Incidence and outcomes associated with early heart failure pharmacotherapy in patients with ongoing cardiogenic shock.

Abstract

OBJECTIVES:

Guidelines recommend β-blockers and renin-angiotensin-aldosterone system blockers to improve long-term survival in hemodynamically stable myocardial infarction patients with a reduced left ventricular ejection fraction. The prevalence and outcomes associated with β and renin-angiotensin-aldosterone system blocker therapy in patients with ongoing cardiogenic shock is unknown.

DESIGN:

Secondary analysis of a randomized controlled trial.

SETTING:

In patients with cardiogenic shock lasting more than 24 hours enrolled in Tilarginine Acetate Injection in a Randomized International Study in Unstable Myocardial Infarction Patients With Cardiogenic Shock, we compared 30-day mortality in patients who received β or renin-angiotensin-aldosterone system blockers (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists) within 24 hours of randomization with those who did not.

INTERVENTIONS:

None.

PATIENTS:

The final study population included 240 patients. A total of 66 patients (27.5%) had either β blocker or renin-angiotensin-aldosterone system blocker administered within the first 24 hours after the diagnosis of cardiogenic shock. β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aldosterone antagonists were prescribed in 18.8%, 10.6%, and 5.0% of patients, respectively.

MEASUREMENTS AND MAIN RESULTS:

The observed 30-day mortality among patients was higher in patients who received β or renin-angiotensin-aldosterone system blockers prior to cardiogenic shock resolution (27.3% vs 16.9%; adjusted hazard ratio, 2.36; 95% CI, 1.06-5.23; p = 0.035). Compared with patients not given β or renin-angiotensin-aldosterone system blockers, the 30-day mortality was higher among patients treated only with β-blockers (33.3% vs 16.9%, p = 0.017) but not among those only treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (18.2% vs 16.9%, p = 1.000).

CONCLUSIONS:

The administration of β or renin-angiotensin-aldosterone system blockers is common in North America and Europe in patients with myocardial infarction and cardiogenic shock prior to cardiogenic shock resolution. This therapeutic practice was independently associated with higher 30-day mortality, although a statistically significant difference was only observed in the subgroup of patients administered β-blockers.

• Authors: Sean van Diepen, Harmony R Reynolds, Amanda Stebbins, Renato D Lopes, Vladimír Džavík, Witold Ruzyllo, Alexander Geppert, Petr Widimsky, E Magnus Ohman, Joseph E Parrillo, Harold L Dauerman, David A Baran, Judith S Hochman, John H Alexander
• Journal: Critical care medicine (Crit Care Med) Vol. 42 Issue 2 Pg. 281-8 (Feb 2014) ISSN: 1530-0293 [Electronic] United States
• PMID: 23982033 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Adrenergic beta-Antagonists
• Angiotensin Receptor Antagonists
• Mineralocorticoid Receptor Antagonists
• N(G)-monomethylarginine acetate
• Arginine

Topics

• Adrenergic beta-Antagonists (therapeutic use)
• Aged
• Angiotensin Receptor Antagonists (therapeutic use)
• Arginine (analogs & derivatives, therapeutic use)
• Double-Blind Method
• Female
• Heart Failure (drug therapy, epidemiology, etiology)
• Humans
• Incidence
• Male
• Middle Aged
• Mineralocorticoid Receptor Antagonists (therapeutic use)
• Renin-Angiotensin System (drug effects)
• Shock, Cardiogenic (complications)
• Time Factors
• Treatment Outcome