Clinical impact of congestion in patients admitted for cardiogenic shock

Recent guidelines have proposed dichotomizing acute heart failure and cardiogenic shock phenotypes based on signs/symptoms of hypoperfusion/congestion.

We aimed to assess the prognostic significance of congestion and its early evolution during the first 24hours in a nationwide cardiogenic shock cohort.

FRENSHOCK was a prospective registry including 772 patients with cardiogenic shock from 49 centres. Patients were classified as cold and wet or cold and dry according to congestive signs. Death at 30days was analysed according to baseline phenotype.

Among 593 patients with cardiogenic shock included, 70.7% were male; the median age was 67.0 (58.0-77.0) years, and 521 patients (87.9%) presented with congestion. Congestive patients had higher rates of previous cardiac disease (60.5% vs. 43.1%; P<0.01) and chronic kidney disease (24.2% vs. 12.5%; P=0.04). No differences were found regarding Society for Cardiovascular Angiography and Interventions class distribution and lactate concentrations. Congestion was associated with an increased 30-day all-cause death rate (hazard ratio: 1.99, 95% confidence interval: 1.05-3.78; P=0.04), particularly among patients with persistent congestion beyond 24hours (hazard ratio: 2.29, 95% confidence interval: 1.20-4.36; P=0.01). Conversely, patients with resolved congestion at 24hours had similar outcomes to non-congestive patients (hazard ratio: 0.76, confidence interval: 0.31-1.88; P=0.56). The negative impact of congestion was confirmed in multivariable Cox regression analysis.

Congestion and its persistence beyond 24hours of management are frequent in patients with cardiogenic shock, and are significantly associated with an increased 30-day all-cause death rate, which may reflect either a direct harmful effect of congestion or difficulties in achieving decongestion in sicker patients. Further studies are warranted to clarify optimal decongestion strategies in patients with cardiogenic shock.