Norepinephrine superior in cardiogenic shock after myocardial infarction

Levy B, Clere-Jehl R, Legras A et el published results of prospective double-blind multicenter randomized control trial comparing Epinephrine and norepinephrine in patients with cardiogenic shock secondary to percutaneous coronary intervention treated acute myocardial infarction.

BACKGROUND

Use of vasopressor agents during severe cardiogenic shock is  to maintain the adequacy of and organ blood flow, which roughly correlates with the blood pressure, With low blood pressure associated with increased risk of mortality.  Use of vasopressors in this condition is mainly based on expert recommendations.

In a randomized controlled study by De Backer,  compared dopamine with norepinephrine In cardiogenic shock And found that dopamine was associated with increased 28-day mortality compared with norepinephrine.

WHERE

This multicenter randomized trial was conducted in the 9 French ICUs.

PATIENTS

Patients,  18 years or older, who had cardiogenic shock due to acute myocardial infarction after being successfully revascularized using percutaneous coronary intervention.  Shock was defined as systolic blood pressure less than 90 mmHg, or MAP of less than 65 With cardiac index less than 2.2 L/min/Meter Squire.  Pulmonary capillary wedge pressure of more than 15 mmHg or echocardiographic evidence of high pressures or ejection fraction less than 40% Along with one evidence of tissue hypoperfusion such as skin mottling, oliguria, elevated lactic acid or altered mental status.

163 patients were enrolled but 106 were excluded(Exclusion criteria viral shock of other origin or early signs of cerebral anoxia, Patient without medical insurance, Adult patients  under legal protection and patient which were considered moribund). Overall 57 patients were enrolled, And were randomized to receive epinephrine or norepinephrine.

An intra-aortic balloon pump was inserted after PCI in 16 out of 27 patients in the epinephrine group, and 15 out of 30 patient seen norepinephrine group.

RESULTS

Primary efficacy and point of Cardiac index evaluation was similar between the 2 groups. There was a higher incidence of refractory shock in the epinephrine group(10 out of 27 in epinephrine group versus 2 out of 30 in norepinephrine group, p= 0.008). This led to early termination of the study.  Heart rate increased significantly with epinephrine while remained unchanged with the norepinephrine (p< 0.0001).

Mortality was similar in 2 groups, 14 out of 27 in epinephrine group and 11 out of 30 in norepinephrine group(p= 0.25).

BOTTOMLINE

In patients with cardiogenic shock secondary to acute MI,  norepinephrine was similar to epinephrine in terms of arterial pressure and cardiac index but had less incidence of refractory shock.