Physiologic Response to Angiotensin II Treatment for Coronavirus Disease 2019–Induced Vasodilatory Shock: A Retrospective Matched Cohort Study

OBJECTIVES: To assess the early physiologic response to angiotensin-II treatment in patients with coronavirus disease 2019-induced respiratory failure and distributive shock DESIGN: Retrospective consecutive-sample cohort study SETTING: Three medical ICUs in New York during the coronavirus disease 2019 outbreak PATIENTS: All patients were admitted to the ICU with respiratory failure and were receiving norepinephrine for distributive shock INTERVENTIONS: The treatment groups were patients who received greater than or equal to 1 hour of angiotensin-II treatment Time-zero was the time of angiotensin-II initiation Controls were identified using a 2:1 hierarchical process that matched for 1) date and unit of admission;2) specific organ support modalities;3) age;4) chronic lung, cardiovascular, and kidney disease;and 5) sex Time-zero in the control group was 21 hours post vasopressor initiation, the mean duration of vasopressor therapy prior to angiotensin-II initiation in the treated group MEASUREMENTS AND MAIN RESULTS: Main outcomes were trajectories of vasopressor requirements (in norepinephrine-equivalent dose) and mean arterial pressure Additionally assessed trajectories were respiratory (Pao(2)/Fio(2), Paco(2)), metabolic (pH, creatinine), and coagulation (d-dimer) dysfunction indices after time-zero We also recorded adverse events and clinical outcomes Trajectories were analyzed using mixed-effects models for immediate (first 6 hr), early (48 hr), and sustained (7 d) responses Twenty-nine patients (n = 10 treated, n = 19 control) were identified Despite matching, angiotensin-II-treated patients had markedly greater vasopressor requirements (mean: 0 489 vs 0 097 µg/kg/min), oxygenation impairment, and acidosis at time-zero Nonetheless, angiotensin-II treatment was associated with an immediate and sustained reduction in norepinephrine-equivalent dose (6 hr model: β = -0 036 µg/kg/min/hr;95% CI: -0 054 to -0 018 µg/kg/min/hr, p (interaction)=0 0002) (7 d model: β = -0 04 µg/kg/min/d, 95% CI: -0 05 to -0 03 µg/kg/min/d;p (interaction) = 0 0002) Compared with controls, angiotensin-II-treated patients had significantly faster improvement in mean arterial pressure, hypercapnia, acidosis, baseline-corrected creatinine, and d-dimer Three thrombotic events occurred, all in control patients CONCLUSIONS: Angiotensin-II treatment for coronavirus disease 2019-induced distributive shock was associated with rapid improvement in multiple physiologic indices Angiotensin-II in coronavirus disease 2019-induced shock warrants further study