Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome

Unverzagt, Susanne; Hirsch, Karin; Buerke, Michael; Thiele, Holger; Haerting, Johannes; Werdan, Karl; Prondzinsky, Roland

doi:10.1002/14651858.cd009669

Cited by 10 publications

(10 citation statements)

References 75 publications

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“…The mortality of patients with cardiogenic shock remains extremely high, especially in combination with respiratory failure (1). Evidence supporting pharmacologic treatments for cardiogenic shock is scarce; a recent Cochrane review concludes that "at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug based therapy as a superior solution to reduce mortality in haemodynamically unstable patients with cardiogenic shock" (2), highlighting the need to research novel treatments for these patients.…”

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confidence: 99%

Pulsatile Venoarterial Perfusion Using a Novel Synchronized Cardiac Assist Device Augments Coronary Artery Blood Flow During Ventricular Fibrillation

et al. 2014

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Patients with cardiogenic shock have a very high mortality. Here we report the first use of a percutaneous pulsatile cardiac assist device, based on a diagonal pump synchronized with the heart cycle by means of an electrocardiographic signal in adult pigs. Eight domestic pigs underwent mandatory ventilation. During sinus rhythm, there were no differences between pulsatile and nonpulsatile perfusion with regard to pulmonary artery pressure, pulmonary wedge pressure, central venous pressure, mean arterial pressure (MAP), mean pulse pressure, and mean coronary artery flow (CAF). After 2 min of complete cardiac arrest (ventricular fibrillation), circulatory support with the i-cor in venoarterial nonpulsatile extracorporeal membrane oxygenation (ECMO) mode (3 L/min) restored systemic circulation, with an increase of MAP to 78.3 mm Hg and CAF to 5.27 mL/min. After changing from ECMO settings to pulsatile mode (3 L/min, 75 bpm, pulse amplitude range 3500 rpm), MAP did not change significantly (75.6 mm Hg); however, CAF increased to 8.45 mL/min. After changing back to nonpulsatile mode, MAP remained stable (83.6 mm Hg), but CAF decreased to 4.85 mL/min. Thereafter, pulsatile cardiac assist was established with a reduced blood flow of 2.5 L/min, and the pulse amplitude range was extended to 4500 rpm. Under these conditions, MAP remained stable (71.0 mm Hg), but CAF significantly increased to 15.2 mL/min (P < 0.05). Percutaneous cardiac support using a venoarterial cardiac assist device equipped with a novel diagonal pump is able to restore and increase systemic and coronary circulation during ventricular fibrillation. Electrocardiographically triggered synchronized cardiac assist provides an additional increase of coronary artery flow. These promising results are to be confirmed in humans.

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Pulsatile Venoarterial Perfusion Using a Novel Synchronized Cardiac Assist Device Augments Coronary Artery Blood Flow During Ventricular Fibrillation

et al. 2014

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“…Eine aktuelle Cochrane-Analyse kam ergänzend zu dem Schluss, dass auf der Basis nur weniger und sehr kleiner Studien keine eindeutigen Aussagen bezüg-lich des Effekts von Dobutamin, Levosimendan oder Vasodilatation beim kardiogenen Schock im Rahmen eines akuten Myokardinfarkts getroffen werden können [68]. In einem experimentellen Modell einer kritischen Myokardischämie führte die Gabe von Dobutamin nur zu einer kurzen transienten Verbesserung der Kontraktilität im Ischämiege-biet.…”

Section: » Vor Negativen Wirkungen Der Doutamingabe Bei Infarktbedingunclassified

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Janssens

et al. 2015

Med Klin Intensivmed Notfmed

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“…10,11 Accordingly, major guidelines do not offer firm guidance on which inotrope is preferred for the initial management of CS, 12 -14 and a 2014 Cochrane review of inotropic agents for myocardial infarction (MI) complicated by CS identified a lack of data comparing the different agents. 15 Clinicians routinely prescribe inotropic therapy for CS based on hemodynamics and adverse effect profile, but it is not clear what effect this has on clinical outcomes. We therefore conducted this retrospective review to compare the safety and efficacy of milrinone or dobutamine as the initial inotrope for the treatment of CS.…”

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

Lewis

Aberle

Altshuler

et al. 2018

J Cardiovasc Pharmacol Ther

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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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Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome

Cited by 10 publications

References 75 publications

Pulsatile Venoarterial Perfusion Using a Novel Synchronized Cardiac Assist Device Augments Coronary Artery Blood Flow During Ventricular Fibrillation

Pulsatile Venoarterial Perfusion Using a Novel Synchronized Cardiac Assist Device Augments Coronary Artery Blood Flow During Ventricular Fibrillation

Katecholamine: Pro und Kontra

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

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