Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock: A Prospective Cohort Study with Long-Term Follow-Up

• Published in: Shock (Augusta, Ga.) Ga.), 2017-01, Vol.47 (1), p.86-92
• Main Authors: Bagate, François, Lellouche, Nicolas, Lim, Pascal, Moutereau, Stephane, Razazi, Keyvan, Carteaux, Guillaume, de Prost, Nicolas, Dubois-Randé, Jean-Luc, Brun-Buisson, Christian, Dessap, Armand Mekontso
• Format: Article
• Language: English
• ISSN: 1073-2322; 1540-0514
• DOI: 10.1097/SHK.0000000000000710

BACKGROUND:Relative adrenal insufficiency (RAI) is common in ICU patients, particularly during septic shock (SS). Cardiogenic shock (CS) may share some pathophysiological features with SS. The aim of this study was to evaluate the prevalence and long-term prognosis of RAI during CS. METHODS:Prospective observational study conducted in the intensive care and cardiology units in one university hospital in France. Patients meeting the criteria for CS without prior corticosteroid therapy were included. Total blood cortisol levels were assessed immediately before (T0) a short corticotropin stimulation test (0.25 mg iv of tetracosactrin) and 30 and 60 minutes afterward. Δmax was defined as the difference between the maximal value after the test and T0. RESULTS:Of the 92 patients enrolled, 42 (46% (95%CI [36–56%]) died in hospital and 7 more died during a median follow-up of 616 [57–2,498] days, for an overall mortality rate of 53% (95%CI [43–63%]), Three groups were identified based on the corticotropin testgroup 1 (T0 ≤798 nmol/l and Δmax >473 nmol/l), group 2 [(T0 >798 nmol/l and Δmax >473 nmol/l) or (T0 ≤798 nmol/l and Δmax ≤472 nmol/l)], and group 3 (T0 >798 nmol/l and Δmax ≤473 nmol/l) with an overall survival of 76%, 43% and 15%, respectively (log rank p = 0.003). In the multivariable analysis, adrenal non-response (group 3) was an independent predictor of mortality (p = 0.04), along with left ventricular ejection fraction, SAPS2 score, and cardiac arrest. CONCLUSIONS:These data suggest that a short corticotropin test has a good prognostic value in CS and allows identifying patients at higher risk of death.