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Seasonal trends of incidence and outcomes of cardiogenic shock : findings from a large, nationwide inpatients sample with 441,696 cases
Critical Care ( IF 8.8 ) Pub Date : 2021-09-06 , DOI: 10.1186/s13054-021-03656-9
Peter Moritz Becher _{1,

2} , Benedikt Schrage _{1,

2} , Alina Goßling ₁ , Nina Fluschnik _{1,

2} , Moritz Seiffert _{1,

2} , Alexander M Bernhardt ₃ , Hermann Reichenspurner ₃ , Paulus Kirchhof _{1,

2} , Stefan Blankenberg _{1,

2} , Dirk Westermann _{1,

2} ,

Affiliation

An increase in the annual incidence of cardiogenic shock (CS) and a growing sub-population of patients without acute myocardial infarction (AMI) was documented in Germany [1]. However, contemporary data regarding seasonal trends of CS irrespective of the underlying cause are rare.

In this study, we aimed to analyze seasonal trends of (i) incidence; (ii) patient characteristics; and (iii) outcomes in a nation-wide sample of more than 400,000 CS cases between 2005 and 2017 in Germany.

For the present analyses, all CS cases (ICD-10-GM code R57.0) in patients ≥ 18 years between 2005 and 2017 in Germany were included. Patients were categorized based on admission in one of four groups: spring, summer, fall, and winter.

Temperature-related morbidity and mortality is a growing public health issue. Several studies outside Germany demonstrated more fatal and nonfatal cardiovascular events in the winter than in the summer [2], but contemporary data is missing. We show in our study: the highest incidence of CS was recorded during the winter, while the lowest incidence of CS was observed in the summer. The number of patients admitted with CS in the winter exceeded those in the summer by almost 10,000 (Table 1). Our study also revealed that in-hospital mortality of CS patients was higher in the winter than in the summer (winter vs. summer, n = 70,727 (61.1%) vs. n = 62,379 (58.8%), p < 0.001) (Fig. 1). Additionally, we found that patients admitted with CS in the winter were slightly older than in those admitted in the summer (winter vs. summer, mean age 71.1 (± 13.6) vs. 70.8 (± 13.8), whereas sex did not differ over the seasons (p = 0.8). Notably, incidence of AMI, pre-hospital and in-hospital cardiac arrest among CS patients varied across seasons as well (p < 0.001). This is in line with previous studies showing increased incidence of sudden cardiac death in the winter [3].

Table 1 Overall seasonal trends of CS cases in Germany from 2007 to 2015

Full size table

The field of temporary mechanical circulatory support (MCS) to manage patients with CS enhanced in the last decade [4]. In this study, intra-aortic balloon pump (IABP) was the most used assist device, followed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist device (LVAD) in CS patients, illustrating the perceived clinical need for MCS devices.

The multidisciplinary shock team approach utilizing protocol-driven care appears to be feasible and to reduce mortality in patients with refractory CS [5, 6]. However, the extent to which the shock team approach and associated outcomes are affected by seasonal variations remains unclear. Further studies have to elucidate whether prolonged transport time due to adverse weather conditions, atherosclerotic/thrombotic incidences in terms of AMI, and time-dependent care processes are influenced by seasonal variations and/or lower temperatures.

The strengths of this study are the large sample size and the well-validated database. Clinical variables such as laboratory values, physiological markers and follow-up data beyond the hospital stay were unfortunately not available in this administrative dataset. The exact time course of the different diagnoses e.g. being prevalent at admission or incident during the hospital stay was not possible to assess in this administrative dataset. This potential bias/confounding has to be taken under consideration when interpreting our results. Finally, validation of our results outside of Germany is needed.

In this nation-wide cohort of more than 400,000 CS patients, incidence and in-hospital mortality of CS varied substantially by season, with lowest incidence/mortality during the summer and highest incidence/mortality during the winter. A better understanding of these seasonal trends, and especially if these can be attributed to temperature changes or factors related to quality of care, needs to be evaluated in future research. This might have important implications for the care of CS patients and could help to improve outcomes.

