Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.).
Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Denmark (J.G.).
Circ Heart Fail. 2024 Jun;17(6):e011437. doi: 10.1161/CIRCHEARTFAILURE.123.011437. Epub 2024 Jun 7.
To assess the effect of targeting higher or lower blood pressure during postresucitation intensive care among comatose patients with out-of-hospital cardiac arrest with a history of heart failure.
The BOX trial (Blood Pressure and Oxygenation Targets After Out-of-Hospital Cardiac Arrest) was a randomized, controlled, double-blinded, multicenter study comparing titration of vasopressors toward a mean arterial pressure (MAP) of 63 versus 77 mm Hg during postresuscitation intensive care. Patients with a history of heart failure were included in this substudy. Pulmonary artery catheters were inserted shortly after admission. History of heart failure was assessed through chart review of all included patients. The primary outcome was cardiac index during the first 72 hours. Secondary outcomes were left ventricular ejection fraction, heart rate, stroke volume, renal replacement therapy and all-cause mortality at 365 days.
A total of 134 patients (17% of the BOX cohort) had a history of heart failure (patients with left ventricular ejection fraction, ≤40%: 103 [77%]) of which 71 (53%) were allocated to a MAP of 77 mm Hg. Cardiac index at intensive care unit arrival was 1.77±0.11 L/min·m in the MAP63-group and 1.78±0.17 L/min·m in the MAP77, =0.92. During the next 72 hours, the mean difference was 0.15 (95% CI, -0.04 to 0.35) L/min·m; =0.22. Left ventricular ejection fraction and stroke volume was similar between the groups. Patients allocated to MAP77 had significantly elevated heart rate (mean difference 6 [1-12] beats/min, =0.03). Vasopressor usage was also significantly increased (=0.006). At 365 days, 69 (51%) of the patients had died. The adjusted hazard ratio for 365 day mortality was 1.38 (0.84-2.27), =0.20 and adjusted odds ratio for renal replacement therapy was 2.73 (0.84-8.89; =0.09).
In resuscitated patients with out-of-hospital cardiac arrest with a history of heart failure, allocation to a higher blood pressure target resulted in significantly increased heart rate in the higher blood pressure-target group. However, no certain differences was found for cardiac index, left ventricular ejection fraction or stroke volume.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03141099.
评估在伴有心力衰竭病史的院外心脏骤停昏迷患者中，复苏后强化治疗期间将血压目标设定为较高或较低水平对患者的影响。
BOX 试验（院外心脏骤停后血压和氧合目标）是一项随机、对照、双盲、多中心研究，比较在复苏后强化治疗期间将升压剂滴定至平均动脉压（MAP）63 毫米汞柱与 77 毫米汞柱的效果。该研究纳入了伴有心力衰竭病史的患者。患者入院后立即插入肺动脉导管。通过对所有纳入患者的病历进行回顾性评估来确定心力衰竭病史。主要结局为复苏后 72 小时内的心指数。次要结局包括左心室射血分数、心率、每搏量、肾脏替代治疗和 365 天时的全因死亡率。
共有 134 名患者（BOX 队列的 17%）有心力衰竭病史（左心室射血分数，≤40%：103 [77%]），其中 71 名（53%）被分配至 MAP 为 77 毫米汞柱组。MAP63 组患者入 ICU 时的心指数为 1.77±0.11 L/min·m，MAP77 组为 1.78±0.17 L/min·m，=0.92。在接下来的 72 小时内，平均差值为 0.15（95%CI，-0.04 至 0.35），=0.22。两组间左心室射血分数和每搏量相似。MAP77 组的心率显著升高（平均差值为 6 [1-12] 次/分，=0.03）。血管加压药的使用也显著增加（=0.006）。365 天时，69 名（51%）患者死亡。365 天死亡率的调整后危险比为 1.38（0.84-2.27），=0.20，肾脏替代治疗的调整后优势比为 2.73（0.84-8.89；=0.09）。
在伴有心力衰竭病史的院外心脏骤停复苏患者中，将血压目标设定为较高水平会导致较高血压目标组的心率显著增加。然而，心指数、左心室射血分数或每搏量没有发现明显差异。
