.9)	89 (10.7)	196 (46.8)	< 0.001
Intra-aortic balloon pump	314 (25.2)	193 (23.3)	121 (28.9)	0.032
Extracorporeal membrane oxygenator	496 (39.8)	239 (28.9)	257 (61.3)	< 0.001
Extracorporeal cardiopulmonary resuscitation	240 (19.2)	81 (9.8)	159 (37.9)	< 0.001
ICU stay, days	11.6 ± 23.7	11.7 ± 22.3	11.2 ± 26.2	0.683
Hospital stay, days	19.2 ± 29.5	21.9 ± 29.4	13.8 ± 29.0	< 0.001
Values are mean ± standard deviation or n (%).
ICU, intensive care unit

Among 496 patients treated with ECMO, 406 received a percutaneous approach (81.9%), a distal perfusion catheter was inserted in 187 (37.7%), and left heart decompression was present in 26 (5.2%). In addition, 240 patients (48.4%) received extracorporeal cardiopulmonary resuscitation, and the median CPR to pump-on time was 31 minutes (interquartile range; 15–49), while the shock to ECMO time was 86 minutes (42–261). Successful weaning was achieved in 266 patients (53.6%), and those who survived to discharge numbered 239 (48.2%).

Of survivors, poor neurologic outcome was noted in 39 (4.7%), 10 with CPC 4 (1.2%) and 29 with CPC 3 (3.5%). Good neurologic outcome was noted in 58 patients with CPC 2 (7.0%) and 731 with CPC 1 (88.3%).

Predictors of In-hospital Mortality

In multi-variable analysis, age ≥ 70 years, cardiac arrest at presentation, vasoactive-inotrope score > 80, continuous renal replacement therapy, and mechanical ventilator were independent predictors for in-hospital mortality (Table 4).

Table 4

Predictors for in-hospital mortality
	Multi-variable analysis
	Adjusted HR	95% CI	p-value
Age ≥ 70 years	1.71	1.33–2.20	< 0.001
Sex, male	0.82	0.64–1.03	0.091
Body mass index, kg/m²	1.00	0.97–1.03	0.833
Cardiac arrest at presentation	1.51	1.17–1.95	0.002
Ischemic etiology	1.25	0.94–1.66	0.134
Hypertension	1.06	0.84–1.35	0.617
Diabetes mellitus	0.99	0.78–1.27	0.955
Current smoking	0.90	0.68–1.19	0.451
Prior history of chronic kidney disease	1.02	0.75–1.39	0.910
Prior history of myocardial infarction	0.96	0.72–1.29	0.789
Hemoglobin, g/dL	1.04	0.99–1.09	0.077
Serum glucose, g/dL	1.00	1.00–1.00	0.083
Transaminase > 1000 U/L	1.45	0.93–2.25	0.098
Vasoactive-inotrope score > 80	2.11	1.70–2.61	< 0.001
Continuous renal replacement therapy	1.54	1.23–1.93	< 0.001
Mechanical ventilator	2.32	1.66–3.23	< 0.001
Intra-aortic balloon pump	1.27	0.99–1.63	0.055
Extracorporeal membrane oxygenator	1.22	0.92–1.61	0.167
CI, confidence interval; HR, hazard ratio
Adjusted variables are age ≥ 70 years, sex, body mass index, cardiac arrest at presentation, ischemic etiology, hypertension, diabetes mellitus, current smoking, prior history of chronic kidney disease and myocardial infarction, hemoglobin, glucose level, transaminase > 1000 U/L, vasoactive-inotrope score > 80, continuous renal replacement therapy, mechanical ventilator, intra-aortic balloon pump, and extracorporeal membrane oxygenator.

We investigated clinical characteristics and predictors of clinical outcomes in CS patients treated with contemporary management from a large-scale, multi-center registry. This study demonstrated the actual state of CS in Korea. The major findings of this study were: (1) in-hospital mortality of CS patients remains high, (2) dopamine and norepinephrine were used as first-line vasopressors, (3) more than half of the patients required MCS devices, and (4) old age, cardiac arrest, high-dose vasopressor, and organ failure were independent predictors of in-hospital mortality.

Cardiogenic shock is a critical illness with a very high rate of fatality. However, most treatment modalities have been tested only empirically with no solid supporting evidence because randomized controlled trials are very difficult to perform in this vulnerable patient subset. For example, over 20 years, there have been only three major randomized controlled trials, mostly in the AMI patients. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial established the role of early coronary revascularization in AMI patients complicated by CS (10). The Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial showed that routine IABP did not reduce patient mortality. The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial showed that multi-vessel PCI did improve clinical outcome.(11, 12)

On the contrary, the registry studies cover a variety of causes of CS. However, those previous studies were relatively small in sample size or were associated with a lower rate of MCS device use, which does not reflect current practice. The CardShock study, a European, multi-center registry, was conducted between 2010 and 2012 but included only 219 patients, 13 of whom were treated with ventricular assist device or ECMO. (13–15) The Japanese Circulation Society Cardiovascular Shock registry conducted between 2012 and 2014 was the largest registry of CS, enrolling 979 patients, (16) but that study did not collect information on vasopressor or MCS usage. The RESCUE study is the largest multi-center, real-world registry of CS patients with a broad spectrum of etiologies. More than half of enrolled patients have received either IABP or ECMO, representing contemporary management of more severe forms of CS. Still, in this study, a total of 419 patients (33.6%) died at index hospitalization, which is consistent with the 30–40% mortality reported in other studies performed in the early 2010s. These findings suggest that the mortality rate of AMI patients complicated by CS may plateau over time despite introduction of new devices and techniques improving coronary artery revascularization. Further, beneficial hemodynamic support may be masked by MCS-related complications such as limb ischemia, systemic embolization, and fatal bleeding in CS patients treated with MCS.