Data and material are available.

Software codes are available.

1.
Schrage B, Becher PM, Gossling A, Savarese G, Dabboura S, Yan I, Beer B, Soffker G, Seiffert M, Kluge S et al: Temporal trends in incidence, causes, use of mechanical circulatory support and mortality in cardiogenic shock. ESC Heart Fail 2021.
2.
Spencer FA, Goldberg RJ, Becker RC, Gore JM. Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction. J Am Coll Cardiol. 1998;31(6):1226–33.
CAS Article Google Scholar
3.
Gerber Y, Jacobsen SJ, Killian JM, Weston SA, Roger VL. Seasonality and daily weather conditions in relation to myocardial infarction and sudden cardiac death in Olmsted County, Minnesota, 1979 to 2002. J Am Coll Cardiol. 2006;48(2):287–92.
Article Google Scholar
4.
Becher PM, Schrage B, Sinning CR, Schmack B, Fluschnik N, Schwarzl M, Waldeyer C, Lindner D, Seiffert M, Neumann JT, et al. Venoarterial extracorporeal membrane oxygenation for cardiopulmonary support. Circulation. 2018;138(20):2298–300.
Article Google Scholar
5.
Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, et al. Standardized team-based care for cardiogenic shock. J Am Coll Cardiol. 2019;73(13):1659–69.
Article Google Scholar
6.
van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136(16):e232–68.
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Collaboration Study Group: Alexander M. Bernhardt³, Hermann Reichenspurner³, Paulus Kirchhof^1,2, Stefan Blankenberg^1,2.

The study itself was funded by the University Heart and Vascular Center Hamburg. PMB and BS are currently funded by the German Research Foundation. This work was partially supported by European Union BigData@Heart (Grant Agreement EU IMI 116074), British Heart Foundation (PG/17/30/32961 to PK; AA/18/2/34218 to PK), German Centre for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, via a grant to AFNET to PK), and Leducq Foundation to PK.

Affiliations

Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
Peter Moritz Becher, Benedikt Schrage, Alina Goßling, Nina Fluschnik, Moritz Seiffert, Paulus Kirchhof, Stefan Blankenberg, Dirk Westermann, Paulus Kirchhof & Stefan Blankenberg
German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
Peter Moritz Becher, Benedikt Schrage, Nina Fluschnik, Moritz Seiffert, Paulus Kirchhof, Stefan Blankenberg, Dirk Westermann, Paulus Kirchhof & Stefan Blankenberg
Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
Alexander M. Bernhardt, Hermann Reichenspurner, Alexander M. Bernhardt & Hermann Reichenspurner

Authors

Peter Moritz BecherView author publications
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Benedikt SchrageView author publications
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Alina GoßlingView author publications
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Nina FluschnikView author publications
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Moritz SeiffertView author publications
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Alexander M. BernhardtView author publications
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Hermann ReichenspurnerView author publications
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Paulus KirchhofView author publications
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Stefan BlankenbergView author publications
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Dirk WestermannView author publications
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Consortia

Collaboration Study Group

Alexander M. Bernhardt
, Hermann Reichenspurner
, Paulus Kirchhof
& Stefan Blankenberg

Contributions

PMB, AG take responsibility for the integrity of the data and the accuracy of the data analysis. All persons have provided the corresponding author with permission to be named in the manuscript. Study concept and design: PMB, AG, BS. Acquisition, analysis, or interpretation of data: PMB, AG, DW. Drafting of the manuscript: PMB, AG. Critical revision of the manuscript for important intellectual content: PMB, AG, BS, NF, MS, DW, AMB, HR, PK, SB. Statistical analysis: AG, PMB, Administrative, technical, or material support: PMB, AG, BS, NF, MS, DW. All authors read and approved ther final manuscript.

