Inotropes, vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis.

Eddy Fan, Bram Rochwerg, Shannon M Fernando, Rebecca Mathew, Behnam Sadeghirad, Daniel Brodie, Emilie P Belley-Côté, Holger Thiele, Sean van Diepen, Pietro Di Santo, Trevor Simard, Juan J Russo, Alexandre Tran, Bruno Lévy, Alain Combes, Benjamin Hibbert

Journal: Canadian journal of anaesthesia = Journal canadien d'anesthesie 2022;69(12):1537-1553

PMID: 36195825

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Abstract

PURPOSE

To compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction.

SOURCE

We conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality.

PRINCIPAL FINDINGS

We included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis.

CONCLUSION

The results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding.

STUDY REGISTRATION

Center for Open Science ( https://osf.io/ky2gr ); registered 10 November 2020.

Address: CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada. [email protected].; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. [email protected].; Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada. [email protected].; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.; Department of Anesthesia, McMaster University, Hamilton, ON, Canada.; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.; Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada.; Population Health Research Institute, Hamilton, ON, Canada.; Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig and Leipzig Heart Institute, Leipzig, Germany.; Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.; Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada.; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada.; Division of Cardiology, Mayo Clinic, Rochester, MN, USA.; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.; Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Nancy, France.; NSERM U1116, Faculté de Médecine, Université de Lorraine, Nancy, France.; Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM Unite Mixte de Recherche (UMRS) 1166, Paris, France.; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Paris, France.

DOI: 10.1007/s12630-022-02337-7

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MeSH Terms: Adult, Humans, Shock, Cardiogenic, Simendan, Intra-Aortic Balloon Pumping, Myocardial Infarction, Hemorrhage, Treatment Outcome