Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry.

Background: Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. Methods: The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours (h) from CICU admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both timepoints, as well as change in VIS from 4h to 24h, were examined. Interaction testing was performed by mechanical circulatory support (MCS) status. Results: Among 3,665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10point increase and decrease from 4h to 24h, respectively. The 4h and 24h VIS were each associated with CICU mortality (13%- 45% and 11%-73% for VIS <10 to ≥40, respectively; ptrend <0.0001 for each). Stratifying by the 4h VIS, changes in VIS from 4h to 24h had a graded association with mortality, ranging from a 2-to->4-fold difference in mortality comparing those with a ≥10-point increase to a ≥10-point decrease in VIS (p-trend <0.0001). The change in VIS alone provided good discrimination of CICU mortality (C-statistic 0.72 [95% CI 0.70-0.75]), and improved discrimination of the 24h SOFA score (0.76 [95% CI 0.74-0.78] from 0.72 [95% CI 0.69-0.74]) and the clinician-assessed SCAI stage (0.77 [95% CI 0.75-0.79] from 0.72 [95% CI 0.70-0.74]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with vs. without MCS (OR per 10-point higher 24h VIS: 1.36 [1.23-1.49] vs. 1.84 [1.69-2.01]; p-interaction<0.0001). Conclusions: Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with potential to be leveraged for clinical decision-making and research applications in CS.