Corresponding authors

Correspondence to Peter Moritz Becher or Dirk Westermann.

Ethics approval

Not applicable.

Consent to participate

Informed consent was obtained from legal guardians.

Consent to publication

Not applicable.

Competing interests

The authors designed the study, analyzed the data, vouch for the data, wrote the paper, and decided to publish. Analysis provided by the Research Data Center of the Federal Bureau of Statistics, Wiesbaden, Germany. All authors have read and approved the manuscript. The manuscript and its contents have not been published previously and are not being considered for publications elsewhere in whole or in part in any language, including publicly accessible web sites or e-print servers. BS has received speakers fee from AstraZeneca and Abiomed (unrelated to the submitted work). DW has received speakers fee from AstraZeneca, Bayer, Novartis and Abiomed (unrelated to the submitted work). PK receives research support for basic, translational, and clinical research projects from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies in the past, but not in the last three years (unrelated to the submitted work). PK is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). SB has received speakers fee from Medtronic, Pfizer, Roche, Novartis, SiemensDiagnostics (unrelated to the submitted work). MS reports personal fees from Abbott, Biotronik, Boston Scientific, Edwards Lifesciences and from Medtronic (unrelated to the submitted work). RSP has received honoraria from Abiomed and Medtronic (unrelated to the submitted work). AMB reports personal fees from Abbott, Abiomed, AstraZeneca, BerlinHeart, Medtronic, Novartis (unrelated to the submitted work). The following authors had nothing to declare: PMB, NF, AG.

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Becher, P.M., Schrage, B., Goßling, A. et al. Seasonal trends of incidence and outcomes of cardiogenic shock : findings from a large, nationwide inpatients sample with 441,696 cases. Crit Care 25, 325 (2021). https://doi.org/10.1186/s13054-021-03656-9

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Received: 28 April 2021
Accepted: 25 June 2021
Published: 06 September 2021
DOI: https://doi.org/10.1186/s13054-021-03656-9

Keywords

Cardiogenic shock
Seasonal trends
Winter
Myocardial infarction
Mechanical circulatory support
Outcomes
Mortality

中文翻译：

心源性休克发病率和结果的季节性趋势：来自全国范围内 441,696 例大型住院患者样本的调查结果

德国记录了心源性休克 (CS) 年发病率的增加和无急性心肌梗死 (AMI) 的患者亚群的增加 [1]。然而，关于 CS 季节性趋势的当代数据（无论其根本原因如何）都很少见。

在这项研究中，我们旨在分析 (i) 发病率的季节性趋势；(ii) 患者特征；(iii) 2005 年至 2017 年间德国超过 400,000 例 CS 病例的全国样本结果。

对于目前的分析，纳入了德国 2005 年至 2017 年间≥18 岁患者的所有 CS 病例（ICD-10-GM 代码 R57.0）。根据入院情况将患者分为四组之一：春季、夏季、秋季和冬季。

与温度相关的发病率和死亡率是一个日益严重的公共卫生问题。德国以外的几项研究表明，冬季的致死性和非致死性心血管事件比夏季多 [2]，但缺少当代数据。我们在研究中表明：冬季 CS 发病率最高，而夏季 CS 发病率最低。冬季入院的 CS 患者人数比夏季多出近 10,000 人（表 1）。我们的研究还显示，冬季 CS 患者的住院死亡率高于夏季（冬季 vs. 夏季，n = 70,727 (61.1%) vs. n = 62,379 (58.8%)，p < 0.001）（图1). 此外，我们发现冬季入院的 CS 患者比夏季入院的患者年龄稍大（冬季与夏季，平均年龄 71.1 (± 13. 6) 与 70.8 (± 13.8)，而性别在不同季节没有差异 (p = 0.8)。值得注意的是，CS 患者的 AMI、院前和院内心脏骤停的发生率也因季节而异（p < 0.001）。这与先前的研究一致，该研究显示冬季心源性猝死的发生率增加 [3]。

