Norepinephrine Equivalent Dose for Mortality Risk Stratification in VA-ECMO Cardiogenic Shock
Abstract
Background Patients with cardiogenic shock (CS) complicated by vasoplegia requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) often need escalating vasopressor support and face high mortality. Norepinephrine equivalent dose (NEE) quantifies vasopressor burden, yet its prognostic value in VA-ECMO remains undefined. Objectives We aimed to characterize the dose-response relationship between NEE and 30-day mortality, identify a clinically relevant NEE threshold, and determine factors associated with high vasopressor burden. Methods This bicentric retrospective study included 572 consecutive patients with CS requiring VA-ECMO. We collected vasopressor regimens, NEE trajectories, and hemodynamic parameters at predefined intervals. Restricted cubic splines assessed dose-response linearity. Maximally selected rank statistics with bootstrap validation identified optimal thresholds. Cox models estimated mortality risk. Multivariable logistic regression identified factors associated with high vasopressor burden. Results The median NEE at ECMO initiation was 0.30 (IQR: 0.09-0.72) μg·kg ·min ; 86.2% received norepinephrine. NEE showed a linear dose-response with mortality (HR: 1.06 per 0.1 μg·kg ·min increment; 95% CI: 1.04-1.08; P < 0.001). A threshold of 0.443 μg·kg ·min identified high vasopressor burden with elevated 30-day mortality (61.8% vs 42.6%; P < 0.001; adjusted HR: 1.42; 95% CI: 1.11-1.81; P = 0.005). Factors associated with high vasopressor burden included mechanical ventilation (OR: 2.96; 95% CI: 1.08-8.07), prior epinephrine use (OR: 1.87; 95% CI: 1.12-3.14), renal replacement therapy before VA-ECMO (OR: 1.76; 95% CI: 1.02-3.03), baseline lactate (OR: 1.05 per mmol/L; 95% CI: 1.01-1.09), and lower Survival After Veno-Arterial ECMO score (OR: 0.96 per point; 95% CI: 0.92-1.00). Left ventricular unloading was inversely associated (OR: 0.54; 95% CI: 0.34-0.87). Conclusions In VA-ECMO-supported CS with vasoplegia, vasopressor burden shows a linear relationship with mortality. A NEE threshold of 0.443 μg·kg ·min may identify patients with elevated mortality risk.
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BibTeX
@article{guinot2026norepinephrine,
title = {{Norepinephrine Equivalent Dose for Mortality Risk Stratification in VA-ECMO Cardiogenic Shock}},
author = {Pierre-Gregoire Guinot and Maxime Nguyen and Osama Abou-Arab and Yazine Mahjoub and Belaid Bouhemad and Christophe Beyls},
journal = {JACC. Advances},
year = {2026},
month = nov,
doi = {10.1016/j.jacadv.2026.103208},
url = {https://u-picardie.hal.science/hal-05848195v1},
note = {CC BY},
}
RIS
TY - JOUR
TI - Norepinephrine Equivalent Dose for Mortality Risk Stratification in VA-ECMO Cardiogenic Shock
AU - Pierre-Gregoire Guinot
AU - Maxime Nguyen
AU - Osama Abou-Arab
AU - Yazine Mahjoub
AU - Belaid Bouhemad
AU - Christophe Beyls
PY - 2026
DA - 2026/11/02
JO - JACC. Advances
DO - 10.1016/j.jacadv.2026.103208
UR - https://u-picardie.hal.science/hal-05848195v1
AB - Background Patients with cardiogenic shock (CS) complicated by vasoplegia requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) often need escalating vasopressor support and face high mortality. Norepinephrine equivalent dose (NEE) quantifies vasopressor burden, yet its prognostic value in VA-ECMO remains undefined. Objectives We aimed to characterize the dose-response relationship between NEE and 30-day mortality, identify a clinically relevant NEE threshold, and determine factors associated with high vasopressor burden. Methods This bicentric retrospective study included 572 consecutive patients with CS requiring VA-ECMO. We collected vasopressor regimens, NEE trajectories, and hemodynamic parameters at predefined intervals. Restricted cubic splines assessed dose-response linearity. Maximally selected rank statistics with bootstrap validation identified optimal thresholds. Cox models estimated mortality risk. Multivariable logistic regression identified factors associated with high vasopressor burden. Results The median NEE at ECMO initiation was 0.30 (IQR: 0.09-0.72) μg·kg ·min ; 86.2% received norepinephrine. NEE showed a linear dose-response with mortality (HR: 1.06 per 0.1 μg·kg ·min increment; 95% CI: 1.04-1.08; P < 0.001). A threshold of 0.443 μg·kg ·min identified high vasopressor burden with elevated 30-day mortality (61.8% vs 42.6%; P < 0.001; adjusted HR: 1.42; 95% CI: 1.11-1.81; P = 0.005). Factors associated with high vasopressor burden included mechanical ventilation (OR: 2.96; 95% CI: 1.08-8.07), prior epinephrine use (OR: 1.87; 95% CI: 1.12-3.14), renal replacement therapy before VA-ECMO (OR: 1.76; 95% CI: 1.02-3.03), baseline lactate (OR: 1.05 per mmol/L; 95% CI: 1.01-1.09), and lower Survival After Veno-Arterial ECMO score (OR: 0.96 per point; 95% CI: 0.92-1.00). Left ventricular unloading was inversely associated (OR: 0.54; 95% CI: 0.34-0.87). Conclusions In VA-ECMO-supported CS with vasoplegia, vasopressor burden shows a linear relationship with mortality. A NEE threshold of 0.443 μg·kg ·min may identify patients with elevated mortality risk.
SN - 2772-963X
ER -