Pre-event guideline-directed optimized medical therapy intensity and in-hospital mortality in heart failure–related cardiogenic shock: insights from the ALT-SHOCK registry

Background The prognostic relevance of pre-event heart failure (HF) guideline-optimized medical therapy (OMT) intensity in HF-related cardiogenic shock (HF-CS) remains poorly defined. Purpose To assess the association between pre-event OMT intensity—defined by the four HF pharmacological pillars—and in-hospital mortality in HF-CS and in the acute decompensated HF-CS (ADHF-CS) subgroup. Methods Multicentre registry including patients with HF-CS (N=248) and the ADHF-CS subgroup (N=135). Pre-event OMT intensity was defined as the number of HF drug classes (0–4) among the four pillars (beta-blocker, RAAS inhibitor and/or ARNI, mineralocorticoid receptor antagonist, SGLT2 inhibitor) and reported as 0-4 pillars, including OMT4 (4/4 pillars) and OMT≥3 (≥3 pillars). The primary endpoint was in-hospital mortality; associations with mortality were estimated using robust Poisson regression (risk ratios, RR) adjusted for age, sex, SCAI class (A-B/C/D-E), admission lactate, baseline haemoglobin and use of mechanical circulatory support (Intra-Aortic Balloon Pump (IABP)/Impella/VA-ECMO). Results In-hospital mortality was 27.0% (67/248) in HF-CS and 31.9% (43/135) in the ADHF-CS subgroup. OMT4 (4/4 pillars) was present in 22/248 (8.9%) HF-CS patients and 21/135 (15.6%) in ADHF-CS patients (p=0.070); OMT≥3 was present in 80/248 (32.3%) and 65/135 (48.1%), respectively (p=0.003). In HF-CS, OMT4 was associated with lower mortality versus <4 pillars (4.5% vs 29.2%, p=0.011; adjusted RR 0.17, 95%CI 0.03–0.96, p=0.045), whereas OMT≥3 was not associated with lower mortality (18.8% vs 31.0%, p=0.061; adjusted RR 0.63, 95%CI 0.38–1.03, p=0.067). In ADHF-CS, both OMT4 (4.8% vs 36.8%, p=0.004; adjusted RR 0.13, 95% CI 0.02–0.74, p=0.021) and OMT≥3 (18.5% vs 44.3%, p=0.002; adjusted RR 0.45, 95%CI 0.26–0.78, p=0.004) were associated with lower mortality. Each additional pre-event pillar was associated with lower risk (adjusted RR per +1 pillar 0.78, 95%CI 0.66–0.92, p=0.003). In ADHF-CS, in-hospital mortality by pre-event OMT score (0–4 pillars) is shown in Figure 1. Conclusions In this real-world HF-CS registry, greater pre-event OMT intensity—most consistently in ADHF-CS—was associated with lower in-hospital mortality. These observational findings are hypothesis-generating and warrant prospective confirmation.