Abstract Background / Introduction The use of adrenaline in cardiogenic shock (CS) patients remains debated. Although adrenaline is frequently employed as inotrope and/or vasopressor in severe presentations of CS, its potential association with increased mortality has raised concerns but with weak data from small studies and randomized trials. The AltShock2 Registry is, by far, the biggest prospective registry on CS patients in Italy and it can provide an updated real-world assessment about the use of vasoactive agent in this clinical setting. Purpose To evaluate the impact of adrenaline administration on in-hospital mortality in patients with cardiogenic shock and to identify independent predictors of mortality within the AltShock2 Registry cohort. Methods All consecutive CS patients enrolled between January 2020 and September 2025 were analyzed. Patients with missing vasoactive therapy data were excluded. Subjects were stratified according to adrenaline use. Demographic, clinical, hemodynamic, and therapeutic variables—including SCAI stage, number and type of vasoactive drugs, lactate and heart rate at admission—were compared between groups. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. ROC analyses were performed to assess discrimination, and propensity score–adjusted and matched analyses were conducted to account for treatment selection bias. Results A total of 1082 patients were included (median age 64 years; 74% male). Adrenaline was used in approximately 45% of cases, typically in patients with more advanced SCAI stages and higher admission lactate levels. Crude mortality was higher in the adrenaline group (55% vs. 35%, p0.001), but this association was not confirmed after propensity adjustment (p=0.42). Independent predictors of mortality included higher lactate at presentation (OR 1.34, 95% CI 1.12–1.60, p0.001), advanced SCAI class (≥D), older age, and chronic kidney disease, whereas adrenaline use itself was not an independent predictor (p=0.29). In ROC analysis, lactate and SCAI stage demonstrated the highest discrimination power (AUC 0.72 and 0.69, respectively), while adrenaline exposure alone yielded poor prognostic value (AUC 0.54). The full multivariable model achieved an AUC of 0.81, indicating good predictive performance. Conclusions In this large, contemporary, multicenter registry of unselected CS patients, adrenaline administration was not independently associated with increased in-hospital mortality after adjustment for baseline risk and shock severity. Mortality remains primarily driven by shock severity (SCAI class) and hypoperfusion (lactate). These findings suggest that adrenaline use likely reflects clinical severity rather than being an intrinsically harmful therapy. Further studies are warranted to define vasoactive choice in CS patients.
Villanova et al. (Fri,) studied this question.