Pre-admission beta-blocker therapy and outcomes in cardiogenic shock: Insights from the Altshock-2 Registry

Abstract

Aims: We aimed to assess the impact of pre-admission beta-blocker (BB) therapy on the clinical characteristics, in-hospital treatment and outcomes of patients with cardiogenic shock (CS).

Methods: All patients enrolled in the multicentre prospective Altshock-2 registry since March 2020 with available data on pre-admission BB therapy were included. Clinical characteristics, in-hospital management, haemodynamic parameters and clinical outcomes were compared in patients with versus without BB therapy. The primary endpoint was in-hospital mortality.

Results: A total of 668 patients were included [median age 66 (56-74) years, male sex 76.5%]: 299 patients (44.8%) with and 369 patients (55.2%) without previous BB therapy. Patients receiving pre-admission BB therapy had more frequently heart failure-related CS (43.8% vs. 17.9%) and less frequently cardiac arrest at presentation (20.1% vs. 27.8%, P = 0.027). Levosimendan was used less frequently and dobutamine was used more frequently in patients with baseline BB therapy (P = 0.033 and P = 0.043, respectively). Differences in the early haemodynamic response to vasoactive drugs were observed between patients with and without previous BB therapy, with a significant impact of baseline BB on mean arterial pressure (MAP) response during norepinephrine infusion (P = 0.012) and with dobutamine having a reduced response in MAP and heart rate in patients receiving BBs before admission (P = 0.023 and P = 0.001, respectively). In-hospital mortality was not significantly different between the BB and no-BB groups (40% vs. 33.7%; adjusted odds ratio 1.32, 95% confidence interval 0.84-2.07, P = 0.224). Similarly, baseline BB therapy was not independently associated with 48 h mortality (12.7% vs. 14.6%; adjusted odds ratio 1.09, 95% confidence interval 0.64-1.87, P = 0.749). The lack of association between baseline BB therapy and mortality was also confirmed at inverse probability of treatment weighting-adjusted analysis.

Conclusions: In a real-world, contemporary cohort of patients with CS, previous BB therapy influenced the haemodynamic response to vasoactive drugs, but it was not associated with in-hospital mortality.

Keywords: Cardiogenic shock; beta‐blockers; inotropes; mortality; vasopressors.

Figure 1

Society for Cardiovascular Angiography and Interventions (SCAI) class at admission in the whole cohort and according to baseline β‐blocker (BB) therapy.

Figure 2

Change in haemodynamic parameters between baseline and the first 24 h according to infusion of epinephrine or norepinephrine (A, MAP during epinephrine infusion; B, HR during epinephrine infusion; C, MAP during norepinephrine infusion; D, HR during norepinephrine infusion). MAP and HR values at baseline and at 24 h are reported in the BB (red) and no‐BB (blue), along with 95% CI. BB, β‐blocker; bpm, beats per minute; CI, confidence interval; HR, heart rate; MAP, mean arterial pressure.

Figure 3

Change in haemodynamic parameters between baseline and the first 24 h according to infusion of dobutamine or levosimendan (A, MAP during dobutamine infusion; B, HR during dobutamine infusion; C, MAP during levosimendan infusion; D, HR during levosimendan infusion). MAP and HR values at baseline and at 24 h are reported in the BB (red) and no‐BB (blue), along with 95% CI. BB, β‐blocker; bpm, beats per minute; CI, confidence interval; HR, heart rate; MAP, mean arterial pressure.