Shriver Jackson L, Hamilton David E, Hesson Ashley M, Mathis Michael R, Thompson Andrea D
University of Michigan, Department of Internal Medicine, Ann Arbor, MI.
University of Michigan, Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI.
medRxiv. 2025 Jul 14:2025.07.11.25331408. doi: 10.1101/2025.07.11.25331408.
Cardiogenic shock has significant associated morbidity and mortality with a wide range of vasoactive management strategies. However, the extent to which variation in vasoactive and inodilator therapies is explained by patient level variables versus clinical practice variation remains underexplored.
The cohort included 4,525 patients admitted to ICUs at Michigan Medicine from 01/01/2014-12/31/2023 diagnosed with cardiogenic shock identified by billing codes. Vasoactive medication utilization was compared across various ICUs (cardiovascular, cardiovascular surgical, non-cardiac). Mixed-effect multiple logistic modeling was used to evaluate to what extent variation in inodilator use was associated with fixed patient-level variables (i.e. prior cardiac arrest) compared to ICU location as a random effect.
Patient encounters were classified as cardiovascular ICU (n = 1,355), cardiovascular surgical ICU (n = 1,405), non-cardiac ICU (n = 723), and multiple ICUs (n = 1,042). Vasoactive and inodilator medication use varied significantly. Inodilators were more frequently used in the cardiac ICU (44.4% [95% CI 40.4-48.3%]), cardiothoracic surgical ICU (64.9% [61.8-68.0%]), and multiple ICU patients (60.8% [57.0-64.6%]) and less frequently in non-cardiac ICU patients (18.8% [12.2-25.4%]). Heart failure was associated with more frequent inodilator use (OR 3.82 [3.06-4.80]), while increased age (OR 0.993 [0.989 - 0.997]), male sex (0.80 [0.70 - 0.91]), and prior cardiac arrest (0.68 [0.58 - 0.81]) were associated with lower use. ICU location attributed to 15.8% of variance in inodilator use, while fixed patient-level variables combined accounted for 6.1% of variance.
A substantial portion of variation in vasoactive medication utilization was attributed to ICU setting.
心源性休克与多种血管活性药物管理策略相关，具有显著的发病率和死亡率。然而，血管活性药物和血管扩张剂治疗的差异在多大程度上是由患者层面的变量而非临床实践差异所导致的，这一点仍未得到充分探索。
该队列包括2014年1月1日至2023年12月31日在密歇根大学医学中心重症监护病房（ICU）住院的4525名患者，这些患者通过计费代码被诊断为心源性休克。比较了不同ICU（心血管、心血管外科、非心脏）中血管活性药物的使用情况。使用混合效应多元逻辑回归模型来评估血管扩张剂使用的差异在多大程度上与固定的患者层面变量（如既往心脏骤停）相关，同时将ICU位置作为随机效应。
患者就诊情况分为心血管ICU（n = 1355）、心血管外科ICU（n = 1405）、非心脏ICU（n = 723）和多个ICU（n = 1042）。血管活性药物和血管扩张剂的使用存在显著差异。血管扩张剂在心脏ICU（44.4% [95% CI 40.4 - 48.3%]）、心胸外科ICU（64.9% [61.8 - 68.0%]）和多个ICU患者（60.8% [57.0 - 64.6%]）中使用更为频繁，而在非心脏ICU患者中使用频率较低（18.8% [12.2 - 25.4%]）。心力衰竭与血管扩张剂使用频率增加相关（OR 3.82 [3.06 - 4.80]），而年龄增加（OR 0.993 [0.989 - 0.997]）、男性（0.80 [0.70 - 0.91]）和既往心脏骤停（0.68 [0.58 - 0.81]）与使用频率降低相关。ICU位置占血管扩张剂使用差异的15.8%，而固定的患者层面变量合计占差异的6.1%。
血管活性药物使用差异的很大一部分归因于ICU设置。
