Diastolic Perfusion Pressure Predicts Response to Inotropes/Vasopressors and Benefit from Mechanical Circulatory Support in Cardiogenic Shock?
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Background
Hemodynamic response to escalation of vasoactive drugs has not been well-characterized in patients with cardiogenic shock CS. We tested the hypothesis that lower diastolic perfusion pressure (DPP=diastolic blood pressure-right atrial pressure) was associated with more limited hemodynamic response to up-titration of vasoactive drugs and with possible benefit from early mechanical circulatory support (MCS) in patients with CS.
Methods
This study consisted of two parts. (i) We evaluated the relationship between baseline DPP and changes in cardiac power output index (CPOI) in response to increase in vasoactive drugs in a cohort of patients with CS (n=93). (ii) We compared all-cause mortality based on baseline DPP in a post hoc analysis of the ECMO CS trial. CPOI responders were defined as post-escalation CPOI≥0.28 W/m 2 .
Results
Vasoactive inotrope score escalated from 11.2±3.9 to 24.5±4.7. Escalation of vasoactive drugs was associated with increases in CPOI to 0.23±0.06 W/m 2 (all p<0.001).
Post-escalation CPOI was directly related to baseline cardiac index and DPP. Baseline DPP discriminated CPO responders from non-responders with optimal cutoff of 37mmHg. Patients with baseline DPP≥37mmHg had greater CPOI increase and lactate clearance. In the ECMO-CS trial, patients with DPP˂37mmHg had lower mortality (HR 0.37, 95% CI 0.14-0.97, P=0.044) with immediate VA ECMO compared to early conservative management, but no significant difference in the subgroup with DPP≥37mmHg.
Conclusion
Lower DPP was associated with more limited hemodynamic response to escalation of vasoactive drugs and potentially greater benefit from early VA-ECMO in CS.
