COVID-19 Induced Shock Subgroups | Hackensack Meridian Health   

Hackensack University Medical Center Cardiologists Publish Study of COVID-19 Induced Shock Subgroups in American Journal of Cardiology

Findings show 10 percent incidence of cardiac shock in this population, attributed to mechanisms by which COVID-19 may impact myocardial function; Hemodynamic assessment and subgrouping of patients may permit tailored therapy based on underlying abnormalities


A new database analysis of critically ill patients with pneumonia related to COVID-19, published in the American Journal of Cardiology1 and conducted at Hackensack Meridian Hackensack University Medical Center (HUMC), is the first study to report the prevalence of different types of shock in patients with COVID-19. The definition of these subgroups may allow therapy to be tailored to the underlying causes of the hemodynamic abnormalities.

The study showed the incidence of cardiogenic shock in this population, characterized by low ejection fraction and low cardiac index, to be 10 percent. This group may benefit from inotropic or mechanical support. Another group with preserved ejection fraction but low cardiac output may respond to volume expansion treatment. Thus, the study may provide better therapeutic approaches to COVID-19 associated shock.

The study authors note that patients with COVID-19 and respiratory failure frequently develop shock, some of which is cardiogenic, a life-threatening condition in which the heart can’t pump enough blood to meet the body’s needs. Potential mechanisms of myocardial injury in COVID-19 include direct injury due to viral infection, consequences of the immune response to COVID, ischemia, dysregulation of the renin-angiotensin system, a hormone system that regulates blood pressure, fluid and electrolytes, and coronary endothelial dysfunction, a type of non-obstructive coronary artery disease.

HUMC established a comprehensive prospective database of patients admitted with COVID-19 starting on March 2, 2020, including demographics, clinical features, laboratory values, and clinical outcomes (the RealWorld database). From that database, patients with shock were identified. Those shock patients who had echocardiograms performed were identified and reviewed, with measurement of ejection fraction (EF, the percentage of blood the heart ejects with each beat, with a normal value of 60-65 percent) and cardiac index (CI, the total output pumped by the heart indexed to body size).

Of 1,275 patients hospitalized at HUMC with COVID pneumonia between March 2 and May 31, 2020, 215 had shock requiring vasopressors of whom 156 had echocardiography to assess ventricular function and stroke volume. Mean age was 67, mean ejection fraction 59.5, and mean cardiac index 2.40. The patients were divided into 4 subgroups defined by EF and CI: 15 had low EF and low CI, 8 had low EF and normal CI, 55 had preserved EF and low CI, and 73 had preserved EF and normal CI. Overall hospital mortality was 73 percent. Mortality was highest in the group with low cardiac index and low ejection fraction at 87 percent.

“Given the potential mechanisms by which COVID-19 may impact myocardial function, the presence of low ejection fraction and low cardiac index in this critically ill group of patients is not surprising,” said Steven M. Hollenberg, M.D., a cardiologist at the Heart & Vascular Hospital, Hackensack University Medical Center, who performed the analysis and along with his colleagues wrote the manuscript. “Low cardiac index despite preservation of ejection fraction suggests underfilling of the left ventricle in these patients, who might benefit from additional blood volume. Hemodynamic assessment of COVID patients with shock by specific subgroups may allow therapy to be tailored to the underlying causes of the hemodynamic abnormalities that are found.”

Joseph E. Parrillo, M.D., chair, Heart & Vascular Hospital, HUMC, said, “this study shows the ability of clinical research databases to answer important clinical questions about the possible mechanisms and potential best treatments for our patients with serious diseases such as shock due to COVID-19.”

“At HUMC we always strive to innovate and find various modalities of treatment including for COVID to serve our patients, community and our team members,” said Lisa Tank, M.D., chief medical officer, HUMC. “This includes conducting important clinical research. I’m proud of the efforts of Dr. Hollenberg and the team at the Heart & Vascular Hospital to better understand how to treat patients with this virus.”

