Aim
The initial bundle of cares strongly affects hemodynamics in acute decompensated heart failure cardiogenic shock (ADHF-CS). We sought to characterize whether 24-hour hemodynamic profiling provides superior prognostic information as compared to admission assessment, and which hemodynamic parameters best predict in-hospital death.
Methods and results
We included 99 patients (62±14 years, 24.2% females) with ADHF-CS and available admission and 24-hour invasive hemodynamic assessment from two academic institutions. Overall, in-hospital mortality was 28.3%. In the admission multivariable model, age (OR=1.08; 95%CI 1.03-1.13; padj=0.002) and CPIRAP (OR=0.62; 95%CI 0.39-0.90; padj=0.022) were significantly associated with in-hospital death. Among several 24-hour hemodynamic univariate predictors of in-hospital death, pulmonary artery elastance (PaE) was the strongest (AUC 0.73; 95%CI 0.66-0.86). At 24-hours, PaE (OR=5.86; 95%CI 1.87-18.50; padj=0.003), PAPi (OR=0.75; 95%CI 0.55-0.92; padj=0.023) and age (OR=1.08; 95%CI 0.1.03-0.1.14; padj=0.005) were independently associated with in-hospital death. This 24-hour model outperformed admission model (AUC 0.85 [0.76-0.93] vs AUC 0.77 [0.67-0.88]; Figure 1). Patients were then grouped according to the optimal cutpoints of PaE 1.11 mmHg/mL and PAPi 2.12. Patients with high 24-hour PaE exhibited the highest in-hospital mortality at either low and high PAPi. The “high PAPi-low PaE” group had best parameter of (bi)ventricular function and lowest right and left filling pressures; the “low PAPi-low PaE” group exhibited parameters of poor RV function and high RAP (prevalent RV dysfunction); the “high PAPi-high PaE” group had signs of LV dysfunction coupled with parameters of relatively preserved RV function (compensated RV afterload mismatch); finally, the “low PAPi-high PaE” group exhibited worse parameters of LV and RV functions, coupled with high degree of pulmonary circulation overload and high biventricular filling pressures (decompensated RV afterload mismatch). We observed a different mortality in the cohorts identified by this classification (13.5 vs 25.0 vs 50.0 vs 43.8%; p=0.016, Figure 2).
Conclusion
PaE was the most powerful 24-hour hemodynamic predictor of in-hospital death in ADHF-CS. This index, coupled with PAPi, may identify patients with RV afterload mismatch and was independently associated with hospital mortality event after adjustment for multiple clinically relevant variables.