Author + information
- Kevin Morine1,
- Michele Esposito1,
- Shiva Annamalai1,
- Robert Pedicini1,
- Lena Jorde1,
- Kyle Gobeil2,
- Jamie Hernandez-Montfort2 and
- Navin Kapur1
Prior to initiating acute mechanical circulatory support (AMCS) for cardiogenic shock (CS), vasoactive agents are used for hemodynamic support to avert multi-system dysfunction or hemo-metabolic shock. The relationship between vasoactive agent use for CS and clinical outcomes is not well-understood.
We retrospectively analyzed all patients (n=140) between 2012-2016 who received veno-arterial extra corporeal membrane oxygenation (VA-ECMO) (n=59) or Impella (n=81) for CS at two institutions.
In-hospital mortality was 49%. Survivors were treated with fewer vasoactive agents (1.3±1.1 vs 2.2±1.3, all comparisons p<0.05; Fig. A). The most common first-line agents were norepinephrine, dobutamine and milrinone. There was no significant mortality difference at low, moderate, and high doses of pressors or inotropes. Compared to 0-1 agents, use of ≥2 agents correlated with a higher Cr (2.1±1.3 vs. 1.4±0.6 mg/dl), higher alanine aminotransferase (ALT) (663±1380 vs. 222±653 IU/L), aspartate aminotransferase (AST) (1265±3185 vs. 331±1034 IU/L), and international normalized ratio (INR) (1.9±1 vs. 1.4±0.4). Use of ≥2 agents correlated with a higher right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio (0.78±0.25 vs. 0.63±0.23) and lower pulmonary artery pulsatility index (1.23±0.78 vs. 1.89±1.8). Receiver operating characteristic (ROC) analysis revealed a C-statistic of 0.838 for in-hospital mortality with an optimal cutoff of ≥2 agents (Fig B).
Vasoactive agents for CS are associated with impaired end-organ function, right heart dysfunction and increased mortality. The number of vasoactive agents may serve as a simple metric of CS severity and identify patients at risk of hemo-metabolic shock who may benefit from early initiation of AMCS.