Resident Physician The Ottawa Hospital Ottawa, Ontario, Canada
Background: Cardiogenic shock (CS) is a heterogeneous disorder with limited therapeutic interventions that can improve patient outcomes in unselected patients. Various phenotype classification systems have been proposed to address this clinical heterogeneity in CS. We explored the relationship between phenotype at the time of CS presentation and clinical outcomes in the randomized DOREMI trial.
METHODS AND RESULTS: This study is a post hoc analysis of 192 participants in the DOREMI trial which compared dobutamine to milrinone in the management of CS. Phenotypes were assigned based on the Cardiogenic Shock Working Group (CSWG) phenotype, Society for Cardiovascular Angiography and Interventions (SCAI) shock classification systems, and acute myocardial infarction (AMI) vs. non-AMI-related CS (non-AMICS). The primary endpoint was the composite of in-hospital mortality, resuscitated cardiac arrest, need for cardiac transplantation or mechanical circulatory support, non-fatal myocardial infarction (MI), transient ischemic attack or stroke, or initiation of renal replacement therapy (RRT).
CSWG phenotypes could be adjudicated in 169 study participants. There were 36 participants (21.3%) with “non-congested” (phenotype I), 84 participants (49.7%) with “cardiorenal” (phenotype II), and 49 participants (29.0%) with “cardiometabolic” (phenotype III) shock. The primary outcome occurred in 36.1% of non-congested, 54.8% of cardiorenal, and 65.2% of cardiometabolic phenotypes (p=0.03). SCAI classification (n = 192) demonstrated increasing incidence of the primary outcome with worsening shock stage (9.1% in SCAI B, 51.0% in SCAI C, 68.2% in SCAI D, and 100% in SCAI E); p< 0.01). 33% of patients experienced AMICS. The primary outcome occurred in 66.2% of patients with AMICS and 42.5% of non-AMICS (p = 0.0001).
Conclusion: Major classification systems of CS phenotypes predict clinical outcomes in clinical trial patients. Prespecified stratification by phenotype may permit personalized treatment strategies, which could result in improved clinical outcomes.
