Diastolic Perfusion Pressure Predicts Response to Inotropes and Vasopressors and Benefit From Mechanical Circulatory Support in Cardiogenic Shock

BACKGROUND: Hemodynamic response to escalation of vasoactive drugs has not been well-characterized in patients with cardiogenic shock (CS). We tested the hypothesis that lower diastolic perfusion pressure (DPP=diastolic blood pressure−right atrial pressure) was associated with more limited hemodynamic response to uptitration of vasoactive drugs and with possible benefit from early mechanical circulatory support in patients with CS. METHODS: This study consisted of 2 parts: (1) we evaluated the relationship between baseline DPP and changes in cardiac power output index (CPOI) in response to increase in vasoactive drugs in a cohort of patients with CS (n=93) and (2) we compared all-cause mortality based on baseline DPP in a post hoc analysis of the ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock). CPOI responders were defined as postescalation CPOI ≥0.28 W/m 2 . RESULTS: Vasoactive inotrope score escalated from 11.2±3.9 to 24.5±4.7. Escalation of vasoactive drugs was associated with increases in CPOI to 0.23±0.06 W/m 2 (all P <0.001). Postescalation CPOI was directly related to baseline cardiac index and DPP. Baseline DPP discriminated cardiac power output responders from nonresponders with an optimal cutoff of 37 mm Hg. Patients with baseline DPP ≥37 mm Hg had greater CPOI increase and lactate clearance. In the ECMO-CS trial, patients with DPP <37 mm Hg had lower mortality (hazard ratio, 0.37 [95% CI, 0.14–0.97]; P =0.044) with immediate venoarterial extracorporeal membrane oxygenation compared with early conservative management but no significant difference in the subgroup with DPP ≥37 mm Hg. CONCLUSIONS: Lower DPP was associated with more limited hemodynamic response to escalation of vasoactive drugs and potentially greater benefit from early venoarterial extracorporeal membrane oxygenation in CS.