Temporal Trends and Clinical Outcomes Associated with Vasopressor and Inotrope Use in The Cardiac Intensive Care Unit

Abstract

Background: The use of norepinephrine may be associated with better outcomes in some patients with shock. We sought to determine whether norepinephrine was associated with lower mortality in unselected cardiac intensive care unit (CICU) patients compared with other vasopressors, and whether patterns of vasopressor and inotrope usage in the CICU have changed over time. Methods: We retrospectively evaluated consecutive adult patients admitted to a tertiary care hospital CICU from January 1, 2007 to December 31, 2015. Vasoactive drug doses were quantified using the peak Vasoactive-Inotropic Score (VIS). Temporal trends were assessed using the Cochran–Armitage trends test and multivariable logistic regression was used to determine predictors of hospital mortality. Results: We included 10,004 patients with a mean age of 67 ± 15 years; vasoactive drugs were used in 2,468 (24.7%) patients. Use of norepinephrine increased over time, whereas dopamine utilization decreased (P < 0.001 for trends). After adjustment for illness severity and other variables, the peak VIS was a predictor of hospital mortality across the entire population (unit odds ratio [OR] 1.013, 95% confidence interval [CI], 1.009–1.017, P < 0.001) and among patients receiving vasoactive drugs (OR 1.018, 95% CI, 1.013–1.022, P < 0.001). Among patients receiving vasoactive drugs, norepinephrine was associated with a lower risk of hospital mortality (OR 0.66, 95% CI, 0.49–0.90, P = 0.008) after adjustment for illness severity and peak VIS. Conclusions: Vasoactive drug use in CICU patients has a dose-dependent association with short-term mortality. Use of norepinephrine in CICU patients is associated with decreased odds of death when compared with other vasoactive drugs.

Association between mean arterial pressure during the first 24 hours and hospital mortality in patients with cardiogenic shock

“…The findings of our study indirectly support the safety of a lower MAP target (i.e., 65-70 mmHg) in CS patients, but did not show a benefit of higher MAP targets among patients with a history of hypertension. Evidence supports the use of vasopressors such as norepinephrine that have a lower rate of cardiovascular adverse events, including increased myocardial oxygen demand, ischemia, arrhythmias, and mortality [1,14]. In general, increasing doses of vasoactive agents increase the risk of cardiovascular adverse events and are associated with higher mortality, and current recommendations suggest the lowest effective dose necessary to achieve a target MAP [3,14].…”

“…Evidence supports the use of vasopressors such as norepinephrine that have a lower rate of cardiovascular adverse events, including increased myocardial oxygen demand, ischemia, arrhythmias, and mortality [1,14]. In general, increasing doses of vasoactive agents increase the risk of cardiovascular adverse events and are associated with higher mortality, and current recommendations suggest the lowest effective dose necessary to achieve a target MAP [3,14]. We observed a strong independent association between higher vasopressor doses based on VIS 24 and higher hospital mortality.…”

“…Blood pressure was preferentially recorded from invasive measurements, when available, and otherwise was recorded from noninvasive measurements. Peak vasopressor and inotrope doses were used to calculate the Vasoactive-Inotropic Score [14]. Admission diagnoses included all ICD-9 diagnostic codes recorded on the day of CICU admission and the day before or after CICU admission; these admission diagnoses were not mutually exclusive, and the primary admission diagnosis could not be determined.…”

Impact of concomitant vasoactive treatment and mechanical left ventricular unloading in a porcine model of profound cardiogenic shock

“…Stepwise injections of microspheres was continued until CS developed, defined as mixed venous oxygen saturation (SvO 2 ) reduction to < 30% or ≤ 50% of baseline value and/or sustained cardiac index < 1.5 L/min/m 2 for ≥10 min. A median of 12 microsphere injections (interquartile range, [9][10][11][12][13][14][15][16][17] was required to induce CS. Following the onset of CS, Impella CP was advanced from the left femoral artery and placed across the aortic valve with the inlet in the left ventricle and outlet in the ascending aorta.…”

“…Exogenous catecholamines stimulating αand/or β-adrenergic receptors are administrated in about 90% of AMICS cases [1,9]. However, observational studies suggest that high dosage and prolonged use of vasoactive drugs are associated with increased mortality [10,11]. β-Adrenergic agonists improve inotropic and chronotropic state, thus improving CO by enhancing myocardial contractility and increasing heart rate (HR) [12].…”