表1 2007-2015年德国CS病例总体季节性趋势

全尺寸表

在过去十年中，用于管理 CS 患者的临时机械循环支持 (MCS) 领域得到了加强 [4]。在这项研究中，主动脉内球囊泵 (IABP) 是最常用的辅助装置，其次是 CS 患者的静脉-动脉体外膜肺氧合 (VA-ECMO) 和左心室辅助装置 (LVAD)，说明临床需要MCS 设备。

利用协议驱动的护理的多学科休克团队方法似乎是可行的，并且可以降低难治性 CS 患者的死亡率 [5, 6]。然而，冲击小组的方法和相关结果受季节性变化影响的程度仍不清楚。进一步的研究必须阐明由于恶劣的天气条件、动脉粥样硬化/血栓形成的 AMI 发病率以及时间依赖性护理过程是否会受到季节变化和/或较低温度的影响而导致的运输时间延长。

这项研究的优势在于样本量大和经过充分验证的数据库。遗憾的是，该管理数据集中没有临床变量，例如实验室值、生理标志物和住院后的随访数据。在这个管理数据集中无法评估不同诊断的确切时间过程，例如在入院时流行或住院期间发生的事件。在解释我们的结果时，必须考虑到这种潜在的偏见/混淆。最后，需要在德国以外验证我们的结果。

在这个由超过 400,000 名 CS 患者组成的全国性队列中，CS 的发病率和院内死亡率因季节而异，夏季发病率/死亡率最低，冬季发病率/死亡率最高。更好地了解这些季节性趋势，特别是如果这些可以归因于温度变化或与护理质量相关的因素，需要在未来的研究中进行评估。这可能对 CS 患者的护理产生重要影响，并有助于改善结果。

数据和材料可用。

软件代码可用。

1.
Schrage B、Becher PM、Gossling A、Savarese G、Dabboura S、Yan I、Beer B、Soffker G、Seiffert M、Kluge S等：心源性休克的发病率、原因、机械循环支持的使用和死亡率的时间趋势。ESC心力衰竭2021。
2.
斯宾塞 FA、戈德堡 RJ、贝克尔 RC、戈尔 JM。第二届全国心肌梗死登记处急性心肌梗死的季节性分布。J Am Coll Cardiol。1998;31(6):1226-33。
CAS 文章谷歌学术
3.
Gerber Y, Jacobsen SJ, Killian JM, Weston SA, Roger VL。1979 年至 2002 年与明尼苏达州奥姆斯特德县心肌梗塞和心源性猝死有关的季节性和日常天气状况。J Am Coll Cardiol。2006;48(2):287-92。
文章谷歌学术
4.
Becher PM、Schrage B、Sinning CR、Schmack B、Fluschnik N、Schwarzl M、Waldeyer C、Lindner D、Seiffert M、Neumann JT 等。用于心肺支持的静脉动脉体外膜肺氧合。循环。2018;138(20):2298–300。
文章谷歌学术
5.
Tehrani BN、Truesdell AG、Sherwood MW、Desai S、Tran HA、Epps KC、Singh R、Psotka M、Shah P、Cooper LB 等。基于团队的标准化心源性休克护理。J Am Coll Cardiol。2019;73(13):1659-69。
文章谷歌学术
6.
van Diepen S、Katz JN、Albert NM、Henry TD、Jacobs AK、Kapur NK、Kilic A、Menon V、Ohman EM、Sweitzer NK 等。心源性休克的当代管理：美国心脏协会的科学声明。循环。2017;136(16):e232-68。
考研谷歌学术

下载参考资料

合作研究小组：Alexander M. Bernhardt ³、Hermann Reichenspurner ³、Paulus Kirchhof ^1,2、Stefan Blankenberg ^1,2。

