Circulation: Heart Failure

ORIGINAL ARTICLE

Clinical Characteristics and Predictors of

In-Hospital Mortality in Patients With Cardiogenic
Shock
Results From the RESCUE Registry
Jeong Hoon Yang, MD*; Ki Hong Choi, MD*; Young-Guk Ko , MD; Chul-Min Ahn , MD; Cheol Woong Yu, MD;
Woo Jung Chun, MD; Woo Jin Jang, MD; Hyun-Joong Kim, MD; Bum Sung Kim, MD; Jang-Whan Bae, MD;
Sang Yeub Lee , MD; Sung Uk Kwon, MD; Hyun-Jong Lee , MD, PhD; Wang Soo Lee , MD; Jin-Ok Jeong , MD;
Sang-Don Park, MD; Seong-Hoon Lim, MD; Sungsoo Cho, MD; Taek Kyu Park, MD; Joo Myung Lee , MD;
Young Bin Song , MD; Joo-Yong Hahn , MD; Seung-Hyuk Choi , MD; Hyeon-Cheol Gwon , MD

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
patients with CS.

METHODS: The RESCUE study (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and
Efficacy of Left Ventricular Assist Device for Korean Patients With CS) is a multicenter, retrospective, and prospective
registry of patients that presented with CS. Between January 2014 and December 2018, 1247 patients with CS were
enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality.
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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 nonischemic 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 intraaortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients
(39.8%). In multivariable analysis, age ≥70years (odds ratio [OR], 2.73 [95% CI, 1.89–3.94], P<0.001), body mass index <25
kg/m2 (OR, 1.52 [95% CI, 1.08–2.16], P=0.017), cardiac arrest at presentation (OR, 2.16 [95% CI, 1.44–3.23], P<0.001),
vasoactive-inotrope score >80 (OR, 3.55 [95% CI, 2.54–4.95], P<0.001), requiring continuous renal replacement therapy
(OR, 4.14 [95% CI, 2.88–5.95], P<0.001), mechanical ventilator (OR, 3.17 [95% CI, 2.16–4.63], P<0.001), intraaortic balloon
pump (OR, 1.55 [95% CI, 1.07–2.24], P=0.020), and extracorporeal membrane oxygenator (OR, 1.85 [95% CI, 1.25–2.76],
P=0.002) were independent predictors for in-hospital mortality.

CONCLUSIONS: The in-hospital mortality of patients with CS remains high despite the high utilization of mechanical circulatory
support. Age, low body mass index, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure
requiring various support devices were poor prognostic factors for in-hospital mortality.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.

Key Words: cardiogenic shock ◼ dopamine ◼ mortality ◼ norepinephrine

Correspondence to: Hyeon-Cheol Gwon, MD, PhD, Heart Stroke Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81
Irwon-ro, Gangnam-gu, Seoul 06351, Korea. Email hcgwon@naver.com
*J.H. Yang and K.H. Choi contributed equally.
The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.120.008141.
For Disclosures, see page 652.
© 2021 American Heart Association, Inc.
Circulation: Heart Failure is available at www.ahajournals.org/journal/circheartfailure

Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141 June 2021 644

 Yang et al
WHAT IS NEW?
• The current article is the first to report contempo-
rary care and prognostic factors of cardiogenic
shock in Korea using the nationwide multicenter
RESCUE (Retrospective and Prospective Obser-
vational Study to Investigate Clinical Outcomes and
Efficacy of Left Ventricular Assist Device for Korean
Patients With CS) registry.
• In patients with various causes of cardiogenic
shock, older age, low body mass index, cardiac
arrest at presentation, amount of vasopressor, and
advanced organ failure requiring various support
devices, including continuous renal replacement
therapy, mechanical ventilator, intraaortic balloon
pump, and extracorporeal membrane oxygenator,
were independent predictors of in-hospital mortality.
WHAT ARE THE CLINICAL IMPLICATIONS?
• The current study shows in-hospital mortality of
patients with cardiogenic shock remains high
despite the frequent utilization of mechanical circu-
latory support in contemporary practice.
• The study supports that clinicians should be aware
of the poor prognosis of cardiogenic shock even
in the contemporary mechanical circulatory support
era and make efforts to reduce in-hospital mortality
through careful critical care.
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Nonstandard Abbreviations and Acronyms
AMI acute myocardial infarction
BMI body mass index
CPC Cerebral Performance Categories
CS cardiogenic shock
CULPRIT- Culprit Lesion Only PCI Versus
SHOCK Multivessel PCI in Cardiogenic Shock
ECMO extracorporeal membrane oxygenator
IABP intraaortic balloon pump
IABP- Intraaortic Balloon Pump in
SHOCK II Cardiogenic Shock II
MCS mechanical circulatory support
RESCUE Retrospective and Prospective Obser-
vational Study to Investigate Clinical
Outcomes and Efficacy of Left Ventric-
ular Assist Device for Korean Patients
With CS
SHOCK Should We Emergently Revascularize
Occluded Coronaries for Cardiogenic
Shock
C
ardiogenic shock (CS) is a circulatory failure related
to an insufficient supply of oxygen to tissues mainly
driven by low cardiac output. Acute myocardial infarc-
tion (AMI) was reported to be the most common cause.
Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141
Cardiogenic Shock in Korea
In-hospital mortality of patients with CS has decreased
in recent years but remains high.1 In particular, refractory
CS, which refers to persistent shock despite appropri-
ate volume resuscitation or use of inotropes or vasopres-
sors, is lethal in more than half of hospitalized patients.2
Recent advances of temporary mechanical hemody-
namic support for patients with CS refractory to conven-
tional medical therapy are expected to improve patient
survival. However, a large-scale, randomized controlled
trial showed that routine use of intraaortic balloon pump
(IABP) as the most popular mechanical circulatory sup-
port (MCS) did not improve survival in CS patients with
complicating AMI.3 However, advanced MCS devices
such as Impella and extracorporeal membrane oxygen-
ator (ECMO) showed favorable outcomes in several reg-
istries.4,5 Although several randomized controlled trials
showed the benefit of early coronary intervention and
some medication strategies,6,7 current therapeutic strate-
gies remain empirical and not evidence-based in patients
with CS.8 Therefore, we conducted the RESCUE (Retro-
spective and Prospective Observational Study to Investi-
gate Clinical Outcomes and Efficacy of Left Ventricular
Assist Device for Korean Patients With CS) registry to
investigate overall characteristics and predictors of clini-
cal outcomes regarding efficacy and safety of contempo-
rary practices in patients with CS.
METHODS
The data, analytic methods, and study materials will not be
made available to other researchers for purposes of reproduc-
ing the results or replicating the procedure.
Study Population
The RESCUE study (Retrospective and Prospective
Observational Study to Investigate Clinical Outcomes and
Efficacy of Left Ventricular Assist Device for Korean Patients
With CS) is a multicenter registry of patients with CS aged
over 19 years. A total of 1247 patients from 12 tertiary cen-
ters between January 2014 and December 2018 was enrolled
(Figure 1). The institutional review board of each hospital
approved the study protocol and waived the requirement for
written informed consent for patients enrolled in the retro-
spective registry (n=954). In the prospective enrollment arm
(n=293), all patients or their legally authorized representatives
provided written informed consent, and all information was
collected prospectively. More detailed information regarding
prospective and retrospective enrollments of each institute is
shown in Table I in the Data Supplement. The inclusion criteria
were as follows: (1) systolic blood pressure <90 mm Hg for 30
minutes or need for inotrope or vasopressor support to achieve
a systolic blood pressure >90 mm Hg and (2) presence of
pulmonary congestion and signs of impaired organ perfusion
(altered mental status, cold periphery, oliguria <0.5 mL/kg per
hour for the previous 6 hours, or blood lactate >2 mmol/L).
Exclusion criteria were (1) out-of-hospital cardiac arrest and
(2) evidence of septic or hypovolemic shock.
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 Yang et al
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Figure 1. A flow diagram showing selection of study patients.
ECMO indicates extracorporeal membrane oxygenator; and IABP, intraaortic balloon pump.
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 neu-
rological 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
(good cerebral performance: conscious, alert, able to work,
might have mild neurological or psychological deficit) and 2
(moderate cerebral disability: conscious, sufficient cerebral
function for independent activities of daily life, able to work in
sheltered environment) were classified as favorable neurologi-
cal outcomes, while CPC scores of 3 (severe cerebral disabil-
ity: conscious, dependent on others for daily support because
of impaired brain function, ranges from ambulatory state to
