Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock

Mathew, Rebecca; Santo, Pietro Di; Jung, Richard G.; Marbach, Jeffrey A.; Hutson, Jordan; Simard, Trevor; Ramirez, F. Daniel; Harnett, David T.; Merdad, Anas; Almufleh, Aws; Weng, Willy; Abdel‐Razek, Omar; Fernando, Shannon M.; Kyeremanteng, Kwadwo; Bernick, Jordan; Wells, George; Chan, Vincent; Froeschl, Michael; Labinaz, Marino; May, Michel R. Le; Russo, Juan; Hibbert, Benjamin

doi:10.1056/nejmoa2026845

Cited by 181 publications

(140 citation statements)

References 23 publications

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“…Despite their ubiquitous use for initial management of cardiogenic shock, there are few prospective data and a paucity of randomized trials to guide their use. 1–8 However, their broad availability, ease of administration, and clinician familiarity favor such agents as the first therapeutic consideration when signs of organ hypoperfusion persist despite empiric volume replacement and vasopressors. There is a lack of robust evidence to suggest the clear benefit of one inotropic agent over another in cardiogenic shock.…”

Section: Patients Hospitalized With Acute Decompensated Hfmentioning

confidence: 99%

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

et al. 2022

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Aim: The “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure” replaces the “2013 ACCF/AHA Guideline for the Management of Heart Failure” and the “2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.” The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. Methods: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients’ interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

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Section: Patients Hospitalized With Acute Decompensated Hfmentioning

confidence: 99%

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

et al. 2022

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“…The DOREMI protocol, eligibility criteria, and methods have been reported previously. 3 In brief, the DOREMI trial was a randomized, doubleblind clinical trial of dobutamine versus milrinone in patients with CS. Individuals who had CS requiring admission to a cardiac intensive care unit (CICU) were eligible.…”

Section: Methodsmentioning

confidence: 99%

“…In this context, the recent DObutamine compaREd to MIlrinone (DOREMI) trial compared dobutamine and milrinone in patients with CS, finding no differences in outcomes between inotropes. 3 Beta-blockers (BBs) are commonly used in patients with cardiovascular disease, including for the management of heart failure with reduced ejection fraction 4−6 and cardiac arrhythmias. 7,8 Accordingly, it is not uncommon for patients presenting with CS to have recently received BB therapy-a treatment with known hemodynamic effects.…”

Section: Introductionmentioning

confidence: 99%

Impact of baseline beta-blocker use on inotrope response and clinical outcomes in cardiogenic shock: a subgroup analysis of the DOREMI trial

et al. 2021

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Background Cardiogenic shock (CS) is associated with significant morbidity and mortality. The impact of beta-blocker (BB) use on patients who develop CS remains unknown. We sought to evaluate the clinical outcomes and hemodynamic response profiles in patients treated with BB in the 24 h prior to the development of CS. Methods Patients with CS enrolled in the DObutamine compaREd to MIlrinone trial were analyzed. The primary outcome was a composite of all-cause mortality, resuscitated cardiac arrest, need for cardiac transplant or mechanical circulatory support, non-fatal myocardial infarction, transient ischemic attack or stroke, or initiation of renal replacement therapy. Secondary outcomes included the individual components of the primary composite and hemodynamic response profiles derived from pulmonary artery catheters. Results Among 192 participants, 93 patients (48%) had received BB therapy. The primary outcome occurred in 47 patients (51%) in the BB group and in 52 (53%) in the no BB group (RR 0.96; 95% CI 0.73–1.27; P = 0.78) throughout the in-hospital period. There were fewer early deaths in the BB group (RR 0.41; 95% CI 0.18–0.95; P = 0.03). There were no differences in other individual components of the primary outcome or in hemodynamic response between the two groups throughout the remainder of the hospitalization. Conclusions BB therapy in the 24 h preceding the development of CS did not negatively influence clinical outcomes or hemodynamic parameters. On the contrary, BB use was associated with fewer deaths in the early resuscitation period, suggesting a paradoxically protective effect in patients with CS. Trial registration ClinicalTrials.gov Identifier: NCT03207165

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“… 1 , 2 , 3 , 4 However, this shift in clinical practice has yet to translate into improved patient outcomes, with clinical trials continuing to report mortality rates of 30% to 60%. 5 , 6 , 7 , 8 …”

Section: Figurementioning

confidence: 99%

Lactate Clearance as a Surrogate for Mortality in Cardiogenic Shock: Insights From the DOREMI Trial

Marbach

Santo

Kapur

et al. 2022

JAHA

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Background Recent studies have shown improved outcomes in cardiogenic shock through protocols directed toward early identification and initiation of mechanical circulatory support. However, objective therapeutic targets—based on clinical and/or laboratory data—to guide real‐time clinical decision making are lacking. Lactate clearance has been suggested as a potential treatment target because of its independent association with mortality. Methods and Results In a post hoc analysis of the DOREMI (Dobutamine Compared to Milrinone in the Treatment of Cardiogenic Shock) trial—a randomized, double‐blind, controlled trial comparing milrinone to dobutamine in the treatment of cardiogenic shock—we used prospectively collected lactate data to evaluate lactate clearance as a surrogate marker for in‐hospital mortality. In total, 82 (57.7%) patients survived to hospital discharge (survivors). In multivariate logistic regression analysis, complete lactate clearance, percentage lactate clearance, and percentage lactate clearance per hour were independently associated with survival beginning as early as 8 hours after enrollment. Complete lactate clearance was the strongest predictor of survival at all time points, with odds ratios ranging between 2.46 (95% CI, 1.09–5.55; P =0.03) at 8 hours to 5.44 (95% CI, 2.14–13.8; P <0.01) at 24 hours. Conclusions Complete lactate clearance is a strong and independent predictor of in‐hospital survival in patients with cardiogenic shock. Together with previously published data, these results further support the validity of lactate clearance as an appropriate surrogate for mortality and as a potential therapeutic target in future cardiogenic shock trials. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03207165.

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Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock

Cited by 181 publications

References 23 publications

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Impact of baseline beta-blocker use on inotrope response and clinical outcomes in cardiogenic shock: a subgroup analysis of the DOREMI trial

Lactate Clearance as a Surrogate for Mortality in Cardiogenic Shock: Insights From the DOREMI Trial

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