Personalisation of Mean Arterial Pressure in Adult Patients With Cardiogenic Shock

Cardiogenic shock is a severe and life-threatening condition. Its prognosis remains very poor with a high mortality rate (up to 50% in clinical series) despite recent therapeutic advances. Current recommendations suggest the use of inotropes and vasopressors to maintain tissue perfusion and prevent organ failure.

During cardiogenic shock, the mean arterial pressure (MAP) level is associated with survival. A post hoc analysis of a recent randomized trial found increased mortality among patients in cardiogenic shock whose average MAP was <70 mmHg during the first 36 hours after randomization, compared to patients with MAP ≥70 mmHg (58% vs. 29%, p<0.01). Another observational study found higher mortality among patients with a mean MAP <65 mmHg during the first 24 hours of shock compared to those with MAP ≥65 mmHg (57% vs. 28%, p<0.001). In this study, the incidence of renal failure was also inversely associated with MAP level. The optimal MAP target remains unknown during cardiogenic shock.

Due to the characteristic venous congestion, the effective perfusion pressure may be very low during cardiogenic shock despite MAP being within the usual target (65 mmHg). Furthermore, increased central venous pressure (CVP) is associated with higher mortality during cardiogenic shock. Considering venous congestion by measuring or estimating CVP is necessary to assess the effective perfusion pressure (MAP minus CVP) in order to protect against organ dysfunction. In this perspective, the MAP target should be increased by the value of the CVP.

The investigators hypothesize that personalizing the MAP target (to achieve an effective perfusion pressure of 65 mmHg) improves organ perfusion and survival during cardiogenic shock compared to the usual MAP target of 65 mmHg.

Inclusion criteria

• Aged ≥18 years
• Cardiogenic shock state, according to the consensus definition,
• SCAI (Society for Cardiovascular Angiography and Interventions) classification ≥ C
• Consent from the patient or close relative / trusted person or emergency inclusion procedure
• Benefiting fromciary of a social security scheme

Exclusion criteria

• Catecholamine infusion for more than 24 consecutive hours;
• CVP < 5 mm Hg at inclusion;
• MAP > 70 mmHg at inclusion;
• Chronic kidney disease stage G4 (defined by an eGFR between 15-29 ml/min/1.73 m²) or G5 (defined by an eGFR less than 15 ml/min/1.73 m²) according to the KDIGO CKD classification at inclusion;
• Chronic dialysis or presence of renal replacement therapy criteria at inclusion ;
• Recovered cardiopulmonary arrest within 7 days prior to inclusion;
• Patient already on mechanical circulatory support at inclusion before enrollment (patients who receive support after inclusion will not be excluded);
• Primary diagnosis of tamponade, pulmonary embolism, or septic shock;
• Hypersensitivity to norepinephrine tartrate or to any of the following excipients: sodium chloride, hydrochloric acid or sodium hydroxide water for injectable preparations;
• Absence of central venous access;
• Known pregnancy or current breastfeeding;
• Under legal guardianship, curatorship, or judicial protection.