severe dementia or paralysis), 4 (coma or vegetative state: any
degree of coma without the presence of all brain death criteria,
unawareness, even if appears awake without interaction with
environment; may have spontaneous eye opening and sleep/
awake cycles, cerebral unresponsiveness), and 5 (brain death:
apnea, areflexia, or electroencephalogram silence) were con-
sidered poor neurological outcomes. Vasoactive-inotropic score
was calculated by the maximal administration rate of vasoactive
Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141
Cardiogenic Shock in Korea
drugs, including dopamine, dobutamine, epinephrine, milrinone,
vasopressin, and norepinephrine during the first 48 hours of
shock using the following formula suggested by Gaies et al10:
vasoactive-inotropic score = dopamine dose (µg/kg per min-
ute) + dobutamine dose (µg/kg per minute) + 100×epineph-
rine dose (µg/kg per minute) + 10×milrinone dose (µg/kg per
minute) + 10 000×vasopressin dose (units/kg per minute) +
100×norepinephrine dose (µg/kg per minute). All-cause mor-
tality was defined as death from any cause.
Statistical Analysis
Categorical variables were tested using the χ2 test or Fisher
exact test, as appropriate and presented as number and rela-
tive frequency. Continuous variables were compared using the
Student t test or Wilcoxon rank-sum test and presented as
mean±SD or median (25th–75th percentile). A multivariable
logistic regression analysis was used to identify the predic-
tors of in-hospital mortality in patients with CS. For practical
purpose, continuous variables were transformed into categori-
cal variables, which were assessed by normal range or cutoff
value as determined in previous studies.11,12 The covariates
considered clinically relevant or that showed a univariate rela-
tionship with outcome (P≤0.2) were entered into a multivari-
able regression model. Clinically intercorrelated variables were
June 2021 646
 Yang et al
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 consid-
ered statistically significant.
RESULTS
Baseline Characteristics
Among the 1293 patients enrolled in this study, 46
were excluded because of out-of-hospital cardiac arrest
(n=44) or withdrawal of consent (n=2). Finally, 1247
patients were analyzed for this study. A total of 419
patients (33.6%) died during the index hospitalization.
The characteristics of these patients are compared with
those of other registries in Table 1.
The main causes of shock were ischemic heart dis-
ease (80.7%), dilated cardiomyopathy (6.1%), myocardi-
tis (3.2%), and nonischemic ventricular arrhythmia (2.5%).
Baseline characteristics are shown in Table 2. Compared
with survivors, nonsurvivors were older and had lower
body mass index (BMI), 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, hypertension, chronic kidney disease, and
prior MI, and were more often female, showed cardiac
arrest at presentation, and had an ischemic cause.
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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%), whereas 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%). Com-
pared with survivors, nonsurvivors received more extra-
corporeal CPR (cardiopulmonary resuscitation) 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 nonsurvivors. Kaplan-Meier curves
showed favorable survival in nonarrest patients (versus
arrest patients) and those with vasoactive-inotrope score
<80 (versus ≥80), BMI≥25 kg/m2 (versus <25 kg/m2),
and lactate <8 mmol/L (versus ≥8 mmol/L; Figure 2).
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 (inter-
quartile range, 15–49), while the shock to ECMO time
Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141
Cardiogenic Shock in Korea
was 86 minutes (interquartile range, 42–261). Successful
weaning was achieved in 266 patients (53.6%), and those
who survived to discharge numbered 239 (48.2%).
Of survivors, poor neurological outcome was noted
in 39 (4.7%), 10 with CPC 4 (1.2%) and 29 with CPC
3 (3.5%). Good neurological outcome was noted in 58
patients with CPC 2 (7.0%) and 731 with CPC 1 (88.3%).
Predictors of In-Hospital Mortality
In multivariable analysis, age ≥70 years, BMI<25 kg/m2,
cardiac arrest at presentation, vasoactive-inotrope score
>80, requiring continuous renal replacement therapy,
mechanical ventilator, IABP, or ECMO were independent
predictors for in-hospital mortality (Table 4). The analysis
using continuous variables without transformation to cat-
egorical variables for age, BMI, log (transaminase), log
(glucose), and log (vasoactive-inotropic score) showed
similar results (Table II in the Data Supplement).
DISCUSSION
We investigated clinical characteristics and predictors of
clinical outcomes in patients with CS treated with con-
temporary management from a large-scale, multicenter
registry. This study demonstrated the actual state of CS
in Korea. The major findings of this study were (1) in-
hospital mortality of patients with CS 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, low BMI, cardiac arrest,
high-dose vasopressor, and organ failure were indepen-
dent predictors of in-hospital mortality.
CS is a critical illness with a very high rate of fatal-
ity. 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 3 major randomized
controlled trials, mostly in patients with AMI. The SHOCK
trial (Should We Emergently Revascularize Occluded
Coronaries for Cardiogenic Shock) established the role
of early coronary revascularization in patients with AMI
complicated by CS.13 The IABP-SHOCK II trial (Intraaor-
tic Balloon Pump in Cardiogenic Shock II) showed
that routine IABP did not reduce patient mortality. The
CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus
Multivessel PCI in Cardiogenic Shock) showed that mul-
tivessel PCI did improve clinical outcome.14,15
On the contrary, the registry studies cover a variety of
causes of CS. However, those previous studies were rela-
tively 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, multicenter
registry, was conducted between 2010 and 2012 but
included only 219 patients, 13 of whom were treated with
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 Yang et al Cardiogenic Shock in Korea

