https://doi.org/10.1007/s00392-025-02625-4
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 2Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; 3Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; 4Marienhospital Osnabrück Klinik für Innere Medizin / Kardiologie und Intensivmedizin Osnabrück, Deutschland; 5Universitätsklinikum Hamburg-Eppendorf Klinik für Intensivmedizin Hamburg, Deutschland; 6Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; 7St. Bartholomew's Hospital Department of Perioperative Medicine London, Großbritannien; 8Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; 9LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland
Background: Patients with cardiogenic shock often require for invasive ventilation due to concomitant respiratory failure but also due to reduced vigilance or prior cardiac arrest, where gas exchange is unimpaired. Especially in case of prior cardiac arrest, invasive ventilation may be prolonged due to unknown neurologic outcome. The impact of invasive ventilation in the collective of cardiogenic shock patients is unknown.
Purpose: To determine associations between invasive ventilation and outcomes in cardiogenic shock, corrected for initial Horowitz quotient (PaO2/FiO2).
Methods: This international observational study enrolled patients with cardiogenic shock between 2010 and 2021 in 16 tertiary care centers of five different countries. Mixed effects linear regressions were used to estimate associations between invasive ventilation on length of ICU-stay. Multivariable cox regression models with competing risk were constructed for invasive ventilation and invasive ventilation stratified into subgroups of PaO2/FiO2 <100, PaO2/FiO2 100-200 and PaO2/FiO2 > 200 to identify predictors of 30-day mortality. Models were adjusted for age, sex, BMI, prior resuscitation, baseline pH and baseline lactate.
Results: This analysis includes 1010 patients [median age 64 years, 724 (71.7%) male], 659 patients (65.2%) receiving invasive ventilation, 395 patients (39.3%) with cardiac arrest. The lowest pH value within 6 hours after index event was 7.3 (IQR 7.2-7.4) and the highest lactate was 4.8 (IQR 2.5-8.5). Invasive ventilation was associated with a lower frequency of discharge from ICU (50.8% vs. 70.7%, p<0.0001) and from hospital (46.4% vs. 65.5%, p<0.0001). In patients with invasive ventilation ICU stay was prolonged for 2-3 days, even after adjusting for relevant confounders (Beta 2.87, 95% CI 0.87-4.88, p 0.005). In patients with invasive ventilation 30-day mortality was 1.91-times higher (95% CI 1.45-2.53, p<0.001) than in patients without invasive ventilation; and although patients with a worse PaO2/FiO2 of <100 and 100-200 had the highest mortality risk (sHR 1.93, 95% CI 1.31-2.86, p<0.001 respectively sHR 1.98, 95% CI 1.42-2.76, p<0.001), the relative increase in mortality risk persisted even in patients with a good pulmonary function and PaO2/FiO2 >200 (sHR 1.50, 95% CI 1.06-2.11, p<0.02).
Conclusion: The hypothesis-generating findings indicate that cardiogenic shock patients receiving invasive ventilation are not only at higher risk because of pulmonary failure, but also because of invasive ventilation itself. Avoiding invasive ventilation and promoting early extubation of patients with invasive ventilation may therefore improve outcomes in patients with cardiogenic shock.