Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients
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Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients.
We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality.
Measurements and results
Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17–76%) and short-term mortality rate was 49% (21–69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8–3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4–6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0–6.0]).
In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.
KeywordsMeta-analysis Cardiogenic shock Epinephrine Prognosis
Compliance with ethical standards
Conflict of interest
AM received lecture fees from Novartis, Orion and Abbott, research grants from Roche and consultant fees from Servier and Sanofi. Other coauthors have no conflicts to declare.
One of the two unpublished data set-the one of Basir-was published after data extraction, and is refered as .
- 2.Prondzinsky R, Unverzagt S, Russ M et al (2012) Hemodynamic effects of intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP shock trial. Shock 37:378–384. https://doi.org/10.1097/SHK.0b013e31824a67af CrossRefPubMedGoogle Scholar
- 10.Levy B, Perez P, Perny J et al (2011) Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med 39:450–455. https://doi.org/10.1097/CCM.0b013e3181ffe0eb CrossRefPubMedGoogle Scholar
- 11.Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Ganster F, Quenot JP, Kimmoun A, Cariou A, Lassus J, Harjola VP, Meziani F, Louis G, Rossignol P, Duarte K, Girerd N, Mebazaa A, Vignon P. Epinephrine versus norepinephrine in cardiogenic shock after acute myocardial infarction. A double-blind, multicenter randomized study. J Am Coll Cardiol. In press.Google Scholar
- 19.Chua H-R, Glassford N, Bellomo R (2012) Acute kidney injury after cardiac arrest. Resuscitation 83:721–727. https://doi.org/10.1016/j.resuscitation.2011.11.030 CrossRefPubMedGoogle Scholar
- 22.Popovic B, Fay R, Cravoisy-Popovic A, Levy B (2014) Cardiac power index, mean arterial pressure, and Simplified Acute Physiology Score II are strong predictors of survival and response to revascularization in cardiogenic shock. Shock 42:22–26. https://doi.org/10.1097/SHK.0000000000000170 CrossRefPubMedGoogle Scholar
- 26.Urban P, Stauffer JC, Bleed D et al (1999) A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction. The (Swiss) multicenter trial of angioplasty for shock-(S)MASH. Eur Heart J 20:1030–1038. https://doi.org/10.1053/euhj.1998.1353 CrossRefPubMedGoogle Scholar
- 28.Huang L, Sun S, Fang X et al (2006) Simultaneous blockade of alpha1- and beta-actions of epinephrine during cardiopulmonary resuscitation. Crit Care Med 34:S483–S485. https://doi.org/10.1097/01.CCM.0000247724.19004.EB CrossRefPubMedGoogle Scholar
- 35.Basir MB, Schreiber T, Dixon S, Alaswad K, Patel K, Almany S, Khandelwal A, Hanson I, George A, Ashbrook M, Blank N, Abdelsalam M, Sareen N, Timmis SBH, O'Neill WW (2018) Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the detroit cardiogenic shock initiative. Catheterization and Cardiovascular Interventions 91(3):454–461CrossRefPubMedGoogle Scholar