Milrinone and dobutamine show no difference for cardiogenic shock treatment

1. Milrinone was shown not to be significantly different than dobutamine for the treatment of cardiogenic shock.

2. In-hospital deaths of patients treated with either milrinone or dobutamine were not significantly different.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Cardiogenic shock is a state of low cardiac output causing end-organ hypoperfusion. Treatments have aimed to improve hemodynamic measures with various medications and devices. Milrinone, a phosphodiesterase 2 inhibitor, is known to increase cardiac inotropy, lusitropy, and peripheral vasodilation. On the other hand, dobutamine, a synthetic catecholamine, improves blood pressure by increasing cardiac output. As such, this study compared the efficacy and safety of milrinone and dobutamine in patients with cardiogenic shock. The study determined milrinone and dobutamine were not significantly different in the treatment of cardiogenic shock. Furthermore, there was no significant difference for in-hospital deaths, resuscitated cardiac arrest, and receipt of mechanical circulatory support. The randomized control trial was limited by dose adjustments based on individual physician assessment rather than a standard protocol and patient recruitment was from a single center. Nonetheless, this study’s results are significant, and its findings highlight no difference in patient outcomes after using milrinone or dobutamine for cardiogenic shock.

Click to read the study in NEJM

Relevant Reading: Efficacy of milrinone and dobutamine in low cardiac output states: systematic review and meta-analysis

In-Depth [randomized controlled trial]: This randomized control trial study enrolled 192 participants at a single cardiac care institute in Canada. Participants included in the study were at least 18 years of age, admitted to the cardiac intensive care unit, and were diagnosed with cardiogenic shock as defined by the Society for Cardiovascular Angiography and Interventions. Participants with a stage A cardiogenic shock were excluded from this study. The participants were randomized in a 1:1 ratio to receive milrinone or dobutamine therapy, respectively. The primary outcome was a composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke diagnosed by a neurologist, or initiation of renal replacement therapy. The primary outcome occurred in 47 participants of the milrinone group (47%) compared to 52 participants in the dobutamine group (54%) (relative risk [RR], 0.90; 95% confidence interval [CI], 0.69 to 1.19; P = 0.47). Furthermore, a time-to-event analysis showed no significant difference between the two treatment groups (hazard ratio [HR], 0.91; 95% CI, 0.61 to 1.34). Additionally, in-hospital death from any causes occurred in 35 participants of the milrinone group (37%) compared to 41 participants in the dobutamine group (43%) (RR, 0.85; 95% CI, 0.60 to 1.21). There was no significant difference in resuscitated cardiac arrest between both groups (HR, 0.78; 95% CI, 0.29 to 2.07) and receipt of mechanical support (HR, 0.78; 95% CI, 0.36 to 1.71). Taken together, milrinone and dobutamine treatment were shown to have no significant difference in the treatment of cardiogenic shock.

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