The prognostic factors found in this study were consistent with those reported in previous studies. Indices of organ failure such as acute kidney injury requiring continuous renal replacement therapy and respiratory failure requiring mechanical ventilator were significant prognostic factors for in-hospital mortality.(15, 16) Cardiac arrest was also a prognostic factor for in-hospital mortality. Our group showed that extracorporeal cardiopulmonary resuscitation had a survival benefit over the conventional approach used in a previous study.(17) Future research regarding optimal strategy of extracorporeal cardiopulmonary resuscitation is needed to improve the mortality rate seen with this RESCUE registry. High vasoactive-inotrope score was a powerful indicator of in-hospital mortality in this study. Recently, our group showed that a high level of vasoactive inotropic support during the first 48 hours was significantly associated with increased in-hospital mortality in adult CS patients.(18) Basically, inotropes or vasopressors can improve hemodynamics in the acute stage through increased myocardial contractility or modification of vascular tone. However, these agents can also be related to adverse cardiovascular events such as hypertension/hypotension, arrhythmias, peripheral, and cardiac ischemia, which may be fatal.(19) Accordingly, the decision whether to increase vasopressor dosage or apply advanced MCS in patients who have already received high-dose vasopressor should be carefully weighed after considering a risk-benefit analysis.

Limitations

Our study has several limitations. First, most patients presented with an ischemic etiology, and patients with non-ischemic cause were heterogeneous and of limited sample size. Second, this registry did not include all mechanical circulatory support because Impella is not currently available in Korea. Third, treatment of CS such as type and amount of fluids and vasopressor/inotropes administered and type and timing of MCS were left to the physician’s discretion, although coronary intervention was based on the guidelines of the Korean Circulation Society.

The in-hospital mortality of CS patients remains high despite high utilization of MCS. Age, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure were poor prognostic factors for in-hospital mortality.

AMI = Acute myocardial infarction

BMI = Body mass index

CI = Confidence interval

CPC = Cerebral performance categories

CS = Cardiogenic shock

ECMO = Extracorporeal membrane oxygenator

IABP = Intra-aortic balloon pump

Ethical Approval and Consent to participate

The institutional review board of each hospital approved the study protocol and waived the requirement for written informed consent for patients enrolled in the retrospective registry. We obtained informed consent from the patients enrolled for prospective registry.

Availability of supporting data

The data that support the findings of this study are available from [Hyeon-Cheol Gwon] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [Hyeon-Cheol Gwon].

Competing interests

The authors declare that they have no competing interests.

Funding: None

Authors' contributions

JHY collected data, conceived of the study, and contributed to interpretation of the data as well as to drafting the manuscript. KHC performed analysis and interpretation of the data and drafted the manuscript. Y-GK collected data and made critical revision of the manuscript for key intellectual content. C-MA collected data and made critical revision of the manuscript for key intellectual content. CWY collected data and made critical revision of the manuscript for key intellectual content. WJC collected data and made critical revision of the manuscript for key intellectual content. WJJ collected data and made critical revision of the manuscript for key intellectual content. H-JK collected data and made critical revision of the manuscript for key intellectual content. BSK collected data and made critical revision of the manuscript for key intellectual content. J-WB collected data and made critical revision of the manuscript for key intellectual content. SYL collected data and made critical revision of the manuscript for key intellectual content. SUK collected data and made critical revision of the manuscript for key intellectual content. H-JL collected data and made critical revision of the manuscript for key intellectual content. WSL collected data and made critical revision of the manuscript for key intellectual content. J-OJ collected data and made critical revision of the manuscript for key intellectual content. S-DP collected data and made critical revision of the manuscript for key intellectual content. S-HL collected data and made critical revision of the manuscript for key intellectual content. SC collected data and made critical revision of the manuscript for key intellectual content. TKP collected data and contributed to interpretation of the data as well as to drafting the manuscript. JML collected data and contributed to interpretation of the data as well as to drafting the manuscript. YBS collected data and contributed to interpretation of the data as well as to drafting the manuscript. J-YH collected data and contributed to interpretation of the data as well as to drafting the manuscript. H-CG collected data and supervised the interpretation of the data as well as the drafting of the manuscript.

Acknowledgements: None

Consent for Publication

The Author hereby grants the Publisher permission to publish the work.

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Prospective and retrospective enrollments of each institute
Additionalfile1.docx
Prospective and retrospective enrollments of each institute
Additionalfile1.docx
Prospective and retrospective enrollments of each institute

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Clinical Characteristics and Predictors of In-hospital Mortality in Patients with Cardiogenic Shock: Results from the RESCUE Registry

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Abstract

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Introduction

Methods

Study Population

Data Collection and Outcomes

Statistical Analysis

Results

Baseline Characteristics

In-hospital Management and Outcomes

Predictors of In-hospital Mortality

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Supplementary Files

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