In this episode, I’ll discuss milrinone vs dobutamine for cardiogenic shock.
There is broad consensus that inotropic support is a mainstay of medical therapy for cardiogenic shock, but there is little high-quality data to support which inotrope is superior.
Researchers recently published in NEJM a randomized double-blinded trial to shed light on which treatment for cardiogenic shock is superior – milrinone or dobutamine?
192 patients with cardiogenic shock were split evenly between milrinone and dobutamine.
The primary outcome was a composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke diagnosed by a neurologist, or initiation of renal replacement therapy. Each of these components was examined separately for secondary outcomes.
The treatment groups did not differ significantly with respect to the primary outcome. There were also no significant differences between the groups with respect to any of the secondary outcomes.
This trial shows there is not a significant difference between milrinone and dobutamine when used in patients with cardiogenic shock.
The trial was pragmatic and was designed to include a broad range of patients in the phases of shock that are typically treated with inotropes. Thus it represents a realistic study that has good external validity. However, the authors expected a large treatment effect in the favor of one of the two agents and powered the trial accordingly. So the possibility does remain for a small treatment effect in favor of one of the 2 inotropes that was not detected in this study.
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