1 Hemodynamic Profiles of Shock in Patients with COVID-19, The American Journal of Cardiology, Volume 153, Pgs. 135-139, August 15, 2021, Steven M. Hollenberg, MD; Lucy Safi, MD; Joseph E Parrillo, MD; Matthew Fata, MD; Brent Klinkhammer, MD; Noha Gayed, MD; Taya Glotzer, MD; Ronaldo C. Go, MD; Elli Gourna-Paleoudis, PhD; David Landers, MD; Sameer Jamal, MD; Neel Shah, MD; Roshan Shah, MD; Jana Tancredi, RN; Zoltan G. Turi, MD.

Hackensack University Medical Center, a 771-bed nonprofit teaching and research hospital, is the largest provider of inpatient and outpatient services in New Jersey. Founded in 1888 as Bergen County’s first hospital, it was the first hospital in New Jersey and second in the nation to become a Magnet®-recognized hospital for nursing excellence. The academic flagship of Hackensack Meridian Health, Hackensack University Medical Center’s campus is home to facilities such as John Theurer Cancer Center, the Heart & Vascular Hospital, and the Sarkis and Siran Gabrellian Women’s and Children’s Pavilion. Recognized as being in the top 1% of hospitals in the nation and #2 in New Jersey by U.S. News & World Report’s 2020-21 “Best Hospitals” Honor Roll, Hackensack University Medical Center also ranked as high-performing in cancer care, cardiology and heart surgery, gastroenterology and GI surgery, geriatrics, nephrology, neurology and neurosurgery, orthopedics, pulmonology, and urology. Hackensack University Medical Center’s comprehensive clinical research portfolio includes studies focused on precision medicine, translational medicine, immunotherapy, cell therapy, and vaccine development.

Hackensack Meridian Health is a leading not-for-profit health care organization that is the largest, most comprehensive and truly integrated health care network in New Jersey, offering a complete range of medical services, innovative research and life-enhancing care.

Hackensack Meridian Health comprises 17 hospitals from Bergen to Ocean counties, which includes three academic medical centers – Hackensack University Medical Center in Hackensack, Jersey Shore University Medical Center in Neptune, JFK Medical Center in Edison; two children’s hospitals – Joseph M. Sanzari Children’s Hospital in Hackensack, K. Hovnanian Children’s Hospital in Neptune; nine community hospitals – Bayshore Medical Center in Holmdel, Mountainside Medical Center in Montclair, Ocean Medical Center in Brick, Palisades Medical Center in North Bergen, Pascack Valley Medical Center in Westwood, Raritan Bay Medical Center in Old Bridge, Raritan Bay Medical Center in Perth Amboy, Riverview Medical Center in Red Bank, and Southern Ocean Medical Center in Manahawkin; a behavioral health hospital – Carrier Clinic in Belle Mead; and two rehabilitation hospitals – JFK Johnson Rehabilitation Institute in Edison and Shore Rehabilitation Institute in Brick.

Additionally, the network has more than 500 patient care locations throughout the state which include ambulatory care centers, surgery centers, home health services, long-term care and assisted living communities, ambulance services, lifesaving air medical transportation, fitness and wellness centers, rehabilitation centers, urgent care centers and physician practice locations. Hackensack Meridian Health has more than 36,000 team members, and over 7,000 physicians and is a distinguished leader in health care philanthropy, committed to the health and well-being of the communities it serves.

The network’s notable distinctions include having four hospitals among the top in New Jersey by U.S. News and World Report. Other honors include consistently achieving Magnet® recognition for nursing excellence from the American Nurses Credentialing Center and being named to Becker’s Health Care’s “150 Top Places to Work in Health Care/2019” list.

The Hackensack Meridian School of Medicine opened in 2018, the first private medical school in New Jersey in more than 50 years, welcomed its third class of students in 2020 to its On3 campus in Nutley and Clifton. Additionally, the network partnered with Memorial Sloan Kettering Cancer Center to find more cures for cancer faster while ensuring that patients have access to the highest quality, most individualized cancer care when and where they need it.

Hackensack Meridian Health is a member of AllSpire Health Partners, an interstate consortium of leading health systems, to focus on the sharing of best practices in clinical care and achieving efficiencies.

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