Early versus delayed introduction of renin angiotensin aldosterone system inhibitors in cardiogenic shock

Abstract

Abstract Background There is currently no recommendation on the appropriate timing of introduction of renin angiotensin aldosterone system inhibitors (RAASi) in patients admitted with cardiogenic shock. Purpose To describe the timing of introduction of RAASi during cardiogenic shock and its association with mortality. Methods We analyzed patients admitted with cardiogenic shock and treated with RAASi between January 1st, 2010, and December 31st, 2020, in our tertiary shock center. The characteristics and outcomes of patients with early RAASi introduction (≤ 3 days from admission) were compared with those who had a delayed RAASi introduction (> 3 days). Inverse propensity score was used to compare the primary outcome of in-hospital mortality. All-cause death or readmission for heart failure/cardiogenic shock was evaluated up to June 1st, 2022. Results The study population included 406 shock patients, 53% (n=215 patients) with early RAASi introduction and 47% (n=191 patients) in the delayed introduction group. Patients treated with early RAASi (vs. delayed introduction) were more frequently admitted for an acute myocardial infarction (53 % vs. 35 %) (p<0.01), had a better left ventricular fraction (LVEF 22% vs. 20 %) (P=0.001) and had less frequently chronic kidney disease (3.2 % vs. 9.4%) (p<0.01). Early RAASi introduction was associated with a higher in-hospital mortality (OR 6.47 (95% CI) 3.4 - 13.4, p<0.001) as compared with delayed introduction (figure 1). Each day of delay before introduction of RAASi was associated with a reduction of in-hospital mortality OR 0.80 95 % CI (0.69 - 0.89) (p<0.01). After a median follow up of 11 (2 – 48) months, there was no difference in the risk of death or heart failure between both strategies (p=0.89) (figure 2). Conclusion Early RAASi introduction during cardiogenic shock was associated with a higher in-hospital mortality, without apparent benefits during the year after discharge. Randomized studies are needed to evaluate the optimal time and dose management of RAAS inhibitors in cardiogenic shock.