Delay in Inotrope Initiation Is Associated With Higher Peak Lactate in Cardiogenic Shock

Tuesday, March 24, 2026

12:30 PM - 1:30 PM Central Time

Location: Connections Central - RST 02

NS

Neil Sahasrabudhe, MD

Disclosure information not submitted.
CM

Christopher Macko, MD

Chief Resident
Kaiser Oakland Medical Center

Disclosure information not submitted.
Marissa Jordan, MD MS (she/her/hers)

California

Disclosure(s): No relevant financial relationship(s) to disclose.
FA

Fiona Angel, MD

Physician
Kaiser Permanente

Disclosure information not submitted.
NR

Nirmala Ramalingam, MPP

GME Administrator
Kaiser Permanente

Disclosure information not submitted.
JY

Jie Yang, MD

Cardiologist
Kaiser Permanente

Disclosure information not submitted.
AC

Amanda Chang, MD

Resident Physician
Kaiser Permanente

Disclosure information not submitted.
JV

Julian Villar, MD

EMCC Attending Physician
Kaiser Permanente

Disclosure information not submitted.

Introduction: Mortality in cardiogenic shock (CS) remains high. Optimal timing of inotrope initiation in deteriorating patients is not clear. We aimed to estimate the relationship between lactate-to-inotrope initiation time and clinical outcomes in patients admitted with early CS who later deteriorated.

Methods: We conducted an observational quality project from 7/1/2024 - 10/1/2024 at a large urban tertiary community medical center. Patients >= 18 years admitted with heart failure (AHF), coronary syndrome (ACS), arrhythmia, or RV failure, and those with ejection fraction (EF) <= 35% were screened daily. We used the Society for Cardiovascular Angiography and Intervention (SCAI) criteria, including patients admitted in SCAI stage B (lactate 2-5 mmol/L or SBP < 90 mmHg without inotropic support) and followed them for 30 days. Exposures of interest were initial serum lactate level and lactate-to-inotrope time. Outcomes of interest were peak lactate and 30-day mortality.

Results: Of 250 screened patients, 87 met criteria for SCAI B. Median age was 73.5 years, 42% were female, and mean EF was 33%. Thirty worsened, 3 were transitioned to comfort care, and 27 received inotropes. For patients with lactate measured prior to inotrope initiation (n=22), median lactate-to-inotrope time for patients with initial lactate level of 2-2.9 mmol/L (n=7) was 20.8 hours (IQR 2.4, 28.5) and 7.0 hours (IQR 5.7, 12.3) for those with lactate >=3 mmol/L (n=8). In patients with initial lactate >=3 mmol/L, lactate-to-inotrope initiation < 7.0 hours (n=4) had median peak lactate of 4.6 mmol/L vs. 8.2 mmol/L (IQR 5.9,10.4) for those with lactate-to-inotrope initiation >=7 hours (n=4).

Conclusions: In patients with SCAI B CS and initial lactate >=3 mmol/L who worsened, delayed initiation of inotropes is associated with higher peak lactate. No significant difference was seen in lactate-to-inotrope time between survivors and non-survivors. A larger analysis is warranted to validate these findings.