August 3, 2017
Angiotensin II for the Treatment of Vasodilatory Shock.
What was the research question?
Does the addition of angiotensin II to the background vasopressors improve blood pressure in patients with catecholamine-resistant vasodilatory shock?
How did they do it?
Randomized, double-blinded, controlled trial with 1:1 assignment in 75 Intensive Care Units across 9 countries (North America, Australasia, Europe).
Total of 321 (out of 344) with vasodilatory shock who were receiving more than 0.2 μg/kg/min of norepinephrine (or the equivalent dose of another vasopressor) to receive infusions of either angiotensin II (163 patients) or placebo (158 patients).
The primary end point was a hemodynamic response defined as an increase in the mean arterial pressure of at least 10 mm Hg or an increase to at least 75 mm Hg without increasing the background vasopressors.
What did they find?
The primary end point was reached by more patients in the angiotensin II group compared to placebo (69.9% vs. 23.4%; P<0.001).
Improvement in the cardiovascular SOFA score was better in the angiotensin II group compared to placebo (−1.75 vs. −1.28, P=0.01).
Serious adverse events were reported in 60.7% of the patients in the angiotensin II group and in 67.1% in the placebo group.
Death rate by day 28 was 46% in the angiotensin II group and in 54% in the placebo group (P=0.12).
What are the limitations of the study?
Primary outcome is not patient-centered outcome
The trial was not powered to detect mortality differences
The trial did not measure other key ICU outcomes such as ICU length of stay or need for renal replacement therapy.
What does it mean?
Angiotensin II effectively increased blood pressure in patients with refractory vasodilatory shock.
More patient-centered outcome data is needed before widely used in the ICU.