(422) Changes in Pulse Pressure after 24 Hours of Initiation of Inotrope Therapy in Cardiogenic Shock is Associated with Adverse Outcomes

PurposeCardiogenic shock (CS) is a leading cause of in-hospital morbidity and mortality. We sought to determine the association between serial changes in hemodynamics after initiation of inotrope therapy and outcomes.MethodsData were obtained from the DOREMI randomized clinical trial. A total of 155 participants with SCAI Stage C CS at a single center from 9/2017 to 5/2020 were included. Participants received either dobutamine or milrinone for CS. Serial measurements of pulse pressure and percent change from baseline were measured at 4, 12, and 24 hours after initiation of inotropes. The primary outcome was a composite of in-hospital death, resuscitated cardiac arrest, cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy. The secondary outcome was in-hospital death.ResultsThe cohort was predominantly male (62.6%), with a mean age of 70.6±12.5 years. A total of 77 (49.7%) participants received milrinone, and the remaining received dobutamine. At baseline, patients with SCAI stage C CS had median pulse pressure of 45 (IQR: [34, 56]) mmHg. Lower absolute change in pulse pressure at 24 hours was associated with the primary outcome (median 2 with IQR: [-4, 10] vs. 9 with IQR [-4, 20] mmHg, p=0.03) and secondary outcome (p=0.027). Participants who met the primary outcome had reduced percent change in pulse pressure compared to baseline (median 4.3% IQR: [-7.7%, 23.8%] vs. 16.5% IQR: [-9.6%, 52.9%], p=0.05). Pulse pressure alone at each time point was not associated with primary outcome (0 hours: p=0.46, 4 hours: p=0.85, 12 hours p=0.89, 24 hours p=0.10).ConclusionIn patients with SCAI Stage C CS, reduced absolute or percent change in pulse pressure at 24 hours after initiation of an inotrope is associated with adverse cardiovascular outcomes. This dynamic change may be considered for decisions regarding early escalation of therapy. Cardiogenic shock (CS) is a leading cause of in-hospital morbidity and mortality. We sought to determine the association between serial changes in hemodynamics after initiation of inotrope therapy and outcomes. Data were obtained from the DOREMI randomized clinical trial. A total of 155 participants with SCAI Stage C CS at a single center from 9/2017 to 5/2020 were included. Participants received either dobutamine or milrinone for CS. Serial measurements of pulse pressure and percent change from baseline were measured at 4, 12, and 24 hours after initiation of inotropes. The primary outcome was a composite of in-hospital death, resuscitated cardiac arrest, cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy. The secondary outcome was in-hospital death. The cohort was predominantly male (62.6%), with a mean age of 70.6±12.5 years. A total of 77 (49.7%) participants received milrinone, and the remaining received dobutamine. At baseline, patients with SCAI stage C CS had median pulse pressure of 45 (IQR: [34, 56]) mmHg. Lower absolute change in pulse pressure at 24 hours was associated with the primary outcome (median 2 with IQR: [-4, 10] vs. 9 with IQR [-4, 20] mmHg, p=0.03) and secondary outcome (p=0.027). Participants who met the primary outcome had reduced percent change in pulse pressure compared to baseline (median 4.3% IQR: [-7.7%, 23.8%] vs. 16.5% IQR: [-9.6%, 52.9%], p=0.05). Pulse pressure alone at each time point was not associated with primary outcome (0 hours: p=0.46, 4 hours: p=0.85, 12 hours p=0.89, 24 hours p=0.10). In patients with SCAI Stage C CS, reduced absolute or percent change in pulse pressure at 24 hours after initiation of an inotrope is associated with adverse cardiovascular outcomes. This dynamic change may be considered for decisions regarding early escalation of therapy.