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 1247 1190 219 979
Region Korea United States Europe Japan
Time period January 2014–Decem- April 1993–August October 2010–Decem- May 2012–June 2014
ber 2018 1997 ber 2012
Demographics
Age, y 66±14 68.7±11.8 68±11 70.3±14.2
Male, n (%) 860 (69.0) 710 (59.7) 162 (74.0) 645 (65.9)
Body mass index, kg/m 2
23.4±3.6 … 26.5 [24.2–29.0] …
Vital sign
Systolic blood pressure, mm Hg 74±29 87.7±22.3 78±14 78.2±15.7
Diastolic blood pressure, mm Hg 47±20 52.3±17.0 47±10 …
Heart rate (beats/min) 83±34 95.7±26.2 90±28 73.0±48.7
Cardiac arrest as presentation 268 (21.5) … 62 (28.3) …
Comorbidities
Diabetes 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, % 36±16 32.6±13.8 33±14 45.0 [30.0–60.0]
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Laboratory
Hemoglobin, g/dL, mean±SD 12.7±2.6 12.9±2.5 12.8±2.2 …
Hemoglobin, g/dL, median [IQR] 12.8 [10.8–14.6]
Serum creatinine, mg/dL, mean±SD 1.6±1.4 1.4±1.4 1.0 [0.8–1.4] …
Serum creatinine, mg/dL, median [IQR] 1.2 [0.9–1.6]
Glucose, mg/dL, mean±SD 223±119 208±105 250±139 …
Glucose, mg/dL, median [IQR] 188 [140–273]
Lactate, mmol/L, mean±SD 6.5±4.7 5.4±3.9 2.8 [1.7–5.8] …
Lactate, mmol/L, median [IQR] 5.2 [3.0–9.3]
Managements
Vasopressor 1081 (86.7) … 181 (82.6) …
Mechanical ventilator 709 (56.9) … 137 (62.6) …
Continuous renal replacement therapy 285 (22.9) … 30 (13.7) …
Intraaortic balloon pump 314 (25.2) 631 (53.0) 122 (55.7) …
ECMO 496 (39.8) … 4 (1.8) …
  ECMO-related complications
   Stroke 18/496 (3.6) … … …
   ECMO site bleeding 62/496 (12.5) … … …
   Gastrointestinal bleeding 27/496 (5.4) … … …
   Limb ischemia 35/496 (7.1) … … …
In-hospital mortality, % 419 (33.6) 731 (61.4) 80 (36.5)
30-d mortality, % 336 (34.3)

Values are mean±SD, medians [IQR], or n (%). ECMO indicates extracorporeal membrane oxygenator; IQR, interquartile range; RESCUE, Retrospective and Prospec-
tive Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock; and SHOCK, Should
We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock.

