Timing of inotropic support is associated with mortality in patients with acute decompensated heart failure-associated cardiogenic shock

Background: Inotropic support is often used to improve hemodynamics and organ perfusion in patients with advanced heart failure-related cardiogenic shock (ADHF-CS). We aimed to evaluate the effect of inotrope timing on patient mortality in patients meeting Society for Cardiovascular Angiography and Interventions (SCAI) stage-C criteria within 24 h of hospital presentation. Methods: We analyzed a local cardiogenic shock database of patients admitted to our cardiovascular intensive care units at the University of Pennsylvania from five emergency departments between 2021 and 2023. Adult patients with left ventricular ejection fraction ≤40% were eligible for inclusion. Patients with hypoperfusion, who met at least one physical, biochemical, and hemodynamic criterion for SCAI-C shock were included. The primary outcome was 28-day mortality. We also compared SCAI criteria and diagnostic examination timing between early and delayed inotropic support groups. Results: A total of 138 out of 623 patients (22%) with cardiogenic shock met inclusion criteria for this study. 28-day mortality was higher in patients who received inotropic therapies ≥8 h after cardiogenic shock onset compared to patients who received earlier support (4-h odds ratio of death (OR) 3.19, 95% CI: 1.34–8.03; 8-h OR: 2.4, 95% CI: 1.09–5.26). 28-day mortality was lower in the early inotrope group (<8 h from shock onset) compared to the delayed (≥8 h) group (15/87; 17% vs. 17/51; 32%, p = 0.031). Patients with early inotropic support more often presented with a cool peripheral exam (34% vs. 16%, p = 0.022) and an initial lactate > 2 mmol/dL (71% vs. 49%, p = 0.009). Delayed inotropic support was associated with hypotension at presentation (84% vs. 57%, p = 0.001), longer time to echocardiography (19 [11–36] vs. 15 [3–24] h, p = 0.053) and time to pulmonary artery catheterization (25 [16–45] vs. 16 [2–46] h, p = 0.042). Conclusion: Our findings suggest that inotropic support initiated within 8 h of acute presentation is associated with decreased 28-day mortality for patients with ADHF-related cardiogenic shock. Peripheral perfusion and cardiac output measurement were less frequently quantified within the first 24 h for patients with delayed inotropic support. Using shock classification tools, such as the SCAI shock criteria, may help identify patients with CS, especially in its early stages.