Schrage, Benedikt

Abstract Aims Cardiogenic shock (CS) is often treated with catecholamines titrated to an adequate target mean arterial pressure (MAP) while minimizing adverse effects. We aim to assess the optimal catecholamine dose/MAP balance in heart failure-associated CS (HF-CS). Methods Patients with HF-CS were retrospectively enrolled from 16 tertiary centres in 5 European countries (2016–2021; NCT03313687). Dosage was quantified by inotropic scores (epinephrine, norepinephrine, and dobutamine). Associations of baseline and seven-day summarized dosage with intensive care unit (ICU) discharge (mixed-effects logistic regression) and 30-day mortality (Cox regression) were analysed. Potential catecholamine/MAP target ratios for optimized outcomes were assessed in models adjusted for age, sex, pH, lactate and prior resuscitation, stratified by centre. Results N = 704 patients: median age 63 years, 74% male, 34% post-resuscitation, median lactate 5.2 mmol/l. Of these, 53% were discharged from ICU, 48% died within 30 days. Higher inotropic scores independently predicted a lower probability of ICU discharge (baseline score: OR 0.78 [95%-CI 0.69–0.88]; summarized score: OR 0.46 [0.38–0.56]; both P < .001) and higher risk of 30-day mortality (baseline score: HR 1.27 [1.15–1.40], summarized score HR 1.83 [1.60–2.09]; both P < .001). A score/MAP ratio <0.403 µg/kg/min/mmHg was associated with higher ICU discharge odds (ceiling effect); a < 0.426 µg/kg/min/mmHg with lower 30-day mortality hazards (no ceiling effect). Lowering catecholamine doses by accepting reduced MAP targets was linked to better outcomes. Conclusion In HF-CS, higher catecholamine support independently associates with worse outcomes. Accepting lower blood pressure targets to reduce catecholamine dosage may improve outcomes. Validation in randomized controlled trials is urgently needed.

Background Lactic acidosis is associated with mortality in patients with cardiogenic shock (CS). Elevated lactate levels and systemic acidemia (low blood pH) have both been proposed as drivers of death. We, therefore, analyzed the association of both high lactate concentrations and low blood pH with 30‐day mortality in patients with CS. Methods and Results This was a 2‐center historical cohort study of unselected patients with CS with available data for admission lactate level or blood pH. CS severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock classification. All‐cause survival at 30 days was analyzed using Kaplan‐Meier curves and Cox proportional‐hazards analysis. There were 1814 patients with CS (mean age, 67.3 years; 68.5% men); 51.8% had myocardial infarction and 53.0% had cardiac arrest. The distribution of SCAI shock stages was B, 10.8%; C, 30.7%; D, 38.1%; and E, 18.7%. In both cohorts, higher lactate or lower pH predicted a higher risk of adjusted 30‐day mortality. Patients with a lactate ≥5 mmol/L or pH <7.2 were at increased risk of adjusted 30‐day mortality; patients with both lactate ≥5 mmol/L and pH <7.2 had the highest risk of adjusted 30‐day mortality. Patients in SCAI shock stages C, D, and E had higher 30‐day mortality in each SCAI shock stage if they had lactate ≥5 mmol/L or pH <7.2, particularly if they met both criteria. Conclusions Higher lactate and lower pH predict mortality in patients with cardiogenic shock beyond standard measures of shock severity. Severe lactic acidosis may serve as a risk modifier for the SCAI shock classification. Definitions of refractory or hemometabolic shock should include high lactate levels and low blood pH.

Aims Early risk stratification is essential to guide treatment in cardiogenic shock (CS). Existing CS risk scores were derived in selected cohorts, without accounting for the heterogeneity of CS. The aim of this study was to develop a universal risk score (the Cardiogenic Shock Score, CSS) for all CS patients, irrespective of the underlying cause. Methods and results Within a registry of 1308 CS unselected patients admitted to a tertiary care hospital between 2009 and 2019, a Cox regression model was fitted to derive the CSS, with 30‐day mortality as main outcome. The CSS's predictive ability was compared to the IABP‐SHOCK II score, the CardShock score and SCAI classification by C‐indices and validated in an external cohort of 934 CS patients. Based on the Cox regression, nine predictors were included in the CSS: age, sex, acute myocardial infarction (AMI‐CS), systolic blood pressure, heart rate, pH, lactate, glucose and cardiac arrest. The CSS had the highest C‐index in the overall cohort (0.740 vs. 0.677/0.683 for IABP‐SHOCK II score/CardShock score), in patients with AMI‐CS (0.738 vs. 0.675/0.689 for IABP‐SHOCK II score/CardShock score) and in patients with non‐AMI‐CS (0.734 vs. 0.677/0.669 for IABP‐SHOCK II score/CardShock score). In the external validation cohort, the CSS had a C‐index of 0.73, which was higher than all other tested scores. Conclusion The CSS provides improved information on the risk of death in unselected patients with CS compared to existing scores, irrespective of its cause. Because it is based on point‐of‐care variables which can be obtained even in critical situations, the CSS has the potential to guide treatment decisions in CS.