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 Yang et al Cardiogenic Shock in Korea

Table 2. Baseline Patient Characteristics

Overall Survivors Nonsurvivors

Variables (n=1247) (n=828) (n=419) P value
Age, y 66±14 64±14 69±14 <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, mm Hg 74±29 77±27 67±32 <0.001

Diastolic blood pressure, mm Hg 47±20 49±19 43±21 <0.001

Heart rate (beats/min) 83±34 83±32 83±38 0.99

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) 0.76
ST-segment–elevation MI 355 (42.9) 355 (42.9) 202 (48.2) 0.07
Comorbidities
Diabetes 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) 0.28
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) 0.17

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) 0.07
Left ventricular ejection fraction, % 36±16 39±16 28±15 <0.001

Laboratory
Hemoglobin, g/dL, mean±SD 12.7±2.6 12.9±2.5 12.2±2.7 <0.001

Hemoglobin, g/dL, median [IQR] 12.8 [10.8–14.6] 13.2 [11.2–14.7] 12.0 [10.3–14.0] <0.001
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Platelets (×103/μL), mean±SD 211±82 218±80 198±82 <0.001

Platelets (×103/μL), median [IQR] 206 [158–255] 211 [168–259] 197 [140–246] <0.001

Total bilirubin, mg/dL, mean±SD 1.0±1.8 1.0±1.9 1.1±1.6 0.50

Total bilirubin, mg/dL, median [IQR] 0.7 [0.4–1.0] 0.6 [0.4–1.0] 0.7 [0.4–1.1] 0.06
Aspartate transaminase, U/L, mean±SD 257±990 210±891 348±1154 0.022
Aspartate transaminase, U/L, median [IQR] 54 [28–170] 44 [26–124] 90 [33–252] <0.001

Alanine transaminase, U/L, mean±SD 144±462 128±464 177±456 0.08

Alanine transaminase, U/L, median [IQR] 34 [19–78] 30 [18–68] 44 [22–109] <0.001

Serum creatinine, mg/dL, mean±SD 1.6±1.4 1.4±1.4 1.8±1.4 <0.001

Serum creatinine, mg/dL, median [IQR] 1.2 [0.9–1.6] 1.1 [0.9–1.5] 1.4 [1.1–2.0] <0.001

Glucose, mg/dL, mean±SD 223±119 208±105 250±139 <0.001

Glucose, mg/dL, median [IQR] 188 [140–273] 179 [135–260] 213 [150–310] <0.001

Lactate, mmol/L, mean±SD 6.5±4.7 5.4±3.9 8.4±5.2 <0.001

Lactate, mmol/L, median [IQR] 5.2 [3.0–9.3] 4.6 [2.7–7.7] 7.8 [4.2–12.1] <0.001

Values are mean±SD, medians [IQR], or n (%). IQR indicates interquartile range; and MI, myocardial infarction.

ventricular assist device or ECMO.16–18 The Japanese Cir-
culation Society Cardiovascular Shock registry conducted
between 2012 and 2014 was the largest registry of CS,
enrolling 979 patients,19 but that study did not collect infor-
mation on vasopressor or MCS usage. The RESCUE study
is the largest multicenter, real-world registry of patients
with CA with a broad spectrum of causes. 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% to 40% mortality reported in other stud-
ies performed in the early 2010s. These findings suggest
that the mortality rate of patients with AMI complicated
by CS may plateau over time despite introduction of new
devices and techniques improving coronary artery revas-
cularization. Furthermore, beneficial hemodynamic support
may be masked by MCS-related complications, such as
limb ischemia, systemic embolization, and fatal bleeding in
patients with CS treated with MCS.