该研究本身由汉堡大学心脏和血管中心资助。PMB 和 BS 目前由德国研究基金会资助。这项工作得到了欧盟 BigData@Heart (Grant Agreement EU IMI 116074)、英国心脏基金会 (PG/17/30/32961 to PK; AA/18/2/34218 to PK)、德国心血管研究中心的部分支持由德国教育和研究部（DZHK，通过向 AFNET 授予 PK 的赠款）和 Leducq 基金会向 PK 提供。

隶属关系

心脏病学系，汉堡大学心脏和血管中心，汉堡，德国
Peter Moritz Becher, Benedikt Schrage, Alina Goßling, Nina Fluschnik, Moritz Seiffert, Paulus Kirchhof, Stefan Blankenberg, Dirk Westermann, Paulus Kirchhof & Stefan Blankenberg
德国心血管研究中心 (DZHK)，合作伙伴网站汉堡/吕贝克/基尔，德国汉堡
Peter Moritz Becher, Benedikt Schrage, Nina Fluschnik, Moritz Seiffert, Paulus Kirchhof, Stefan Blankenberg, Dirk Westermann, Paulus Kirchhof & Stefan Blankenberg
德国汉堡大学心脏和血管中心心血管外科
Alexander M. Bernhardt、Hermann Reichenspurner、Alexander M. Bernhardt & Hermann Reichenspurner

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财团

合作研究组

亚历山大·M·伯恩哈特
, 赫尔曼·赖肯斯珀纳
, 保卢斯·基尔霍夫
& 斯蒂芬·布兰肯伯格

贡献

PMB, AG 对数据的完整性和数据分析的准确性负责。所有人都已向通讯作者提供了在手稿中署名的许可。研究概念和设计： PMB、AG、BS。数据采集、分析或解释： PMB、AG、DW。手稿起草： PMB，AG。对重要知识内容的手稿进行批判性修订： PMB、AG、BS、NF、MS、DW、AMB、HR、PK、SB。统计分析： AG、PMB、行政、技术或物质支持： PMB、AG、BS、NF、MS、DW。所有作者都阅读并批准了最终手稿。

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利益争夺

作者设计了这项研究，分析了数据，保证了数据，撰写了论文，并决定发表。分析由德国威斯巴登联邦统计局研究数据中心提供。所有作者均已阅读并批准了该手稿。手稿及其内容以前没有发表过，也没有考虑在其他地方以任何语言全部或部分发表，包括可公开访问的网站或电子打印服务器。BS 已收到来自 AstraZeneca 和 Abiomed 的演讲者费用（与提交的作品无关）。DW 收到了来自 AstraZeneca、Bayer、Novartis 和 Abiomed 的演讲者费用（与提交的作品无关）。PK 获得欧盟、英国心脏基金会、Leducq 基金会、医学研究委员会（英国）和德国心血管研究中心，来自几家活跃于心房颤动的药物和设备公司，过去曾收到过几家此类公司的酬金，但在过去三年中没有（与提交的工作无关）。PK 被列为伯明翰大学持有的两项专利的发明人（心房颤动治疗 WO 2015140571，心房颤动标记物 WO 2016012783）。SB 已收到来自美敦力、辉瑞、罗氏、诺华、西门子诊断的演讲者费用（与提交的作品无关）。MS 报告来自雅培、Biotronik、波士顿科学、爱德华兹生命科学和美敦力（与提交的工作无关）的个人费用。RSP 已收到 Abiomed 和 Medtronic 的酬金（与提交的工作无关）。AMB 从雅培、Abiomed、AstraZeneca、BerlinHeart、Medtronic、Novartis（与提交的工作无关）。以下作者无需声明：PMB、NF、AG。

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Becher, PM, Schrage, B., Goßling, A.等。心源性休克发病率和结果的季节性趋势：来自全国范围内 441,696 例大型住院患者样本的研究结果。重症监护 25, 325 (2021)。https://doi.org/10.1186/s13054-021-03656-9

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