Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor which may be suitable for use in these patients.
What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response?
and Methods: We performed a multicenter retrospective study at five tertiary medical centers in the United States. The primary endpoint of hemodynamic responsiveness to angiotensin II was defined as attainment of MAP ≥ 65 mmHg with a stable or reduced total vasopressor dosage 3 hours after drug initiation.
Of 270 included patients, 181 (67%) experienced hemodynamic responsiveness to angiotensin II. Responders had greater increase in MAP (+10.3 v. +1.6 mmHg, p < 0.001) and reduction in vasopressor dosage (-0.20 v. +0.04 mcg/kg/min, p < 0.001) compared to non-responders at 3 hours. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11, 95% CI 1.05-1.17, p < 0.001) and receipt of vasopressin (OR 6.05, 95% CI 1.98-18.6, p = 0.002). In severity-adjusted multivariable analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (HR 0.50, 95% CI 0.35-0.71, p <0.001). Arrhythmias occurred in 28 (10%) and venous thromboembolism was identified in 4 patients.
In post-marketing use for vasopressor-refractory shock, 67% of angiotensin II recipients experienced a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Angiotensin II responders experienced a reduced mortality.

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