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 Yang et al Cardiogenic Shock in Korea

Table 3. In-Hospital Management Methods

Overall Survivors Nonsurvivors

Variables (n=1247) (n=828) (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, mean±SD 73±137 46±124 128±143 <0.001

Vasoactive-inotropic score, median [IQR] 25 [10–80] 16 [7–41] 70 [23–177] <0.001

Requiring mechanical ventilator 709 (56.9) 347 (41.9) 362 (86.4) <0.001

Requiring continuous renal replacement therapy 285 (22.9) 89 (10.7) 196 (46.8) <0.001

Requiring intraaortic balloon pump 314 (25.2) 193 (23.3) 121 (28.9) 0.032
Requiring extracorporeal membrane oxygenator 496 (39.8) 239 (28.9) 257 (61.3) <0.001

Requiring extracorporeal cardiopulmonary resuscitation 240 (19.2) 81 (9.8) 159 (37.9) <0.001

ICU stay, d, mean±SD 12±24 12±22 11±26 0.68

ICU stay, d, median [IQR] 5.0 [2.0–12.0] 5.0 [2.0–12.0] 4.0 [1.0–12.0] 0.003
Hospital stay, d, mean±SD 19±30 22±29 14±29 <0.001

Hospital stay, d, median [IQR] 10.0 [4.0–20.5] 11.0 [6.0–25.0] 6.0 [1.5–16.0] <0.001

Values are mean±SD, medians [IQR], or n (%). ICU indicates intensive care unit; and IQR, interquartile range.

The prognostic factors found in this study were con-
sistent with those reported in previous studies. Indices of
organ failure such as acute kidney injury requiring con-
tinuous renal replacement therapy and respiratory failure
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requiring mechanical ventilator were significant prog-
nostic factors for in-hospital mortality.18,19 Cardiac arrest
was also a prognostic factor for in-hospital mortality.
Our group showed that extracorporeal cardiopulmonary

Figure 2. Kaplan-Meier curves for all causes of death for 90 d after the index admission.
A, Cardiac arrest (blue line) vs nonarrest (red line). B, Vasoactive-inotropic score (VIS) ≥80 (blue line) vs <80 (red line). C, Body mass index
(BMI) ≥25 kg/m2 (blue line) vs <25 kg/m2 (red line). D, Lactate ≥8 mmol/L (blue line) vs <8 mmol/L (red line).

Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141 June 2021 650

 Yang et al Cardiogenic Shock in Korea

Table 4. Predictors for In-Hospital Mortality

Univariate analysis Multivariable analysis*

OR 95% CI P value Adjusted OR 95% CI P value

Requiring continuous renal replacement therapy 7.30 5.45–9.77 <0.001 4.14 2.88–5.95 <0.001

Vasoactive-inotrope score >80 5.62 4.26–7.41 <0.001 3.55 2.54–4.95 <0.001

Requiring mechanical ventilator 8.80 6.45–12.0 <0.001 3.17 2.16–4.63 <0.001

Age≥70 y 2.16 1.70–2.74 <0.001 2.73 1.89–3.94 <0.001

Cardiac arrest at presentation 4.67 3.51–6.21 <0.001 2.16 1.44–3.23 <0.001

Requiring extracorporeal membrane oxygenator 3.91 3.05–5.01 <0.001 1.85 1.25–2.76 0.002
Transaminase >1000 U/L 2.04 1.16–3.59 0.015 1.81 0.86–3.81 0.12
Requiring intraaortic balloon pump 1.34 1.02–1.74 0.034 1.55 1.07–2.24 0.020
Body mass index <25 kg/m2 1.54 1.18–2.01 0.001 1.52 1.08–2.16 0.017
Diabetes 1.45 1.14–1.85 0.003 1.24 0.89–1.75 0.21
Ischemic cause 1.05 0.78–1.41 0.76 1.23 0.82–1.85 0.31
Serum glucose >9.2 mmol/L (166 mg/dL) 1.73 1.36–2.21 <0.001 1.20 0.87–1.67 0.26
Prior history of myocardial infarction 1.42 1.01–1.99 0.047 1.16 0.74–1.80 0.52
Prior history of chronic kidney disease 2.44 1.67–3.55 <0.001 1.12 0.68–1.84 0.67
Anemia 2.14 1.68–2.71 <0.001 1.11 0.80–1.53 0.55
Hypertension 1.32 1.04–1.67 0.021 0.96 0.68–1.35 0.81
Current smoking 0.62 0.48–0.82 <0.001 0.94 0.63–1.39 0.74
Sex, male 0.76 0.59–0.97 0.029 0.81 0.58–1.14 0.23

OR indicates odds ratio.

