In-hospital outcomes similar with milrinone, dobutamine for treatment of cardiogenic shock
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In the CAPITAL Do-Re-Mi trial, there was no difference in outcomes in patients treated with the widely used agents milrinone and dobutamine for in-hospital treatment of cardiogenic shock.
The cornerstone of medical therapy [for cardiogenic shock] relies on vasopressors and inotropes, but prospective randomized data is lacking. Milrinone and dobutamine are two of the most widely used agents, but clinical equipoise remains,” Rebecca Mathew, MD, FRCPC, cardiologist and critical care medicine fellow at the University of Ottawa Heart Institute, said during a presentation at the virtual American Heart Association Resuscitation Science Symposium.
The CAPITAL Do-Re-Mi trial enrolled 192 patients hospitalized for cardiogenic shock from September 2017 to March 20 (mean age, 60.5 years).
The primary composite endpoint included all-cause in-hospital mortality; resuscitated cardiac arrest; need for transplant or mechanical circulatory support; nonfatal MI; transient ischemia attack or stroke; and new initiation of renal replacement therapy. Secondary safety and efficacy outcomes included the individual components of the primary composite endpoint; presence of acute kidney injury; normalization of lactate; requirement of mechanical ventilation following randomization; and ventricular arrhythmia.
“Our study was designed to be pragmatic and replicate clinical practice in which shock is defined clinically rather than based on invasive hemodynamics,” Mathew said. “Our study found a mortality rate of 40%, which is similar to trials that use hemodynamic parameters for enrollment.”
The primary composite outcome occurred in 49% of the milrinone group vs. 54% of the dobutamine group (HR = 0.9; 95% CI, 0.69-1.19; P = .47).
Investigators observed no significant difference among any of the secondary outcomes:
- all-cause in-hospital mortality: 37% of milrinone group vs. 43% of dobutamine group (RR = 0.85; 95% CI, 0.6-1.21; P = .38);
- initiation of renal replacement therapy: 22% of milrinone group vs. 17% of dobutamine group (RR = 1.31; 95% CI, 0.73-2.36; P = .36);
- presence of acute kidney injury: 92% of milrinone group vs. 90% of dobutamine group (RR = 1.02; 95% CI, 0.94-1.12; P = .62);
- normalization of lactate: 46% of milrinone group vs. 56% of dobutamine group (RR = 0.8; 95% CI, 0.56-1.15; P = .23);
- requirement of mechanical ventilation: 6% of milrinone group vs. 7% of dobutamine group (RR = 0.86; 95% CI, 0.3-2.46; P = .77); and
- ventricular arrythmia: 15% of milrinone group vs. 18% of dobutamine group (RR = 0.82; 95% CI, 0.43-1.57; P = .56).
“When we first sought out to design this study, there were no randomized controlled trials examining the clinical question, despite a lack of robust data,” Mathew said in the presentation. “We found no differences in primary composite outcome or in any important secondary outcomes. Selection of inotropes could reasonably be based on physician comfort cost and an individual patient’s response to therapy.”
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Mathew R, et al. AOS.03 – Lightning round oral abstract presentations: Best of the best oral abstracts. Presented at: American Heart Association Scientific Sessions; Nov. 13-17, 2020 (virtual meeting).
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