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Contemporary Practice Patterns of Vasoactive Use in Cardiogenic Shock in the American Heart Association Cardiogenic
Siddharth M Patel1, David D Berg1, Erin A Bohula1
1Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital Harvard Medical School Boston MA USA.
Insights
In cardiogenic shock (CS) management, inopressors like norepinephrine are most frequently used. Practice patterns for vasoactive agents vary based on CS cause and severity, informing future treatment strategies.
Area of Science:
- Cardiology
- Pharmacology
- Critical Care Medicine
Background:
- Vasoactive agents are the primary treatment for cardiogenic shock (CS).
- Current practices for selecting vasoactive agents in CS are not well understood.
Purpose of the Study:
- To characterize contemporary practice patterns of vasoactive agent selection in patients with cardiogenic shock.
- To identify factors influencing vasoactive agent choice in CS management.
Main Methods:
- Analysis of data from the American Heart Association (AHA) CS Registry (2022-2024).
- Inclusion of CS admissions treated with vasoactive agents within 6 hours of onset.
- Categorization of agents into inopressors, inodilators, and pure vasopressors.
Main Results:
- Among 6847 CS admissions, 49.5% received one agent and 50.5% received two or more.
- Inopressors were most common (73.7%), followed by inodilators (48.3%) and pure vasopressors (27.5%).
- Norepinephrine was the most frequent agent (64.7%), with use patterns varying by CS etiology and severity.
Conclusions:
- Inopressors, particularly norepinephrine, are the most utilized vasoactive agents in contemporary CS care.
- CS etiology and severity significantly influence vasoactive agent selection.
- These findings provide insight into current CS treatment and guide future research on optimal vasoactive strategies.
Background:
Vasoactives are the predominant first line of therapy for management of cardiogenic shock (CS). Contemporary practice patterns regarding vasoactive agent selection in CS have not been well characterized.
Methods:
The American Heart Association (AHA) CS Registry captures consecutive CS admissions across participating hospitals in the United States. Admissions treated with vasoactive agents within 6 hours of CS onset were included. Agents were categorized as inopressors (norepinephrine, epinephrine, dopamine), inodilators (dobutamine, milrinone), and pure vasopressors (vasopressin, phenylephrine).
Results:
From 2022 to 2024, among 6847 CS admissions across 84 sites, 3387 (49.5%) were treated with a single vasoactive agent and 3460 (50.5%) were treated with ≥2 agents. Inopressors were used most commonly (73.7% of CS cases), with inodilators and pure vasopressors used in 48.3% and 27.5% of cases respectively. Norepinephrine was used most frequently (64.7%), followed by dobutamine (31.6%) and epinephrine (28.9%). Pure vasopressor use consisted primarily of vasopressin (83.5% of use). Use patterns differed by CS etiology with greater inopressor use in acute myocardial infarction-CS and greater inodilator use in acute-on-chronic heart failure-CS. Use of inopressors and pure vasopressors was greater and inodilator use lower in those with cardiac arrest, supported by mechanical circulatory support, or at higher Society of Cardiovascular Angiography and Interventions shock stage.
Conclusions:
In a broad population with CS in contemporary practice, inopressors are the most commonly used vasoactive category, with norepinephrine being the most frequently used agent. Several factors including CS etiology and severity are associated with differential practice patterns for vasoactive selection. These data depict the contemporary landscape and may help inform future evidence generation around optimal vasoactive selection for patients with CS.
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