Circulatory Support Escalation in Cardiogenic Shock: Outcomes and Predictors of Successful Escalation From an...

Circulatory support escalation is often required during cardiogenic shock (CS) treatment. Currently, no large-scale data is available to inform how escalation strategies integrate in contemporary CS management and affect outcomes.

We assessed the frequency, outcomes, and prognostic implications of escalation from a retrospective international registry of patients with CS from 4 cardiac intensive care units. Escalation was defined as any incremental change in the circulatory support strategy after an initial bundle of care was established for at least 4 hours.

Among 602 consecutive patients with CS, escalation was required in 30%. Patients were escalated to inotropes/vasopressors (36%), intra-aortic balloon pump (39%), Impella (14%), or venoarterial extracorporeal membrane oxygenation (11%). Escalation was associated with a higher hospital mortality rate (43% versus 21%; P<0.001; adjusted odds ratio, 3.42 [95% CI, 2.21-3.35]) and a greater transition to heart replacement therapies (23% versus 5%; P<0.001; adjusted odds ratio, 6.01 [95% CI, 3.31-11.27]), when adjusted for age, sex, chronic kidney disease, markers of CS severity on admission, CS cause, and admission source. Escalation was associated with a higher risk of complications, including acute kidney injury, major bleeding, and stroke. These outcomes occurred more frequently with high-profile mechanical circulatory support (Impella, V-A extracorporeal membrane oxygenation). Complications mediated 24% (95% CI, 9%-40%) of the association between escalation and hospital death. Escalated patients were successfully discharged alive in 42%. Age, the Society for Cardiovascular Angiography and Intervention B to C stage at escalation, tricuspid annular plane systolic excursion at escalation, and mean urinary output ≥1 mL/kg per hour in the 6 hours preceding escalation were independently associated with successful escalation when adjusted for sex, chronic kidney disease, and markers of CS severity on admission and at time of escalation.

Circulatory support escalation is prevalent in patients treated for CS. Escalation is associated with a higher risk of hospital death, complications, and transition to heart replacement therapy, consistent with the intrinsically higher risk profile and expected trajectory of escalated patients. However, outcomes may differ according to the specific escalation strategy. Resorting to escalation in younger patients, in less severe CS stages, when the right ventricular function and urinary output are still preserved, is associated with a higher chance of subsequent survival.