*Adjusted variables are age ≥70 y, sex, body mass index <25 kg/m2, cardiac arrest at presentation, ischemic cause, hypertension, diabetes,
current smoking, prior history of chronic kidney disease and myocardial infarction, anemia (hemoglobin <13 g/dL in men, <12 g/dL in women
according to World Health Organization criteria), glucose >9.2 mmol/L (166 mg/dL), transaminase >1000 U/L, vasoactive-inotrope score >80,
continuous renal replacement therapy, mechanical ventilator, intraaortic balloon pump, and extracorporeal membrane oxygenator.
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resuscitation had a survival benefit over the conventional
approach used in a previous study.20 Future research
regarding the optimal strategy of extracorporeal car-
diopulmonary 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 patients with
CS.21 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/hypoten-
sion, arrhythmias, peripheral, and cardiac ischemia,
which may be fatal.22 Accordingly, the decision whether
to increase vasopressor dosage or apply advanced MCS
in patients who have already received high-dose vaso-
pressor should be carefully weighed after considering a
risk-benefit analysis.
Limitations
Our study has several limitations. First, most patients
presented with an ischemic cause, and patients with
nonischemic cause were heterogeneous and of limited
sample size. Second, this registry did not include all MCS
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.
Conclusions
The in-hospital mortality of patients with CS remains
high despite high utilization of MCS. Age, low BMI, car-
diac arrest at presentation, amount of vasopressor, and
advanced organ failure requiring various support devices
were poor prognostic factors for in-hospital mortality.
ARTICLE INFORMATION
Received November 9, 2020; accepted April 8, 2021.
Affiliations
Division of Cardiology, Department of Medicine, Heart Vascular Stroke Insti-
tute, Samsung Medical Center (J.H.Y., K.H.C., T.K.P., J.M.L., Y.B.S., J.-Y.H., S.-
H.C., H.-C.G.) and Department of Cardiology, Samsung Changwon Hospital
(W.J.C.), Sungkyunkwan University School of Medicine, Seoul, Republic of Ko-
rea. Division of Cardiology, Severance Cardiovascular Hospital, Yonsei Univer-
sity College of Medicine, Seoul, Republic of Korea (Y.-G.K., C.-M.A.). Division of
Cardiology, Department of Internal Medicine, Korea University Anam Hospital,
Seoul, Republic of Korea (C.W.Y.). Department of Cardiology, Ewha Woman’s
University Seoul Hospital, Ehwa Woman’s University School of Medicine, Seoul,
Republic of Korea (W.J.J.). Division of Cardiology, Department of Internal Medi-
cine, Konkuk University Medical Center, School of Medicine, Konkuk University,
Seoul, Republic of Korea (H.-J.K., B.S.K.). Department of Internal Medicine,

Circ Heart Fail. 2021;14:e008141. DOI: 10.1161/CIRCHEARTFAILURE.120.008141 June 2021 651

 Yang et al
Chungbuk National University College of Medicine, Cheongju, Republic of Ko-
rea (J.-W.B., S.Y.L.). Division of Cardiology, Department of Internal Medicine,
Ilsan Paik Hospital, University of Inje College of Medicine, Seoul, Republic of
Korea (S.U.K.). Division of Cardiology, Department of Medicine, Sejong General
Hospital, Bucheon, Republic of Korea (H.-J.L.). Division of Cardiology, Depart-
ment of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
(W.S.L.). Division of Cardiology, Department of Internal Medicine, Chungnam
National University Hospital, Daejeon, Republic of Korea (J.-O.J.). Division of
Cardiology, Department of Medicine, Inha University Hospital, Incheon, Repub-
lic of Korea (S.-D.P.). Division of Cardiovascular Medicine, Department of In-
ternal Medicine, Dankook University Hospital, Dankook University College of
Medicine, Cheonan, Republic of Korea (S.-H.L., S.C.).
.Disclosures
None.
Supplemental Materials
Tables I–II
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