Aggressive Up-titration of Heart Failure Guideline-Directed Medical Therapies in Cardiogenic Shock Supported by a Percutaneous Ventricular Assist Device.

Abstract

Background: Survival after cardiogenic shock (CS) remains dismal and largely unaltered in clinical trials, contrasting heart failure with reduced ejection fraction where new drugs have established guideline directed therapy, improving long term outcomes. Unfortunately, unfavorable effects on blood pressure and glomerular perfusion limits their use in CS. A percutaneous ventricular assist device (pVAD) supports cardiac output and blood pressure, offering an option to counteract these negative drug effects.

Objectives: This study aimed to evaluate if a protocol prolonging pVAD support to up-titrate heart failure drugs, is feasible and safe.

Methods: All CS patients treated with pVAD after the introduction of the protocol in October 2021 were included as was a control group of patients between 2019 and October 2021. Data were retrospectively extracted from health records to calculate the use of heart failure drugs and study outcomes.

Results: 28 patients were in the intervention cohort, 33 in the historical cohort. Median ages were 61 and 68 years and acute myocardial infarction was predominant etiology. SCAI shock stages were D or E in 82% vs 69% (p=0.449). Lactate levels were 6.2 mmol/L (2.8-9.9 mmol/L) and 6.6 mmol/L (2-12 mmol/L); p=0.341. In the intervention group, at discharge, 94% was treated with spironolactone 25 mg, 94% with dapagliflozin/empaglifozin 10 mg, 100% with valsartan or sacubitril/valsartan and 94% with rate control, associated to significantly higher treatment intensity, compared to the historical cohort. 90-day survival was 71% in the intervention group vs 52% in the historical cohort (p=0.081), and complications rates were comparable.

Conclusion: Prolonging pVAD support to uptitrate medical therapy is feasible and safe.