Hemodynamic variables and mortality in cardiogenic shock: a retrospective cohort study

Christian Torgersen, Christian A Schmittinger, Sarah Wagner, Hanno Ulmer, Jukka Takala, Stephan M Jakob, Martin W Dünser, Christian Torgersen, Christian A Schmittinger, Sarah Wagner, Hanno Ulmer, Jukka Takala, Stephan M Jakob, Martin W Dünser

Abstract

Introduction: Despite the key role of hemodynamic goals, there are few data addressing the question as to which hemodynamic variables are associated with outcome or should be targeted in cardiogenic shock patients. The aim of this study was to investigate the association between hemodynamic variables and cardiogenic shock mortality.

Methods: Medical records and the patient data management system of a multidisciplinary intensive care unit (ICU) were reviewed for patients admitted because of cardiogenic shock. In all patients, the hourly variable time integral of hemodynamic variables during the first 24 hours after ICU admission was calculated. If hemodynamic variables were associated with 28-day mortality, the hourly variable time integral of drops below clinically relevant threshold levels was computed. Regression models and receiver operator characteristic analyses were calculated. All statistical models were adjusted for age, admission year, mean catecholamine doses and the Simplified Acute Physiology Score II (excluding hemodynamic counts) in order to account for the influence of age, changes in therapies during the observation period, the severity of cardiovascular failure and the severity of the underlying disease on 28-day mortality.

Results: One-hundred and nineteen patients were included. Cardiac index (CI) (P = 0.01) and cardiac power index (CPI) (P = 0.03) were the only hemodynamic variables separately associated with mortality. The hourly time integral of CI drops <3, 2.75 (both P = 0.02) and 2.5 (P = 0.03) L/min/m2 was associated with death but not that of CI drops <2 L/min/m2 or lower thresholds (all P > 0.05). The hourly time integral of CPI drops <0.5-0.8 W/m2 (all P = 0.04) was associated with 28-day mortality but not that of CPI drops <0.4 W/m2 or lower thresholds (all P > 0.05).

Conclusions: During the first 24 hours after intensive care unit admission, CI and CPI are the most important hemodynamic variables separately associated with 28-day mortality in patients with cardiogenic shock. A CI of 3 L/min/m2 and a CPI of 0.8 W/m2 were most predictive of 28-day mortality. Since our results must be considered hypothesis-generating, randomized controlled trials are required to evaluate whether targeting these levels as early resuscitation endpoints can improve mortality in cardiogenic shock.

Figures

Figure 1
Figure 1
Schematic description of the cardiac index time integral and the time integral of cardiac index drops below 3 L/min/m2 during the first 24 hours after intensive care unit admission. Dotted area = cardiac index time integral. Coloured area = time integral of cardiac index drops below 3 L/min/m2.
Figure 2
Figure 2
Histograms showing the time in hours of hemodynamic variable recordings in the study population. CVP = central venous pressure; HR = heart rate; MAP = mean arterial blood pressure; PAC = pulmonary artery catheter.

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