Aggressive Up-Titration of Heart Failure Guideline-Directed Medical Therapies in Cardiogenic Shock Supported by a Percutaneous Ventricular Assist Device

Abstract

Background: Survival rates after cardiogenic shock (CS) remain dismal and largely unaltered in clinical trials, contrasting heart failure with reduced ejection fraction, where new drugs have established guideline-directed therapy, improving long-term outcomes. Unfortunately, unfavorable effects on blood pressure and glomerular perfusion limit their use in CS. A percutaneous ventricular assist device (pVAD) supports cardiac output and blood pressure, offering an option to counteract these negative drug effects.

Objectives: This study aimed to evaluate whether a protocol prolonging pVAD support to uptitrate heart failure drugs is feasible and safe.

Methods: All patients with CS treated with pVAD after the introduction of the protocol in October 2021, were included, as was a control group of patients between 2019 and October 2021. Data were retrospectively extracted from health records to calculate the use of heart failure drugs and study outcomes.

Results: The intervention cohort included 28 patients, and the historical cohort included 33 patients. Median ages were 61 and 68 years, and acute myocardial infarction was the predominant etiology. Society for Cardiovascular Angiography and Intervention (SCAI) shock stages were D or E in 82% vs 69% (P = 0.449). Lactate levels were 6.2 mmol/L (2.8-9.9 mmol/L) and 6.6 mmol/L (2-12 mmol/L; P = 0.341). In the intervention group, at discharge, 94% were treated with spironolactone 25 mg, 94% with dapagliflozin/empaglifozin 10 mg, 100% with valsartan or sacubitril/valsartan, and 94% with rate control, associated with significantly higher treatment intensity compared to the historical cohort. The 90-day survival rate was 71% in the intervention group vs 52% in the historical cohort (P = 0.081), and complication rates were comparable.

Conclusion: Prolonging pVAD support to uptitrate medical therapy is feasible and safe.

Keywords: Cardiogenic shock; guideline-directed medical therapy; mechanical circulatory support; percutaneous ventricular assist device.