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Published on: June 12, 2021
Microaxial Flow Pump Use in Different Phenotypes of Cardiogenic Shock-a Secondary Analysis of the DanGer Shock Trial
Elric Zweck1, Rasmus P Beske2, Christian Hassager3
1Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
Insights
Cardiogenic shock (CS) phenotypes have distinct outcomes, with non-congested CS faring best and cardiometabolic CS worst. Microaxial flow pump (mAFP) use showed the greatest mortality benefit in non-congested CS patients.
Area of Science:
- Cardiology
- Critical Care Medicine
- Translational Research
Background:
- Three distinct cardiogenic shock (CS) phenotypes—non-congested, cardiorenal, and cardiometabolic—have been validated in patient datasets.
- The DanGer Shock trial previously established a mortality benefit for microaxial flow pump (mAFP) use in myocardial infarction-related CS.
- This post-hoc analysis investigates the trajectories and outcomes of these CS phenotypes within the DanGer Shock trial population.
Purpose of the Study:
- To retrospectively assign patients from the DanGer Shock trial to one of three predefined CS phenotypes.
- To analyze the clinical, laboratory, and hemodynamic trajectories within each CS phenotype over the initial 72 hours.
- To evaluate the 180-day mortality outcomes stratified by CS phenotype and allocation to mAFP or standard care.
Main Methods:
- Patients were retrospectively categorized into non-congested (41%), cardiorenal (11%), or cardiometabolic (48%) CS phenotypes.
- Multiple random forest imputation was used to address missing data for phenotyping.
- 180-day mortality and clinical parameter trajectories were assessed, stratified by mAFP or standard care allocation.
Main Results:
- 180-day mortality was highest in the cardiometabolic CS phenotype (69%), followed by cardiorenal CS (47%), and lowest in non-congested CS (33%).
- Clinical, metabolic, and hemodynamic trajectories, along with treatment responses, varied significantly across the CS phenotypes.
- mAFP use was associated with reduced mortality in non-congested CS (OR 0.51 [0.28-0.91], p=0.02), with no significant benefit in other phenotypes.
Conclusions:
- Predefined CS phenotypes exhibit distinct clinical outcomes, with cardiometabolic CS associated with the worst prognosis and non-congested CS with the best.
- The apparent mortality benefit of mAFP was most pronounced in the non-congested CS phenotype.
- These findings suggest phenotype-specific treatment strategies and warrant prospective validation.
Background:
Three cardiogenic shock (CS) phenotypes have been proposed and validated in various datasets: noncongested (phenotype I), cardiorenal (phenotype II), and cardiometabolic CS (phenotype III). The DanGer Shock trial demonstrated a mortality benefit of microaxial flow pump (mAFP) use in myocardial infarction-related CS. In this post-hoc analysis, we aimed to assess the trajectories and outcomes of these phenotypes in the DanGer Shock population.
Methods:
Patients randomized to the DanGer Shock trial were retrospectively assigned to 1 of 3 CS phenotypes at admission. Missing values for phenotyping were imputed using multiple random forest imputation. Outcomes were 180-day mortality and the trajectories of key clinical, laboratory and hemodynamic parameters first 72 hours within phenotypes, stratified by allocation to mAFP or standard of care.
Results:
Of 355 adult patients in the trial, 145 (41%), 38 (11%), and 172 (48%) patients were in the noncongested, cardiorenal, and cardiometabolic phenotypes, respectively. The 180-day mortality was greater in cardiometabolic (69%) compared with the noncongested (33%) and cardiorenal CS (47%) groups. Clinical metabolic and hemodynamic trajectories and their treatment response differed between phenotypes. mAFP use was associated with lower mortality in noncongested CS (odds ratio, 0.51 [0.28-0.91], P = .02). The odds of mortality were 0.81 [0.57-1.16] (P = .25) in cardiometabolic and 0.91 [0.35-2.34] (P = .84) in cardiorenal CS (P for interaction: .43).
Conclusion:
In this post-hoc analysis of the DanGer Shock trial, predefined CS phenotypes showed distinct outcomes, with the noncongested phenotype faring best and the cardiometabolic the worst. The greatest apparent benefit of mAFP was observed in noncongested CS. These findings are hypothesis-generating and warrant confirmation in prospective studies.
Clinical Trial Registration:
ClinicalTrials.gov unique identifier: NCT01633502. Condensed Abstract In this DanGer Shock post-hoc analysis, study participants were retrospectively assigned to 1 of 3 cardiogenic shock (CS) phenotypes: noncongested, cardiorenal, or cardiometabolic CS. In total, 41%, 11%, and 48% of all 355 patients were in these phenotypes, respectively. The 180-day mortality was greater in the cardiometabolic (69%) compared with the noncongested (33%) and cardiorenal CS (47%) groups. mAFP use was associated with lower mortality in the noncongested and numerically in the cardiometabolic, but not in cardiorenal CS group. In summary, CS phenotypes showed distinct outcomes, with the noncongested phenotype faring best and the cardiometabolic faring the worst. The greatest apparent benefit of mAFP was observed in noncongested CS.
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