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Arterial Lactate in Cardiogenic Shock: Prognostic Value of Clearance Versus Single Values
Georg Fuernau1, Steffen Desch2, Suzanne de Waha-Thiele1
1Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Lübeck, Lübeck, Germany; German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany.
Insights
Lactate levels measured 8 hours after admission (L2) are superior for predicting mortality in cardiogenic shock (CS) compared to initial lactate (L1) or lactate clearance (LC). An L2 level of 3.1 mmol/l is a key indicator for early prognosis in CS patients.
Area of Science:
- Cardiology
- Intensive Care Medicine
- Biomarkers
Background:
- Early prognosis in cardiogenic shock (CS) is vital for treatment selection.
- Arterial lactate is a common point-of-care parameter in CS.
- Lactate clearance (LC) is well-studied in septic shock but not well-established in CS.
Purpose of the Study:
- To compare the predictive value of admission lactate (L1), 8-hour lactate (L2), and lactate clearance (LC) for mortality in CS.
- To determine if L2 is a superior predictor of mortality compared to L1 and LC.
Main Methods:
- Subanalysis of the IABP-SHOCK II trial and registry data.
- Prospective collection of lactate levels (L1 and L2).
- Assessment of all-cause mortality at 30 days as the primary endpoint.
Main Results:
- L2 demonstrated superior predictive performance (AUC 0.76) compared to L1 (AUC 0.69) and LC (AUC 0.59).
- An L2 cutoff of ≥3.1 mmol/l was independently predictive of mortality.
- L2 and LC were independently predictive in multivariable analysis, with L2 showing higher predictive power.
Conclusions:
- Arterial lactate measured 8 hours post-admission (L2) is a better predictor of mortality in CS than baseline lactate or LC.
- An L2 cutoff of 3.1 mmol/l can aid in early prognosis assessment for CS patients.
- This L2 cutoff may serve as a new therapeutic target in CS management.
Objectives:
This study sought to compare single lactate values at admission (L1) and after 8 h (L2) with lactate clearance (LC) for mortality prediction in cardiogenic shock (CS).
Background:
Early estimation of prognosis in CS complicating acute myocardial infarction is crucial for tailored treatment selection. Arterial lactate is the most widely used point-of-care parameter in CS. In septic shock, lactate reduction over time-LC-has been extensively investigated. However, in CS, only limited data exist, and the prognostic value of LC is unknown.
Methods:
This study is a subanalysis of the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial and the corresponding registry. Lactate levels were prospectively collected. All-cause mortality at 30 days was assessed as primary endpoint.
Results:
For 671 of 783 (85.7%) patients, L1 and L2 values were available. The area under the receiver-operating characteristic curve (L1: 0.69; L2: 0.76; LC: 0.59) showed no difference between L1 and LC (p = 0.20). In contrast, L2 was a significantly better predictive parameter than L1 or LC (p < 0.001 for both). In multivariable stepwise Cox regression analysis, L2 ≥3.1 mmol/l (best cutoff value by Youden index) and LC <-3.45%/h remained independently predictive for time to death (p < 0.001 for both), with L2 showing the highest chi-square test score (42.1) and hazard ratio (2.89; 95% confidence interval: 2.10 to 3.97).
Conclusions:
Arterial lactate after 8 h is superior in mortality prediction in comparison with baseline lactate and LC. A cutoff value of 3.1 mmol/l for lactate after 8 h showed the best discrimination for assessing early prognosis in CS and may serve as new treatment goal. (Intraaortic Balloon Pump in Cardiogenic Shock II [IABP-SHOCK II]; NCT00491036).
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