Delta Lactate: Prognostic Surrogate of Lactate Clearance in Predicting Mortality from Cardiogenic Shock
Presenter
Arjun Aggarwal, MD, Dell Medical School at the University of Texas at Austin, Austin, TX
Arjun Aggarwal, MD1, Manoj Thangam, MD2, Elena Deych, MS2, David A. Morrow, MD, MPH3, Sunil V. Rao, MD, FSCAI4, Marc Daniel Samsky, MD5, James T. Devries, MD, FSCAI6, Michael N. Young, MD6, Lauren Gilstrap, MD, MPH6, Prakash Balan, MD7, Pratik Doshi, MD8, Richard G. Bach, MD9, Karen E. Joynt-Maddox, MD, MPH2 and Amit P. Amin, MD, MSc, MBA2, (1)Dell Medical School at the University of Texas at Austin, Austin, TX, (2)Barnes Jewish Hospital at Washington University School of Medicine, Saint Louis, MO, (3)Brigham and Women's Hospital, Boston, MA, (4)NYU Langone Health, New York, NY, (5)Duke University Health System, Durham, NC, (6)Dartmouth-Hitchcock Medical Center, Lebanon, NH, (7)Banner - University Medical Center Phoenix, Phoenix, AZ, (8)University of Texas Health McGovern Medical School Houston, Houston, TX, (9)Washington University School of Medicine, Saint Louis, MO
Keywords: Acute Coronary Syndromes (ACS), Cardiogenic shock, Heart Failure and Hemodynamic support
Background
Serum lactate is a frequently used prognostic tool in septic shock, but the prognostic value of lactate is not well understood in cardiogenic shock. Furthermore, even less is known regarding lactate clearance in this population. Pathophysiologically, lactate clearance may be a better marker of prognosis than isolated lactate values since it provides insight into the dynamic nature of cardiogenic shock. Therefore, we created a formula termed delta lactate, calculated as [(maximum lactate – last available lactate)/maximum lactate] to represent lactate clearance and examined the association between initial, maximum, and delta lactate on 30-day mortality in cardiogenic shock.
Methods
We analyzed 8,757 adult patients with cardiogenic shock and
> 1 lactate measurement from 7 hospitals within a single, large healthcare system between December 1999 and March 2020. The primary outcome was 30-day mortality with primary predictive variables of initial, maximum, and delta lactate. Delta lactate was categorized into <25%, 25-50%, and >50%, representing percent-clearance. The independent association of lactate and mortality was assessed with multivariable regression models adjusted for demographics, vital signs, comorbidities, procedures, and laboratory values.
Results
Among 8,757 patients, 2,497 (28.5%) expired within 30 days. After adjusting for available variables, higher initial and maximum lactate levels were associated with increased 30-day mortality (initial > 2 mmol/L and max < 4 mmol/L: OR 1.65, CI 1.38-1.98; initial < 2 mmol/L and max > 4 mmol/L: OR 3.43, CI 2.65-4.44; initial > 2 mmol/L and max > 4 mmol/L: OR 3.5, CI 2.97-4.13). Higher delta lactate was associated with decreased 30-day mortality (delta lactate 25-50% vs. <25%: OR 0.76, CI 0.64-0.9; delta lactate >50% vs. <25%: OR 0.39, CI 0.33-0.45).
Conclusions
Elevated initial and maximum lactate levels were associated with higher 30-day mortality, and high delta lactate was associated with lower 30-day mortality in patients with cardiogenic shock. These data support the prognostic value of delta lactate, a novel representation of lactate clearance, in evaluating mortality in cardiogenic shock.