Outcomes based on blood pressure in patients on continuous flow left ventricular assist device support: An Interagency Registry for Mechanically Assisted Circulatory Support analysis.
LVAD
blood pressure
mortality
outcomes
stroke
Journal
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
ISSN: 1557-3117
Titre abrégé: J Heart Lung Transplant
Pays: United States
ID NLM: 9102703
Informations de publication
Date de publication:
05 2020
05 2020
Historique:
received:
05
03
2019
revised:
14
11
2019
accepted:
20
11
2019
pubmed:
14
12
2019
medline:
21
1
2021
entrez:
14
12
2019
Statut:
ppublish
Résumé
An optimal blood pressure (BP) range to mitigate morbidity and mortality on left ventricular assist device (LVAD) support has not been clearly defined. Average Doppler opening pressure, mean arterial pressure (MAP), and/or systolic blood pressure (SBP) were calculated in operative survivors (n = 16,155) of LVAD support in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). BP distributions were used to group patients into low (BP <25th percentile), normal (25-75th percentile), high (75th-95th percentile), and very high (>95th percentile). Associations between BP and adverse events were evaluated using Cox regression (hazard ratio[HR], 95% confidence interval). The median (25th, 75th) MAP, Doppler, and SBP (mm Hg) during continuous flow LVAD support were 84 (77, 90), 85 (80, 92), and 99 (90, 107) mm Hg, respectively. BP had a bimodal risk association with survival. At 3 years, survival was 58% ± 1.8% in those with low MAP (≤75 mm Hg) vs 70% ± 0.9%, 71% ± 1.5%, and 63% ± 3.0% in the those with normal, high, or very high average MAP, respectively. Patients with chronically low MAP (≤75 mm Hg), Doppler (≤80 mm Hg), and SBP (<90 mm Hg) had 35%-42% higher adjusted hazards of death than patients with normal or high BP (p ≤ 0.0001). Patients with MAP >100 mm Hg, Doppler ≥105 mm Hg, and SBP ≥120 mm Hg had 17%-20% higher adjusted hazards of death than those with normal pressures (p < 0.05). In patients on axial flow LVADs, elevated SBP (HR 1.08 [95% confidence interval, 1.04-1.13] per 10 mm Hg increase) but not MAP correlated with increased incident of stroke. In INTERMACS, BP extremes during LVAD support increase the risk for adverse events, supporting a MAP goal >75 mm Hg and <90 mm Hg. Hypotension conferred the highest risk for mortality. Excessive BP control should be avoided, and Doppler opening pressure should not be assumed to represent MAP in all patients.
Sections du résumé
BACKGROUND
An optimal blood pressure (BP) range to mitigate morbidity and mortality on left ventricular assist device (LVAD) support has not been clearly defined.
METHODS
Average Doppler opening pressure, mean arterial pressure (MAP), and/or systolic blood pressure (SBP) were calculated in operative survivors (n = 16,155) of LVAD support in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). BP distributions were used to group patients into low (BP <25th percentile), normal (25-75th percentile), high (75th-95th percentile), and very high (>95th percentile). Associations between BP and adverse events were evaluated using Cox regression (hazard ratio[HR], 95% confidence interval).
RESULTS
The median (25th, 75th) MAP, Doppler, and SBP (mm Hg) during continuous flow LVAD support were 84 (77, 90), 85 (80, 92), and 99 (90, 107) mm Hg, respectively. BP had a bimodal risk association with survival. At 3 years, survival was 58% ± 1.8% in those with low MAP (≤75 mm Hg) vs 70% ± 0.9%, 71% ± 1.5%, and 63% ± 3.0% in the those with normal, high, or very high average MAP, respectively. Patients with chronically low MAP (≤75 mm Hg), Doppler (≤80 mm Hg), and SBP (<90 mm Hg) had 35%-42% higher adjusted hazards of death than patients with normal or high BP (p ≤ 0.0001). Patients with MAP >100 mm Hg, Doppler ≥105 mm Hg, and SBP ≥120 mm Hg had 17%-20% higher adjusted hazards of death than those with normal pressures (p < 0.05). In patients on axial flow LVADs, elevated SBP (HR 1.08 [95% confidence interval, 1.04-1.13] per 10 mm Hg increase) but not MAP correlated with increased incident of stroke.
CONCLUSIONS
In INTERMACS, BP extremes during LVAD support increase the risk for adverse events, supporting a MAP goal >75 mm Hg and <90 mm Hg. Hypotension conferred the highest risk for mortality. Excessive BP control should be avoided, and Doppler opening pressure should not be assumed to represent MAP in all patients.
Identifiants
pubmed: 31831209
pii: S1053-2498(19)31768-1
doi: 10.1016/j.healun.2019.11.016
pmc: PMC7200289
mid: NIHMS1545104
pii:
doi:
Types de publication
Journal Article
Multicenter Study
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
441-453Subventions
Organisme : NHLBI NIH HHS
ID : HHSN268201100025C
Pays : United States
Informations de copyright
Copyright © 2019 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.
Références
JACC Heart Fail. 2015 Oct;3(10):818-28
pubmed: 26450000
Circ Heart Fail. 2013 Sep 1;6(5):1005-12
pubmed: 23811966
N Engl J Med. 2017 Feb 2;376(5):451-460
pubmed: 28146651
J Heart Lung Transplant. 2014 Jan;33(1):23-34
pubmed: 24418731
Circ Heart Fail. 2015 May;8(3):551-6
pubmed: 25870369
J Heart Lung Transplant. 2019 Apr;38(4):396-405
pubmed: 30559034
J Heart Lung Transplant. 2017 Jan;36(1):1-12
pubmed: 27865732
J Heart Lung Transplant. 2015 Apr;34(4):503-8
pubmed: 25540881
JACC Heart Fail. 2018 Sep;6(9):792-802
pubmed: 30007559
Adv Chronic Kidney Dis. 2018 Sep;25(5):443-453
pubmed: 30309462
Circulation. 2019 Jan 8;139(2):155-168
pubmed: 30586698
Ann Thorac Surg. 2019 Feb;107(2):341-353
pubmed: 30691584