The association between mean arterial pressure and outcomes in patients with cardiogenic shock: insights from the DOREMI trial.

Aug 16, 2021

Contributor: Simon Parlow,Pietro Di Santo,Rebecca Mathew,Richard G Jung,Trevor Simard,Taylor Gillmore,Brennan Mao,Omar Abdel-Razek,F Daniel Ramirez,Jeffrey A Marbach,Alexander Dick,Christopher Glover,Juan J Russo,Michael Froeschl,Marino Labinaz,Shannon M Fernando,Benjamin Hibbert

The association between mean arterial pressure and outcomes in patients with cardiogenic shock: insights from the DOREMI trial.

Cardiogenic shock (CS) is a state of low cardiac output resulting in end-organ hypoperfusion. Despite high in-hospital mortality rates, little evidence exists regarding the optimal mean arterial pressure (MAP) target in CS. We therefore evaluated the relationship between achieved MAP and clinical outcomes in patients with CS.
We performed a post hoc analysis of the CAPITAL DOREMI trial: a randomized, double-blind trial comparing dobutamine to milrinone in patients with CS. We divided patients into a high MAP group (average MAP ≥ 70 mmHg over the 36 h following randomization), and a low MAP group (average MAP < 70 mmHg). Our primary outcome included in-hospital all-cause mortality, resuscitated cardiac arrest, need for cardiac transplantation or mechanical circulatory support, non-fatal myocardial infarction, transient ischaemic attack or stroke, or initiation of renal replacement therapy. In total, 71 (37.0%) patients achieved an average MAP < 70 mmHg, and 121 (63.0%) achieved an average MAP ≥ 70 mmHg. The primary outcome occurred in 48 (67.6%) patients in the low MAP group and 51 (42.2%) patients in the high MAP group [adjusted relative risk (aRR) 0.70; 95% confidence interval (CI) 0.53-0.92; P = 0.01]. All-cause mortality occurred in 41 (57.8%) and 35 (28.9%) patients in the low and high MAP groups, respectively (aRR 0.56; 95% CI 0.40-0.79; P < 0.01). There were no significant differences in any secondary outcomes between each group.
In patients with CS treated with inotrope therapy, low MAP is associated with worse clinical outcomes. Randomized data evaluating optimal MAP targets in CS is needed to guide medical therapy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

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About The Expert

Simon Parlow

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Pietro Di Santo

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Room 101, Ottawa, Ontario, K1G 5Z3, Canada.

Rebecca Mathew

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Richard G Jung

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada.

Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada.

Trevor Simard

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada.

Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, 200 First St. SW, Rochester, Minnesota, 55905, USA.

Taylor Gillmore

Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada.

Brennan Mao

Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, K1H 8M5, Canada.

Omar Abdel-Razek

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

F Daniel Ramirez

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Jeffrey A Marbach

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, 02111, USA.

Alexander Dick

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Christopher Glover

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Juan J Russo

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Michael Froeschl

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Marino Labinaz

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Shannon M Fernando

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Critical Care, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.

Benjamin Hibbert

CAPITAL Research Group, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada.

Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Room #3206, Ottawa, Ontario, K1H 8M5, Canada.

References

PubMed