Conventional Hemodynamic Resuscitation May Fail to Optimize Tissue Perfusion: An Observational Study on the Effects of Dobutamine, Enoximone, and Norepinephrine in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Abstract

AimTo investigate the effects of inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock.Methods and ResultsThirty patients with cardiogenic shock were included. Patients received dobutamine, enoximone, or norepinephrine. We performed hemodynamic measurements at baseline and after titration of the inotropic agent until cardiac index (CI) ≥2.5 L.min−1.m−2 or mixed-venous oxygen saturation (SvO2) ≥70% (dobutamine or enoximone), and mean arterial pressure (MAP) ≥70 mmHg (norepinephrine). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD). All patients reached predefined therapeutic targets. The inotropes did not significantly change delta-T. Dobutamine did not change PCD. Enoximone increased PCD (9.1 [8.9–10.2] vs. 11.4 [8.4–13.9] mm.mm−2; p<0.05), and norepinephrine tended to decrease PCD (9.8 [8.5–11.9] vs. 8.8 [8.2–9.6] mm.mm−2, p = 0.08). Fifteen patients (50%) died within 30 days after admission. Patients who had low final PCD (≤10.3 mm.mm−2; 64%) were more likely to die than patients who had preserved PCD (>10.3 mm.mm−2; mortality 72% vs. 17%, p = 0.003).ConclusionThis study demonstrates the effects of commonly used inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Despite hemodynamic optimization, tissue perfusion was not sufficiently restored in most patients. In these patients, mortality was high. Interventions directed at improving microcirculation may eventually help bridging the gap between improved hemodynamics and dismal patient outcome in cardiogenic shock.

Microcirculatory and mitochondrial hypoxia in sepsis, shock, and resuscitation

“…Studies of other types of shock and cardiovascular compromise have reported the loss of systemic and microcirculatory coherence, showing this finding to be a common occurrence. Examples in addition to sepsis include traumatic hemorrhagic shock (96), heart failure (26,27), and malaria (44). A main area of research concerns the inability of fluid therapy to resolve the disparity between macro-and microcirculation (e.g., 53).…”

Retracted: rhBNP therapy can improve clinical outcomes and reduce in‐hospital mortality compared with dobutamine in heart failure patients: a meta‐analysis

“…Inotropic agents are popular in current treatment guidelines for HF and dobutamine is recommended in parenteral therapy for inotropic support [15,16]. Dobutamine is a synthetic catecholamine widely used in the management of stress, cardiogenic shock and HF [17,18]. Dobutamine primarily stimulates β 1 -adrenergic receptors, and partly the β 2 -adrenergic receptors, in the heart to produce dose-dependent ionotropic and chronotropic effects, and is used for maintenance of cardiac functions in severe heart failure [19,20].…”

“…Both dobutamine and rhBNP are used for the treatment of severe and acute decompensated HF, which is the most common cause of in-hospital mortality and readmissions among elderly patients [27,15]. However, the negative effects of dobutamine, such as increased cardiac output and elevated myocardial oxygen demand, increase the risk of myocardial ischaemia, tachyarrhythmias and ventricular dysfunction in HF patients [17,13]. Similarly, the side effects of rhBNP treatment in HF patients include low blood pressure, headache, nausea, decreased heart rate and impaired renal function [28,29].…”

Reconsidering Vasopressors for Cardiogenic Shock

“…13,74 A vasoconstrictor strategy for CS treatment promotes an approach based on BP, which, while important, does not necessarily reflect CO or tissue perfusion. 64,75 The important interpatient variability may preclude application of a rigid oversimplified therapeutic scheme. Vasopressors can be employed as an emergency treatment, but this can rapidly be modified on the basis of a personalized therapeutic strategy.…”