No difference between milrinone, dobutamine in treatment of cardiogenic shock
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Among patients with cardiogenic shock, there was no difference between the inotropic agents milrinone and dobutamine in clinical outcomes, according to findings published in The New England Journal of Medicine.
For the randomized, double-blind DOREMI study, the researchers assigned 192 patients with cardiogenic shock to milrinone or dobutamine. The primary outcome was in-hospital death from any cause, resuscitated cardiac arrest, heart transplantation, receipt of mechanical circulatory support, nonfatal MI, initiation of renal replacement therapy or neurologist-diagnosed nonfatal stroke or transient ischemic attack.
Rebecca Mathew, MD, cardiologist and critical care specialist at the University of Ottawa Heart Institute and assistant professor of medicine at the University of Ottawa, Ontario, Canada, and colleagues found there was no difference between the groups in the primary outcome (milrinone, 49%; dobutamine, 54%; RR = 0.9; 95% CI, 0.69-1.19; P = .47).
The researchers also found no differences in the following secondary outcomes:
- In-hospital death (milrinone, 37%; dobutamine, 43%; RR = 0.85; 95% CI, 0.6-1.21);
- resuscitated cardiac arrest (milrinone, 7%; dobutamine, 9%; HR = 0.78; 95% CI, 0.29-2.07);
- receipt of mechanical circulatory support (milrinone, 12%; dobutamine, 15%; HR = 0.78; 95% CI, 0.36-1.71);
- neurologist-diagnosed stroke or TIA (milrinone, 1%; dobutamine, 2%; HR = 0.5; 95% CI, 0.05-5.5); and
- initiation of renal replacement therapy (milrinone, 22%; dobutamine, 17%; HR = 1.39; 95% CI, 0.73-2.67).
There were no cases of heart transplantation, and only one patient, in the milrinone group, had nonfatal MI, Mathew and colleagues wrote.
The groups also did not differ in total length of stay, ICU length of stay or duration of inotropic treatment.
According to the study background, the two agents work differently and are used interchangeably in clinical practice, but there are concerns about the effects of dobutamine on heart rate and myocardial oxygen consumption.
“In contrast to our hypothesis, we did not find a significant advantage of milrinone over dobutamine with respect to the composite primary outcome or secondary outcomes,” the researchers wrote. “Moreover, we did not identify any significant between-group differences in safety outcomes or in surrogate markers of resuscitation, including heart rate, blood pressure and serum lactate level. The incidence of adverse clinical outcomes, including in-hospital death, was high in both groups.”
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