Current real-life use of vasopressors and inotropes in cardiogenic shock - adrenaline use is associated with excess organ injury and mortality
Por:
Tarvasmaki, T, Lassus, J, Varpula, M, Sionis, A, Sund, R, Kober, L, Spinar, J, Parissis, J, Banaszewski, M, Cardoso, JS, Carubelli, V, Di Somma, S, Mebazaa, A, Harjola, VP
Publicada:
4 jul 2016
Resumen:
Background: Vasopressors and inotropes remain a cornerstone in stabilization of the severely impaired hemodynamics and cardiac output in cardiogenic shock (CS). The aim of this study was to analyze current real-life use of these medications, and their impact on outcome and on changes in cardiac and renal biomarkers over time in CS.
Methods: The multinational CardShock study prospectively enrolled 219 patients with CS. The use of vasopressors and inotropes was analyzed in relation to the primary outcome, i.e., 90-day mortality, with propensity score methods in 216 patients with follow-up data available. Changes in cardiac and renal biomarkers over time until 96 hours from baseline were analyzed with linear mixed modeling.
Results: Patients were 67 (SD 12) years old, 26 % were women, and 28 % had been resuscitated from cardiac arrest prior to inclusion. On average, systolic blood pressure was 78 (14) and mean arterial pressure 57 (11) mmHg at detection of shock. 90-day mortality was 41 %. Vasopressors and/or inotropes were administered to 94 % of patients and initiated principally within the first 24 hours. Noradrenaline and adrenaline were given to 75 % and 21 % of patients, and 30 % received several vasopressors. In multivariable logistic regression, only adrenaline (21 %) was independently associated with increased 90-day mortality (OR 5.2, 95 % CI 1.88, 14.7, p = 0.002). The result was independent of prior cardiac arrest (39 % of patients treated with adrenaline), and the association remained in propensity-score-adjusted analysis among vasopressor-treated patients (OR 3.0, 95 % CI 1.3, 7.2, p = 0.013); this was further confirmed by propensity-score-matched analysis. Adrenaline was also associated, independent of prior cardiac arrest, with marked worsening of cardiac and renal biomarkers during the first days. Dobutamine and levosimendan were the most commonly used inotropes (49 % and 24 %). There were no differences in mortality, whether noradrenaline was combined with dobutamine or levosimendan.
Conclusion: Among vasopressors and inotropes, adrenaline was independently associated with 90-day mortality in CS. Moreover, adrenaline use was associated with marked worsening in cardiac and renal biomarkers. The combined use of noradrenaline with either dobutamine or levosimendan appeared prognostically similar.
Filiaciones:
Tarvasmaki, T:
Univ Helsinki, Emergency Med, POB 340, Helsinki 00029, Finland
Helsinki Univ Hosp, Dept Emergency Med & Serv, POB 340, Helsinki 00029, Finland
Lassus, J:
Univ Helsinki, Div Cardiol, Heart & Lung Ctr, Helsinki, Finland
Helsinki Univ Hosp, Helsinki, Finland
Varpula, M:
Univ Helsinki, Div Cardiol, Heart & Lung Ctr, Helsinki, Finland
Helsinki Univ Hosp, Helsinki, Finland
Sionis, A:
Hosp Santa Creu & Sant Pau, Dept Cardiol, Intens Cardiac Care Unit, Biomed Res Inst St Pau IIB St Pau, Barcelona, Spain
Sund, R:
Univ Helsinki, Ctr Res Methods, Fac Social Sci, Dept Social Res, Helsinki, Finland
Kober, L:
Copenhagen Univ Hosp, Rigshosp, Div Heart Failure Pulm Hypertens & Heart Transpla, Copenhagen, Denmark
Spinar, J:
Univ Hosp Brno, Dept Internal Med & Cardiol, Brno, Czech Republic
Parissis, J:
Attikon Univ Hosp, Heart Failure Clin, Athens, Greece
Attikon Univ Hosp, Secondary Cardiol Dept, Athens, Greece
Banaszewski, M:
Inst Cardiol, Intens Cardiac Therapy Clin, Warsaw, Poland
Cardoso, JS:
Univ Porto, Porto Med Sch, Sao Joao Hosp Ctr, Dept Cardiol,CINTESIS, Oporto, Portugal
Carubelli, V:
Univ Brescia, Div Cardiol, Dept Med & Surg Specialties Radiol Sci & Publ Hlt, Brescia, Italy
Civil Hosp Brescia, Brescia, Italy
Di Somma, S:
Univ Rome Sapienza, Emergency Med St Andrea Hosp, Dept Med Sci & Translat Med, Rome, Italy
Mebazaa, A:
Hop Lariboisiere, AP HP, INSERM, U942, Paris, France
Univ Paris Diderot, Paris, France
Harjola, VP:
Univ Helsinki, Emergency Med, POB 340, Helsinki 00029, Finland
Helsinki Univ Hosp, Dept Emergency Med & Serv, POB 340, Helsinki 00029, Finland
Gold, Green Published
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