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The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock

Abstract

Purpose

This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors’ health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed.

Methods

Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008–2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status.

Results

Sixty-five patients (47 %) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m2, Glasgow coma score <6, creatinine >150 μmol/L, lactate (<2, 2–8, or >8 mmol/L), and prothrombin activity <50 %. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7 % for ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95 % CI 0.77–0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors’ HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34 % (95 % CI 20–49 %) anxiety, 20 % (95 % CI 8–32 %) depression, and 5 % (95 % CI 0–12 %) PTSD symptoms reported.

Conclusions

The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients.

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Correspondence to Alain Combes.

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Conflicts of interest

Dr. Combes is the primary investigator of the EOLIA trial, NCT01470703, a randomized trial of VV-ECMO supported in part by MAQUET. Dr. Combes has received honoraria for lectures from MAQUET.

Additional information

Take-home message: The ENCOURAGE score proposed herein combines seven simple variables, readily available at pre-ECMO implantation, that might help physicians communicate objective prognostic information to surrogates, better select ECMO candidates among severe AMI patients, and might also be used to stratify inclusion of AMI-related cardiogenic shock patients in future randomized VA-ECMO studies. Long-term health-related quality of life was deemed satisfactory, although physical and emotional difficulties persisted in one-third of survivors.

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Muller, G., Flecher, E., Lebreton, G. et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med 42, 370–378 (2016). https://doi.org/10.1007/s00134-016-4223-9

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Keywords

  • Extracorporeal membrane oxygenation
  • Acute myocardial infarction
  • Cardiogenic shock
  • Outcome assessment
  • Long-term quality of life