Cardiovascular Critical Care I
Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock (DOREMI) (N
Engl J Med 2021;385:516-25)
First prospective trial studying milrinone and dobutamine for cardiogenic shock management
(n=192) during the index hospitalization
| (a) | Median ejection fraction was 25%, and around two-thirds of patients had ischemic |
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cardiomyopathy. Most patients (90%) fell into SCAI cardiogenic shock classes C (classic)
and D (deteriorating).
| (b) | Milrinone or dobutamine was initiated at a dose determined by a standard dosing scale |
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ranging from 1 to 5, corresponding to 2.5, 5, 7.5, 10, and greater than 10 mcg/kg/minute
for dobutamine and 0.125, 0.25, 0.5, and greater than 0.5 mcg/kg/minute for milrinone.
Inotropes were adjusted in a blinded fashion.
ii.
Composite primary outcome (in-hospital mortality from any cause, resuscitated cardiac arrest,
receipt of cardiac transplantation, or mechanical circulatory support, nonfatal MI, transient
ischemic attack or stroke, or initiation of renal replacement therapy) did not differ between the
two groups. Of importance, this study highlights the persisting high mortality rates in patients
with cardiogenic shock (around 40%).
iii.
Both dobutamine and milrinone had high rates of arrhythmias leading to intervention, and
there was no difference in sustained hypotension or vasopressor requirements for either
medication.
Sepsis Occurrence in Acutely Ill Patients (SOAP) II landmark trial (N Engl J Med 2010;362:779-89)
International multicenter trial (n=1679) that compared the 28-day mortality of norepinephrine
with that of dopamine in the management of shock
| (a) | Included if signs of malperfusion and MAP less than 70 mm Hg or SBP less than 100 |
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mm Hg, despite adequate fluid challenge (at least 1000 mL of crystalloids or 500 mL of
colloids unless the CVP was greater than 12 mm Hg or the pulmonary artery occlusion
pressure was greater than 14 mm Hg)
| (b) | Allowed titration to maximums of norepinephrine 0.19 mcg/kg/minute versus dopamine |
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20 mcg/kg/minute, after which open-label norepinephrine was allowed (open-label
norepinephrine doses did not exceed 1.1 mcg/kg/minute during the study period)
| (c) | Epinephrine and vasopressin were permitted as rescue agents (similar use in both groups). |
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| (d) | Dobutamine use was greater in the norepinephrine group (19.4% vs. 14.8%). |
ii.
Showed that dopamine was associated with a significantly higher mortality rate than was
norepinephrine with or without dobutamine in patients with cardiogenic shock in subgroup
analysis
iii.
Dopamine was associated with more adverse events than norepinephrine in the management
of all shock subtypes, predominantly driven by the incidence of arrhythmias (24.1% vs. 12.1%,
p<0.001). Tachyarrhythmias with dopamine had the greatest incidence within the first 36
hours after randomization.
| d. | Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in cardiogenic |
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shock [OptimaCC] (J Am Coll Cardiol 2018;72:173-82)
Prospective, double-blind, multicenter, randomized study (n=57) that compared cardiac
index evolution and refractory cardiogenic shock between epinephrine and norepinephrine in
patients with cardiogenic shock post-MI
ii.
Trial showed that cardiac index evolution did not differ between groups, though the rate of
refractory cardiogenic shock was significantly higher in the epinephrine arm than in the
norepinephrine arm (37% vs 7%). However, this was largely driven by an increase in lactic
acid in the epinephrine group. Epinephrine is a known cause of type B lactic acidosis.
iii.
Tachycardia and lactic acidosis were also significantly increased in the epinephrine group.