Comparative Effectiveness and Safety Between Milrinone or Dobutamine as Initial Inotrope Therapy in Cardiogenic Shock

Inotropes are an integral component of the early stabilization of the patient presenting with cardiogenic shock. Despite years of clinical experience with the 2 most commonly used inotropes, dobutamine and milrinone, there remains limited data comparing outcomes between the two. We conducted a retrospective review to compare the effectiveness and safety of milrinone or dobutamine for the initial management of cardiogenic shock. Adult patients with cardiogenic shock regardless of etiology who received initial inotrope therapy with either milrinone (n = 50) or dobutamine (n = 50) and did not receive mechanical circulatory support were included. The primary end point was the time to resolution of cardiogenic shock. Changes in hemodynamic parameters from baseline and adverse events were also assessed. Resolution of shock was achieved in similar numbers in both the groups (milrinone 76% vs dobutamine 70%, P = .50). The median time to resolution of shock was 24 hours in both groups ( P = .75). There were no differences in hemodynamic changes during inotrope therapy, although dobutamine trended toward a greater increase in cardiac index. Arrhythmias were more common in patients treated with dobutamine than milrinone, respectively (62.9% vs 32.8%, P < .01), whereas hypotension occurred to a similar extent in both groups (milrinone 49.2% vs dobutamine 40.3%, P = .32). The use of concomitant vasoactive medications, dosage required, and duration of therapy did not differ between groups. There was no difference in the overall rate of discontinuation due to adverse event; however, milrinone was more commonly discontinued due to hypotension (13.1% vs 0%, P < .01) and dobutamine was more commonly discontinued due to arrhythmia (0% vs 11.3%, P < .01). Milrinone and dobutamine demonstrated similar effectiveness and safety profiles but with differences in adverse events. The choice of milrinone or dobutamine as initial inotrope therapy for cardiogenic shock may depend more on tolerability of adverse events.

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Cardiogenic Shock and Short-Term Mechanical Circulatory Support Options in the Current Era: Focus on Adverse Events

Journal of Cardiac Failure ◽

10.1016/j.cardfail.2018.07.454 ◽

2018 ◽

Vol 24 (8) ◽

pp. S127

Author(s):

Iosif Taleb ◽

Antigone Koliopoulou ◽

Anwar Tandar ◽

Stephen McKellar ◽

Jose Nativi-Nicolau ◽

...

Keyword(s):

Adverse Events ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Circulatory Support ◽

Short Term

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Multidisciplinary approach and early use of percutaneous mechanical circulatory support devices in patients with cardiogenic shock

European Heart Journal ◽

10.1093/ehjci/ehaa946.1239 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Venuti ◽

M Gramegna ◽

L Baldetti ◽

F Calvo ◽

V Pazzanese ◽

...

Keyword(s):

Heart Failure ◽

Mortality Rate ◽

Adverse Events ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Multidisciplinary Approach ◽

Circulatory Support ◽

Coronary Syndrome ◽

Early Use

Abstract Background Despite progresses in the reperfusion strategies, the prognosis of patients with cardiogenic shock (CS) remains poor with a high in-hospital mortality rate. Percutaneous mechanical circulatory support systems (pMCS) reducing afterload, preload and myocardial oxygen demand, preventing compensatory tachycardia and increasing mean arterial pressure, lead to improve end-organ perfusion. Since CS progression to a refractory shock state is deleterious, timing of treatment represents a crucial issue in these patients. Purpose The aim of our study was to assess whether a multidisciplinary approach and an early use of pMCS could be safe and effective in improving CS patients' outcome. Methods We examined the outcome in terms of one-month survival of 62 patients (75.8% males, mean age 67.7±12.2 years) admitted between January and December 2018 to our Cardiac Intensive Care Unit (CICU) with cardiogenic shock due to acute coronary syndrome (ACS), acute heart failure (AHF) and other causes in 43.5%, 21.6%, 35.4% of cases respectively. For each patient, a Multidisciplinary Shock Team (CS-Team) including critical care specialists, interventional cardiologists and advanced heart failure specialists, was involved and the early use of pMCS was considered. Results Overall, 52 (83.9%) CS patients underwent pMCS implant, including intra-aortic ballon pump counterpulsation (IABP), Impella system (Impella), venous-arterial extracorporeal membrane oxygenation (VA ECMO) in 67.7%, 46.7%, 11.3% of cases respectively. Median time from the first CS-Team contact to the pMCS implantation was 32.5 (30–60) minutes. Among ACS-CS group, AHF-CS group and CS-due to other causes group, pMCS were implanted in 25 (92.5%), 12 (92.3%) and 15 (68.1%) patients respectively. Lower extremities ischemia, gastrointestinal/intracerebral and life-threatening bleeding and ischemic stroke were observed as pMCS related adverse events in 9.7%, 6.4%, 1.6%, 3.2%, 6.4% of cases respectively. At one month, 56 (90.3%) CS patients were discharged alive while 6 (9.7%) CS patients died during the CICU stay. Conclusion A multidisciplinary approach of CS patients, contemplating an early and extensive use of pMCS, may be effective in the reduction of in-hospital mortality rate with a low and acceptable occurrence of pMCS related adverse events. Funding Acknowledgement Type of funding source: None

