Heart Failure
Hospital Tier and Cardiogenic Shock Outcomes in the US
- Authors: JACC: Heart Failure authors (Nationwide Readmissions Database analysis)
- Journal / date: JACC: Heart Failure, May 2026 (Vol 14, No 5)
- DOI / URL: 10.1016/j.jchf.2026.103100 | PMID 42104977
- Source basis: Full text (JACC login)
- Study type: Retrospective database, propensity-matched
- Population: 623,835 adults hospitalized with cardiogenic shock (2016-2022)
- Center stratification:
- Level 3: non-PCI/MCS/CTS, ICU only (38-40%)
- Level 2: + PCI, IABP, pVAD (19-21%)
- Level 1A: + ECMO, non-percutaneous VAD, CTS (27-36%)
- Level 1: + durable LVAD/transplant (7%)
- Key findings (propensity-matched vs Level 1, 29.5% mortality):
- Level 1A: 38.4% mortality, aOR 1.33
- Level 2: 41.1%, aOR 1.44
- Level 3: 45.2%, aOR 1.63 (all p<0.001)
- Survival benefit at Level 1 persisted across age, cardiac arrest, MCS use, location, and insurance subgroups
- LOS and costs higher at Level 1 / 1A
- Lower MCS use at non-Level-1 centers (aOR 0.62 at Level 1A, 0.27 at Level 2)
- Why it matters (clinical takeaway):
- Real-world validation of tiered cardiogenic shock care — stepwise mortality benefit from Level 3 → Level 1 supports the SCAI/AHA/ACC tiered framework.
- Aggressively pursue transfer to Level 1 centers when CS patients are at lower-tier facilities — the ~16% absolute mortality difference (Level 3 vs Level 1) is large.
- Reinforces regionalization of shock care and shock-team protocols within networks.
- Caveats / limitations: Database study — residual confounding by case mix and pre-transfer status. NRD does not capture all clinical detail (cause of CS, etc.).
- Referenced trials pulled forward: DanGer Shock (AMI-CS Impella benefit, already on watch-list) and mAFP HF-CS review (cross-link to JCF article).