Abstract
Vasopressors and inotropes are routinely used in acute myocardial infarction (AMI) related cardiogenic shock (CS) to improve hemodynamics. We aimed to investigate the effect of routinely used vasopressor and inotropes on mortality in AMI related CS. A systematic search of MEDLINE, EMBASE and CENTRAL was performed up to 20 February 2019. Randomized and observational studies reporting mortality of AMI related CS patients were included. At least one group should have received the vasopressor/inotrope compared with a control group not exposed to the vasopressor/inotrope. Exclusion criteria were case reports, correspondence and studies including only post-cardiac surgery patients. In total, 19 studies (6 RCTs) were included, comprising 2478 CS patients. The overall quality of evidence was graded low. Treatment with adrenaline, noradrenaline, vasopressin, milrinone, levosimendan, dobutamine or dopamine was not associated with a difference in mortality between therapy and control group. We found a trend toward better outcome with levosimendan, compared with control (RR 0.69, 95% CI 0.47–1.00). In conclusion, we found insufficient evidence that routinely used vasopressors and inotropes are associated with reduced mortality in patients with AMI related CS. Considering the limited evidence, this study emphasizes the need for randomized trials with appropriate endpoints and methodology.
Highlights
Cardiogenic shock (CS) is a low cardiac output state that leads to hypoperfusion and subsequent multi-organ failure with high mortality rates [1,2]
In this systematic review and meta-analysis, we addressed the following questions: (1) Is treatment with adrenaline, noradrenaline, vasopressin, milrinone, levosimendan, dobutamine or dopamine associated with reduced mortality in patients with Acute myocardial infarction (AMI) related cardiogenic shock (CS)? and (2) What is the effect of these drugs on complications and safety outcomes (e.g., duration of supportive measures, length of intensive care unit (ICU) stay, hemodynamic effects, organ failure and therapy-related complications)?
There were 137 CS patients treated with adrenaline, 594 CS patients treated with noradrenaline, 8 CS patients treated with vasopressin, 50 CS patients treated with milrinone, 209 CS patients treated with levosimendan, 200 CS patients treated with dobutamine and 367 CS patients treated with dopamine
Summary
Cardiogenic shock (CS) is a low cardiac output state that leads to hypoperfusion and subsequent multi-organ failure with high mortality rates [1,2]. Vasopressors and inotropes are routinely used in the treatment of CS to improve hemodynamics and restore organ perfusion. Scientific statements recommend noradrenaline as the first-line pharmacologic treatment strategy in CS, with the addition of inotropes in patients with persistent low cardiac output [4,5]. Vasopressors and inotropes are used in patients with AMI related CS, in the assumption that they improve and maintain adequate coronary perfusion and cardiac output. These drugs are associated with arrhythmias and may increase the myocardial oxygen demand by increasing the contractility, afterload and/or by reducing coronary perfusion [9]
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