Objective: To evaluate the role of volume management guided by extravascular lung water index(EVLWI) in improving the clinical outcomes and cardiac function for patients with cardiogenic shock. Methods: This study was a single-center, prospective cohort study. Patients with cardiogenic shock admitted to the Department of Cardiovascular Medicine, Shanghai East Hospital from July 2022 to December 2023 were enrolled. Patients were matched 1∶1 by propensity score and divided into EVLWI group and control group. In the control group, the volume management strategy was determined by the attending physician based mainly on conventional factors, including clinical features, biochemical assessments, and certain blood pressure measurements. In EVLWI group, the volume management plan was formulated by integrating conventional factors with EVLWI derived from pulse index continuous cardiac output (PiCCO) monitoring. Baseline clinical data, in-hospital treatment, and hemodynamic data were collected. Major adverse cardiovascular events and cardiac function related parameters were compared at 30 d after treatment between the two groups. Baseline EVLWI levels were compared between the non-survivors and the survivors in the EVLWI group. The receiver operating characteristic curve was plotted to assess the accuracy of baseline EVLWI and central venous pressure in predicting all-cause mortality at 30 d after treatment in patients with cardiogenic shock, and subgroup analysis was performed according to ischemic/non-ischemic etiology and with/without use of inotropic drugs. Kaplan-Meier curve was used for survival analysis, with log-rank tests comparing all-cause mortality, cardiac death, and readmission rate for heart failure at 30 d after treatment. Results: A total of 200 patients with cardiogenic shock were enrolled, aged (71.35±12.82) years, 144(72%) males, EVLWI group and control group 100 patients each. Compared with the control group, EVLWI group had lower all-cause mortality (16%(16/100) vs. 42%(42/100), log-rank P<0.01), cardiac death (14%(14/100) vs. 34%(34/100), log-rank P<0.01), and readmission rate for heart failure (4%(4/100) vs. 12%(12/100), log-rank P=0.03) at 30 d after treatment. Subgroup analysis showed that EVLWI-guided volume management was associated with lower all-cause mortality at 30 d after treatment in patients with cardiogenic shock of ischemic or non-ischemic etiology and with or without inotropic drugs (all P<0.05). In EVLWI group, baseline EVLWI levels were higher in non-survivors than those in survivors [(15.99±6.47) ml/kg vs.(9.75±2.55) ml/kg, P<0.01]. The baseline EVLWI could predicting all-cause mortality at 30 d after treatment in patients with cardiogenic shock, with an area under the receiver operating characteristic curve of 0.84 (95%CI: 0.75-0.94, P<0.01), while the baseline central venous pressure had no predicting value (AUC=0.54, 95%CI: 0.40-0.69, P=0.60). The optimal cutoff value of EVLWI in pridicting all-cause mortality at 30 d after treatment in patients with cardiogenic shock was >10.3 ml/kg. With the optimization of hemodynamic parameters, left ventricular ejection fraction was improved in EVLWI group, and serum levels of N-terminal pro-brain natriuretic peptide, creatinine, alanine aminotransferase and lactic acid were decreased (all P<0.05). Conclusion: EVLWI-guided volume management exerts a beneficial effect on therapeutic decision-making and improves clinical outcomes and cardiac function in patients with cardiogenic shock.
目的： 评估血管外肺水指数（EVLWI）指导容量管理对于改善心原性休克患者的临床预后和心功能的作用。 方法： 本研究为单中心前瞻性队列研究。纳入200例2022年7月至2023年12月于同济大学附属东方医院心内科就诊的心原性休克患者，经1∶1倾向性评分匹配分为EVLWI组和对照组。对照组由主诊医生基于临床表现、生化测定和血压指标等决定容量管理策略；EVLWI组采用脉搏指示连续心排血量技术监测血管外肺水状态，并结合上述指标制订容量管理方案。收集患者的基线临床资料、住院治疗情况及血流动力学数据。比较两组患者治疗后30 d主要不良心血管事件和心功能相关参数。比较EVLWI组中死亡和存活患者的基线EVLWI水平。绘制受试者工作特征曲线，评估基线EVLWI及中心静脉压预测心原性休克患者治疗后30 d全因死亡的准确性，并根据缺血/非缺血性病因、有/无使用正性肌力药物进行亚组分析。生存分析采用Kaplan-Meier曲线，采用log-rank法比较心原性休克患者治疗后30 d全因死亡、心原性死亡及心力衰竭再入院率。 结果： 纳入的200例心原性休克患者年龄为（71.35±12.82）岁，男性144例（72%），EVLWI组和对照组各100例。与对照组相比，EVLWI组患者治疗后30 d全因死亡率［16%（16/100）比42%（42/100），log-rank P<0.01］、心原性死亡率［14%（14/100）比34%（34/100），log-rank P<0.01］及心力衰竭再入院率［4%（4/100）比12%（12/100），log-rank P=0.03］均较低。亚组分析显示，无论缺血或非缺血性病因所致心原性休克，以及是否使用正性肌力药物的患者，EVLWI指导容量管理均使治疗后30 d全因死亡率显著减低（P均<0.05）。EVLWI组中死亡患者的基线EVLWI水平显著高于存活者［（15.99±6.47）ml/kg比（9.75±2.55）ml/kg，P<0.01］。基线EVLWI预测心原性休克患者治疗后30 d全因死亡的受试者工作特征曲线下面积为0.84（95%CI：0.75~0.94，P<0.01），EVLWI>10.3 ml/kg是预测的最佳切点值。而基线中心静脉压对预测心原性休克患者治疗后30 d全因死亡无价值（AUC=0.54，95%CI：0.40~0.69，P=0.60）。随着血流动力学参数的优化，EVLWI组左心室射血分数升高，血清N末端B型利钠肽原、肌酐、谷丙转氨酶和乳酸水平降低（P均<0.05）。 结论： EVLWI指导的容量管理有利于优化心原性休克的治疗，改善患者临床预后。.