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Epinephrine, norepinephrine confer similar effects in cardiogenic shock after acute MI
The effects on arterial pressure and cardiac index were similar in patients with acute MI and secondary cardiogenic shock who were treated with epinephrine compared with norepinephrine, researchers reported.
These two agents also resulted in a similar increased incidence of refractory shock, according to the study published in the Journal of the American College of Cardiology.
Secondary cardiogenic shock
Bruno Levy, MD, PhD, of Réanimation Médicale Brabois at Centre Hospitalier Universitaire de Nancy in France, and colleagues analyzed data from 57 patients with cardiogenic shock after an acute MI between September 2011 and August 2016 in nine ICUs in France. Patients were randomly assigned epinephrine (n = 27; median age, 68 years; 52% men) or norepinephrine (n = 30; median age, 66 years; 80% men).
Data were recorded periodically throughout the study such as systolic and diastolic arterial pressure, vital signs, heart rate, right atrial pressure and echocardiographic left ventricular ejection fraction. Plasma samples were also collected periodically during the study, which was used to measure plasma high-sensitivity troponin T levels, growth differentiation factor-15 and N-terminal pro-B-type natriuretic peptide levels.
The main safety endpoint was the incidence of refractory cardiogenic shock. The primary efficacy endpoint was cardiac index evolution. Secondary efficacy endpoints included changes in other hemodynamic variables over time, use of inotropes, cardiac power index, biomarker levels, Sequential Organ Failure Assessment (SOFA) score evolution during the first 72 hours, lactate level and lactate clearance.
Cardiac index evolution was similar from baseline to 72 hours between both groups (P = .43). More patients assigned epinephrine had refractory shock compared with those assigned norepinephrine (37% vs. 7%; OR = 8.24; 95% CI, 1.61-42.18), which led to the premature termination of the study by the data and safety monitoring board.
Patients assigned epinephrine had increases in heart rate from hour 2 to hour 24, whereas heart rates in those assigned norepinephrine remained unchanged (P = .031).
Metabolic changes
Compared with the norepinephrine group, the epinephrine group had some unfavorable metabolic changes, including an increase in lactic acidosis (P < .0001) and cardiac double product (P = .0002) from hour 2 to hour 24.
“To obtain the same effect on global perfusion and tissue oxygenation, epinephrine-treated patients had higher cardiac double product, lactic acidosis and a differential regulation of growth differential factor-15 pathway (a stress responsive cytokine that increases in response to hypoxia, oxidative stress, inflammation and cell injury),” Levy and colleagues wrote. “Overall, these effects could explain the increased occurrence of refractory [cardiogenic shock] in epinephrine-treated patients secondary to excessive adrenergic overstimulation likely mimicking an acute catecholamine-induced cardiomyopathy as previously described with epinephrine use or upon administration of very high doses of dobutamine.”
In a related editorial, Sean van Diepen, MSc, MD, assistant professor of critical care medicine at University of Alberta in Canada, wrote: “Levy et al have applied a robust methodological design to compare two of the most commonly used inopressors in [cardiogenic shock], and the study provides important insights into the temporal hemodynamic and biochemical changes associated with norepinephrine and epinephrine therapy. Vasoactive therapy trials in the [cardiogenic shock] population have historically been difficult to perform, and this pilot study is clearly a welcome addition to a clinical space that is largely void of high-quality evidence. Our growing understanding of the diversity of [cardiogenic shock] underscores the need for a better taxonomy of the severity and hemodynamic phenotypes, as well as the underlying etiologies of [cardiogenic shock], that could help drive a more precise therapeutic approach in this high-risk population.” – by Darlene Dobkowski
Disclosures: Levy reports he received lecture fees from Baxter, Lilly, Orion and Pulsion and consultant fees from Baxter, Novartis and Orion. Van Diepen reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.