Safety and efficacy of early use of mineralocorticoid receptor antagonists in cardiogenic shock: a propensity score-matched analysis.

Background: Despite its high incidence and mortality, the level of evidence for cardiogenic shock (CS) treatments remains very low. This study aims to evaluate the influence of early treatment with mineralocorticoid receptor antagonist (MRA) in CS.

Methods: FRENSHOCK is a prospective registry including 772 CS patients from 49 centres. The association between early MRA use and 30-day all-cause mortality was assessed in a 1:3 propensity-matched cohort. Early MRA use was defined as documented use within 24 h of admission.

Results: Among the 693 CS patients included, MRAs were used in 91 (13.1%). Patients treated with MRA presented with a more frequent history of cardiac disease (78.0% vs. 56.0%, p < 0.01) and had lower LVEF (20.0% vs. 25.0%, p = 0.01). After matching, 91 patients treated with MRA were compared to 273 patients who did not receive MRA. MRA use was associated with a significant reduction in 30-day mortality, with a matched HR of 0.49 (0.27-0.91), p = 0.02. In subgroup analysis, the benefit of MRA appeared more pronounced in patients with severely reduced LVEF (≤ 20%) or acute myocardial infarction. There were no increased risks of hyperkalaemia or worsening renal function after 24 h of management, albeit with a risk of hypotension.

Conclusion: In this prospective, multicentre, nationwide, propensity score-matched study of patients with a broad spectrum of CS aetiologies, early MRA use was associated with a significant reduction in 30-day all-cause mortality. Further randomized trials are needed to confirm its benefit and clarify its role in therapeutic management.