The Effectiveness of Inodilators in Reducing Short Term Mortality among Patient with Severe Cardiogenic Shock: A Propensity-Based Analysis

Pirracchio, Romain; Pařenica, Jiří; Resche-Rigon, Matthieu; Chevret, Sylvie; Špinar, Jindřich; Jarkovský, Jiří; Zannad, Faı̈ez; Alla, François; Mebazaa, Alexandre

doi:10.1371/journal.pone.0071659

Cited by 47 publications

(29 citation statements)

References 33 publications

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“…[20][21][22][23][24][25][26] Despite these important caveats, patients with critically low CO generally cannot be stabilized medically without inotropic support, and inodilator therapy appears beneficial in cardiogenic shock. 27 In the absence of severe hypotension, an inodilator is preferred over an inoconstrictor for increasing CO due to more favorable effects on afterload, cardiac filling pressures, and myocardial blood flow. [28][29][30][31][32] Dobutamine Dobutamine augments myocardial contractility via strong B1R stimulation with mild to moderate B2R agonism and mild A1R agonism, producing a strong dose-dependent increase in SV and CO with moderate increases in HR and a variable effect on MAP (Tables 1 and 2).…”

Section: Goals Of Resuscitationmentioning

confidence: 99%

Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit

Jentzer

Coons

Link

et al. 2014

J Cardiovasc Pharmacol Ther

148

106

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This paper summarizes the pharmacologic properties of vasoactive medications used in the treatment of shock, including the inotropes and vasopressors. The clinical application of these therapies is discussed and recent studies describing their use and associated outcomes are also reported. Comprehension of hemodynamic principles and adrenergic and non-adrenergic receptor mechanisms are salient to the appropriate therapeutic utility of vasoactive medications for shock. Vasoactive medications can be classified based on their direct effects on vascular tone (vasoconstriction or vasodilation) and on the heart (presence or absence of positive inotropic effects). This classification highlights key similarities and differences with respect to pharmacology and hemodynamic effects. Vasopressors include pure vasoconstrictors (phenylephrine and vasopressin) and inoconstrictors (dopamine, norepinephrine, and epinephrine). Each of these medications acts as vasopressors to increase mean arterial pressure by augmenting vascular tone. Inotropes include inodilators (dobutamine and milrinone) and the aforementioned inoconstrictors. These medications act as inotropes by enhancing cardiac output through enhanced contractility. The inodilators also reduce afterload from systemic vasodilation. The relative hemodynamic effect of each agent varies depending on the dose administered, but is particularly apparent with dopamine. Recent large-scale clinical trials have evaluated vasopressors and determined that norepinephrine may be preferred as a first-line therapy for a broad range of shock states, most notably septic shock. Consequently, careful selection of vasoactive medications based on desired pharmacologic effects that are matched to the patient's underlying pathophysiology of shock may optimize hemodynamics while reducing the potential for adverse effects.

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Section: Goals Of Resuscitationmentioning

confidence: 99%

Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit

Jentzer

Coons

Link

et al. 2014

J Cardiovasc Pharmacol Ther

148

106

View full text Add to dashboard Cite

show abstract

“…In terms of background medication, patients on beta blockers theoretically respond better to levosimendan or milrinone, as these drugs act independently of the βadrenergic receptors; the same is true in the case of beta-1 receptor down-regulation that has been noticed in HF [34]. Concerning the hemodynamic status, in the presence of persistent hypotension, besides adequate volume status, norepinephrine is the vasopressor of choice and can be used in combination with vasodilating inotropes such as dobutamine and levosimendan in an effort to enhance cardiac contractility while maintaining adequate blood pressure for tissue perfusion; vasopressor may subsequently be withdrawn with the amelioration of cardiac performance [35]. The combination of two different classes of inotropes, in contrast, does not seem to provide additional benefit.…”

Section: Inotropes In Acute Heart Failurementioning

confidence: 94%

“…A propensity score-matched analysis by the GREAT network showed that combining vasopressors (epinephrine, norepinephrine, or dopamine) with vasodilating inotropes (dobutamine, levosimendan or PDE inhibitors) leads to better survival than vasopressors alone [35].…”

Section: Inotropes In Cardiogenic Shockmentioning

confidence: 99%

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus

Farmakis

Agostoni

Baholli

et al. 2019

International Journal of Cardiology

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Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure.

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“…In one recent Cochrane systemic review assessing inotropic agents on CS, the included studies were of no milrinone treatment group [14]. Data from a large pooled retrospective analysis supported that the addition of an inodilator to vasopressors was associated with lower mortality, however, only 1% patients treated with PDE3 inhibitors [15].…”

Section: Introductionmentioning

confidence: 99%

Milrinone is associated with lower in hospital mortality in patients with cardiogenic shock: a retrospective analysis of the MIMIC-III database

Xue¹,

Wang²,

Peng³

et al. 2020

Preprint

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BackgroundAlthough milrinone has been widely used in daily clinical practice, its effect on survival in patients with cardiogenic shock (CS) is not known. The primary purpose of this study was to evaluate the effectiveness of milrinone on in hospital mortality in a large critical care cohort of patients with CS of various etiological causes.MethodsPatients with CS were identified from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Propensity score matching (PSM) was used to account for the baseline differences in the probability to receive milrinone or not. Multivariate Cox regression model was employed to adjust for imbalance by including parameters and potential confounders.ResultsA total of 1068 critically ill patients with CS were enrolled for this analysis, including 161 in the milrinone group and 907 in the non-milrinone group. Multivariate Cox regression model results found milrinone was associated with a significantly decreased in hospital mortality in critically ill patients with CS (HR 0.61, 95% CI 0.45-0.83; P=0.001). The impact of milrinone on survival benefit in CS was remaining in patients with non-ACS, while it was not statistically significant in subgroup with ACS (HR 0.66, 95% CI 0.40-1.07; P=0.093). Similar results were replicated after PSM.ConclusionsOur study observed that milrinone was related with improved survival in patients with CS, but it was not associated with improved outcome in patients complicated with ACS. The results need to be verified in randomized controlled trials.

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The Effectiveness of Inodilators in Reducing Short Term Mortality among Patient with Severe Cardiogenic Shock: A Propensity-Based Analysis

Cited by 47 publications

References 33 publications

Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit

Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus

Milrinone is associated with lower in hospital mortality in patients with cardiogenic shock: a retrospective analysis of the MIMIC-III database

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