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Right Atrial Pressure Is Associated With Outcomes in Patient With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.563853 ◽

2021 ◽

Vol 8 ◽

Author(s):

Carlos D. Davila ◽

Michele Esposito ◽

Colin S. Hirst ◽

Kevin Morine ◽

Lena Jorde ◽

...

Keyword(s):

Logistic Regression ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Atrial Pressure ◽

Right Atrial ◽

Right Atrial Pressure ◽

Circulatory Support ◽

Hemodynamic Changes ◽

Acute Mechanical Circulatory Support

Background: We describe the association between longitudinal hemodynamic changes and clinical outcomes in patients with cardiogenic shock (CS) receiving acute mechanical circulatory support devices (AMCS) at a single center. We hypothesized that improved right atrial pressure is associated with better survival in CS.Methods: Retrospective analysis of patients from Tufts Medical Center that received AMCS for CS. Baseline characteristics and invasive hemodynamics were collected, analyzed, and correlated against outcomes. Hemodynamics were recorded at different time intervals during index admission [pre-AMCS, 24 h after AMCS (post AMCS), and last available set of hemodynamics (final-AMCS)]. Logistic regression was performed to determine variables associated with in-hospital mortality.Results: A total of 76 patients had longitudinal hemodynamics available. In hospital mortality occurred in 46% of the cohort. Mean baseline right atrial pressure (RAP) was significantly higher among non-survivors vs. survivors (19.5+6.6 vs. 16.4+5.3 mmHg). Change in right atrial pressure from baseline to before device removal (ΔRA:final AMCS—pre AMCS) was significantly different between survivors and non survivors (−6.5 ± 6.9 mmHg vs. −2.5 ± 6.2 mmHg p = 0.03). Unadjusted logistic regression revealed baseline RAP (OR: 1.1 95% CI: 1.0–1.2), 24 h post device implant RAP (OR: 1.3 95% CI: 1.1–1.4), and final RAP (OR: 1.3 95% CI: 1.1–1.5) to be significant predictors of in-hospital mortality. In a multivariate logistic regression baseline RAP was no longer significantly associated with mortality in the overall cohort, while 24 h (OR: 1.26 95% CI: 1.1–1.5) and final RAP (OR: 1.3 95% CI: 1.1–1.6) remained statistically significant.Conclusion: We report a novel retrospective analysis of hemodynamic changes in patients with CS receiving AMCS. Our findings identify the potential importance of venous congestion as a prognostic marker of mortality. Furthermore, early decongestion or reduced RA pressure is associated with better survival in these critically ill CS patients. These observations suggest the need for further study in larger retrospective and prospective cohorts of patients with varying degrees of CS severity.

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Clinical Characteristics and Predictors of In-hospital Mortality in Patients with Cardiogenic Shock: Results from the RESCUE Registry

10.21203/rs.3.rs-102981/v1 ◽

2020 ◽

Author(s):

Jeong Hoon Yang ◽

Ki Hong Choi ◽

Young-Guk Ko ◽

Chul-Min Ahn ◽

Cheol Woong Yu ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Primary Outcome ◽

Circulatory Support ◽

Limited Data ◽

Inotrope Score ◽

High Utilization ◽

Variable Analysis

Abstract Background: In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean CS patients.Methods: The RESCUE study is a multi-center, retrospective and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality. Results: In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and non-ischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intra-aortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multi-variable analysis, age ≥70 years, cardiac arrest at presentation, vasoactive-inotrope score >80, continuous renal replacement therapy, and mechanical ventilator were independent predictors for in-hospital mortality.Conclusions: The in-hospital mortality of CS patients remains high despite the high utilization of mechanical circulatory support. Age, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure were poor prognostic factors for in-hospital mortality.Trial registration: RESCUE registry, Clinicaltrials.gov, NCT02985008, Registered 01 January 2014 - Retrospectively and Prospectively registered https://clinicaltrials.gov/ct2/show/NCT02985008.

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