Association of Hemo-Metabolic Trajectory and Cardiogenic Shock Mortality: Analysis from the CSWG Registry

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ABSTRACT Background Cardiogenic shock (CS) is as a hemodynamic disorder that can progress to systemic metabolic derangements. Prior studies have reported hemodynamic parameters associated with mortality in limited cohorts or at single time points. Hemodynamic trajectories have not been described. Objectives We studied the association between hemodynamics and in-hospital mortality in patients with CS due to heart failure (HF-CS) and acute myocardial infarction (AMI-CS). Methods Using data from the large multicenter Cardiogenic Shock Working Group (CSWG) registry, we analyzed hemo-metabolic data obtained at the time of pulmonary artery catheter (PAC) insertion (baseline) and at PAC removal or death (final). Univariable regression analyses for prediction of in-hospital mortality were conducted for baseline and final hemo-metabolic values, as well as the interval change (delta-P), and analyzed based on CS etiology and survival status. Results 2,260 patients with PAC data were included (70% male, age 61±14, 61% HF-CS, 27% AMI-CS). In-hospital mortality was higher in the AMI-CS group (40.1%) compared to HF-CS (22.4%), p<0.001). In the HF-CS cohort, survivors exhibited lower right atrial pressure (RAP), pulmonary artery pressures (PAP), cardiac output/index (CO/CI), lactate and higher blood pressure (BP) than non-survivors at baseline. In this cohort, during hospitalization, improvement in metabolic (AST, lactate), BP, hemodynamic (RAP, PAPi, PA compliance for right sided profile and CO/CI for left sided profile), had association with survival. In the AMI-CS cohort, a lower systolic BP and higher PAP were associated with odds of death at baseline. Improvement in metabolic (lactate), BP, hemodynamic (RAP, PAPi for right-sided profile and CO/CI for left-sided profile) were associated with survival. Conclusions In a large contemporary CS registry, few hemo-metabolics at baseline determined survival in AMI-CS; rather hemodynamic trajectories had a strong association with outcomes in both cohorts. These findings suggest the importance of monitoring hemo-metabolic trajectories to tailor management in patients with CS. What is New? While previous cardiogenic shock studies have reported hemodynamic parameters associated with mortality in limited cohorts or at single time points, we used data from a large multi-center registry to analyze hemodynamic trajectory in patients with cardiogenic shock from pulmonary artery catheter insertion to removal. We found that few baseline hemodynamic parameters were predictive of survival in AMI-CS. However, in both AMI-CS and HF-CS, the hemodynamic trajectory was strongly associated with outcomes. What Are the Clinical Implications? Our findings suggest that targeted interventions in patients with cardiogenic shock impact clinical outcomes independently of baseline hemodynamic derangement and highlight the importance of invasive hemodynamic monitoring to tailor management in these patients.

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