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Beyond Mean Arterial Pressure: Organ Perfusion Pressure as a Hemodynamic Target in Cardiogenic Shock
Omar Khayat1, Bahy Abofrekha1, Marc-Andre Ehrenfels1
1Staten Island University Hospital, Northwell Health, Northwell Health, New Hyde Park, NY, USA.
Insights
Organ Perfusion Pressure (OPP), considering both arterial and venous pressures, is a better predictor of outcomes in cardiogenic shock. Higher OPP correlates with reduced mortality and improved kidney function, highlighting its prognostic value.
Area of Science:
- Critical Care Medicine
- Cardiology
- Nephrology
Background:
- Current cardiogenic shock (CS) management focuses on mean arterial pressure (MAP), potentially neglecting venous congestion's role in effective organ perfusion.
- Organ Perfusion Pressure (OPP = MAP - CVP) offers a more comprehensive measure by integrating both arterial and central venous pressures.
- The prognostic significance of OPP in CS regarding mortality, renal function, and resource utilization remains underexplored.
Purpose of the Study:
- To investigate the prognostic value of Organ Perfusion Pressure (OPP) in patients with cardiogenic shock.
- To assess the association between OPP and in-hospital mortality, renal function, and intensive care unit (ICU) resource utilization.
- To determine if OPP provides incremental prognostic information beyond traditional markers in CS.
Main Methods:
- Retrospective cohort study using the MIMIC-IV critical care database.
- Inclusion of adult patients diagnosed with cardiogenic shock, excluding other shock types.
- Analysis of primary outcomes (in-hospital and ICU mortality) and secondary outcomes (ICU length of stay, vasopressor/inotrope duration, urine output, renal replacement therapy, mechanical ventilation), with multivariable regression adjusting for key covariates.
Main Results:
- A 5 mmHg increase in 24-hour mean OPP was independently associated with a significant reduction in in-hospital mortality (aOR 0.79).
- Higher OPP demonstrated a protective effect on renal function, evidenced by increased urine output and reduced odds of requiring renal replacement therapy (aOR 0.65).
- The study included 189 CS patients, with prevalent comorbidities like coronary artery disease and heart failure with reduced ejection fraction.
Conclusions:
- Elevated Organ Perfusion Pressure (OPP) is independently linked to improved survival and renal preservation in cardiogenic shock patients.
- OPP offers valuable prognostic insights, particularly for renal outcomes, suggesting a potential shift in management strategies.
- Further prospective studies are warranted to validate these findings and explore therapeutic interventions targeting OPP.
Background:
Current cardiogenic shock (CS) management primarily targets mean arterial pressure (MAP), often overlooking the impact of venous congestion on the effective perfusion gradient. Organ Perfusion Pressure (OPP = MAP - CVP) integrates both. We investigated OPP's prognostic value for mortality, renal function, and resource utilization.
Methods:
This retrospective cohort study utilized MIMIC-IV database, a single-center, critical care database, to identify adult CS patients. Patients with other forms of shock were excluded. Primary outcomes were in-hospital and ICU mortality. Secondary outcomes included ICU length of stay (LOS), vasopressors/inotropes duration (VID), urine output (UO) over the initial 36 hours, renal replacement therapy (RRT) and invasive mechanical ventilation (IMV). Multivariable models adjusted for demographics (age, sex), comorbidities (Hypertension, diabetes, heart failure, atrial fibrillation, CKD), and shock severity (Cardiac arrest, Vasoactive-Inotropic Score, Maximum lactate) across standardized 12-hour landmarks.
Results:
Among 189 patients (mean age 65.3±14.2 years, 65.6% male), prevalent comorbidities included coronary artery disease (52.4%) and HFrEF (50.8%). Acute myocardial infarction was present in 26.5% of cases. Every 5 mmHg increase in 24-hour mean OPP was independently associated with reduced in hospital mortality (aOR 0.79, 95% CI 0.65-0.96, p=0.020). Higher OPP was associated with renal protection, with increased urine output (+0.21 mL/kg/hr, p<0.001) and reduced odds of renal replacement therapy (aOR 0.65, p<0.001).
Conclusions:
In CS, a higher OPP is independently associated with improved survival, renal preservation, and resource efficiency. OPP provided incremental value especially for renal outcomes. Prospective interventional trials are mandatory for validation.
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