Justin Y Chow1, Maria E Vadakken2, Richard P Whitlock2,3,4, Alex Koziarz4,5, Craig Ainsworth1,6, Faizan Amin1,6, William F McIntyre1,2, Catherine Demers1, Emilie P Belley-Côté7,8,9. 1. Department of Medicine, Division of Cardiology, McMaster University, Hamilton, ON, Canada. 2. Population Health Research Institute, Hamilton, ON, Canada. 3. Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada. 4. Department of Health Research, Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. 5. Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 6. Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada. 7. Department of Medicine, Division of Cardiology, McMaster University, Hamilton, ON, Canada. ebelleycote@me.com. 8. Population Health Research Institute, Hamilton, ON, Canada. ebelleycote@me.com. 9. Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada. ebelleycote@me.com.
Abstract
PURPOSE: Cardiogenic shock carries high morbidity and mortality. The purpose of this review was to determine the safety and efficacy of pulmonary artery catheterization (PAC) in adult patients hospitalized with cardiogenic shock. SOURCE: We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC vs no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened articles, abstracted data, and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using the GRADE framework. Outcomes of interest were mortality, length of stay, and procedural complications. PRINCIPAL FINDINGS: We identified 19 eligible observational studies (≥ 2,716,287 patients) and no randomized controlled trials; 14 studies were at high risk of bias (lack of adjustment for prognostic variables and/or co-interventions). When pooling adjusted results, PAC was associated with improved survival to hospital discharge (relative risk [RR], 0.77; 95% confidence interval [CI], 0.64 to 0.91, I2 = 98%; very low-quality evidence) and at longest available follow-up (RR, 0.72; 95% CI, 0.60 to 0.87; I2 = 99%; very low-quality evidence). Unadjusted length of stay was 3.5 days longer (95% CI, 1.49 to 5.54; I2 = 100%; very low-quality evidence) with PAC. Procedural complications were inconsistently reported. CONCLUSIONS: Very low-quality observational evidence suggests PAC use in patients with cardiogenic shock is associated with lower mortality. Overall, these results support consideration of PAC for hemodynamic assessment in cardiogenic shock. Prospective randomized clinical trials are needed to further characterize the role of PAC in this population.
PURPOSE: Cardiogenic shock carries high morbidity and mortality. The purpose of this review was to determine the safety and efficacy of pulmonary artery catheterization (PAC) in adult patients hospitalized with cardiogenic shock. SOURCE: We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC vs no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened articles, abstracted data, and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using the GRADE framework. Outcomes of interest were mortality, length of stay, and procedural complications. PRINCIPAL FINDINGS: We identified 19 eligible observational studies (≥ 2,716,287 patients) and no randomized controlled trials; 14 studies were at high risk of bias (lack of adjustment for prognostic variables and/or co-interventions). When pooling adjusted results, PAC was associated with improved survival to hospital discharge (relative risk [RR], 0.77; 95% confidence interval [CI], 0.64 to 0.91, I2 = 98%; very low-quality evidence) and at longest available follow-up (RR, 0.72; 95% CI, 0.60 to 0.87; I2 = 99%; very low-quality evidence). Unadjusted length of stay was 3.5 days longer (95% CI, 1.49 to 5.54; I2 = 100%; very low-quality evidence) with PAC. Procedural complications were inconsistently reported. CONCLUSIONS: Very low-quality observational evidence suggests PAC use in patients with cardiogenic shock is associated with lower mortality. Overall, these results support consideration of PAC for hemodynamic assessment in cardiogenic shock. Prospective randomized clinical trials are needed to further characterize the role of PAC in this population.
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