Key result
Individual vasoactive choice, including epinephrine, within each SCAI class was not significantly associated with 30-day mortality in patients with acute myocardial infarction and cardiogenic shock after multivariable adjustment.
Why the study?
The study aimed to compare the achievement of treatment targets and outcomes in relation to vasoactive strategy in AMICS patients stratified by SCAI shock classification.
Does the specific choice of vasoactive strategy affect hemodynamic target achievement and 30-day mortality in patients with AMICS stratified by SCAI shock class?
Cohort (n=1,249)
Yes
Does the specific choice of vasoactive strategy affect hemodynamic target achievement and 30-day mortality in patients with AMICS stratified by SCAI shock class?
Effect estimate: OR 1.28 (95% CI 0.72-2.28)
p-value: p=0.396
In patients with AMICS, while higher SCAI shock stages require greater vasoactive loads to achieve hemodynamic targets, the specific choice of vasoactive agent does not independently impact 30-day mortality after adjustment.
Vasoactive choice should not yet guide AMICS therapy by SCAI class; this observational analysis leaves open the need for randomized confirmation.
BACKGROUND: Vasoactive treatment is a cornerstone in treating hypoperfusion in cardiogenic shock following acute myocardial infarction (AMICS). The purpose was to compare the achievement of treatment targets and outcome in relation to vasoactive strategy in AMICS patients stratified according to the Society of Cardiovascular Angiography and Interventions (SCAI) shock classification. METHODS: Retrospective analysis of patients with AMICS admitted to cardiac intensive care unit at two tertiary cardiac centers during 2010-2017 with retrieval of real-time hemodynamic data and dosages of vasoactive drugs from intensive care unit databases. RESULTS: Out of 1,249 AMICS patients classified into SCAI class C, D, and E, mortality increased for each shock stage from 34% to 60%, and 82% (p<0.001). Treatment targets of mean arterial blood pressure > 65mmHg and venous oxygen saturation > 55% were reached in the majority of patients; however, more patients in SCAI class D and E had values below treatment targets within 24 hours (p<0.001) despite higher vasoactive load and increased use of epinephrine for each severity stage (p<0.001). In univariate analysis no significant difference in mortality within SCAI class D and E regarding vasoactive strategy was observed, however in SCAI class C, epinephrine was associated with higher mortality and a significantly higher vasoactive load to reach treatment targets. In multivariate analysis there was no statistically association between individually vasoactive choice within each SCAI class and 30-day mortality. CONCLUSION: Hemodynamic treatment targets were achieved in most patients at the expense of increased vasoactive load and more frequent use of epinephrine for each shock severity stage. Mortality was high regardless of vasoactive strategy; only in SCAI class C, epinephrine was associated with a significantly higher mortality, but the signal was not significant in adjusted analysis.
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Udesen et al. (2022) conducted a cohort in Acute myocardial infarction and cardiogenic shock (AMICS) (n=1,249). Epinephrine vs. Other vasoactive strategies was evaluated on 30-day mortality (adjusted) (OR 1.28, 95% CI 0.72-2.28, p=0.396). Individual vasoactive choice, including epinephrine, within each SCAI class was not significantly associated with 30-day mortality in patients with acute myocardial infarction and cardiogenic shock after multivariable adjustment.
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