Impact of baseline beta-blocker use on inotrope response and clinical outcomes in cardiogenic shock: a subgroup analysis of the DOREMI trial

Abstract

Background Cardiogenic shock (CS) is associated with significant morbidity and mortality. The impact of beta-blocker (BB) use on patients who develop CS remains unknown. We sought to evaluate the clinical outcomes and hemodynamic response profiles in patients treated with BB in the 24 h prior to the development of CS. Methods Patients with CS enrolled in the DObutamine compaREd to MIlrinone trial were analyzed. The primary outcome was a composite of all-cause mortality, resuscitated cardiac arrest, need for cardiac transplant or mechanical circulatory support, non-fatal myocardial infarction, transient ischemic attack or stroke, or initiation of renal replacement therapy. Secondary outcomes included the individual components of the primary composite and hemodynamic response profiles derived from pulmonary artery catheters. Results Among 192 participants, 93 patients (48%) had received BB therapy. The primary outcome occurred in 47 patients (51%) in the BB group and in 52 (53%) in the no BB group (RR 0.96; 95% CI 0.73–1.27; P = 0.78) throughout the in-hospital period. There were fewer early deaths in the BB group (RR 0.41; 95% CI 0.18–0.95; P = 0.03). There were no differences in other individual components of the primary outcome or in hemodynamic response between the two groups throughout the remainder of the hospitalization. Conclusions BB therapy in the 24 h preceding the development of CS did not negatively influence clinical outcomes or hemodynamic parameters. On the contrary, BB use was associated with fewer deaths in the early resuscitation period, suggesting a paradoxically protective effect in patients with CS. Trial registration ClinicalTrials.gov Identifier: NCT03207165

Lactate Clearance as a Surrogate for Mortality in Cardiogenic Shock: Insights From the DOREMI Trial

“… 17 , 18 , 19 , 20 , 21 As such, whether LC may be an appropriate treatment target in CS has not yet been established. In a substudy of the recently published DOREMI (Dobutamine Compared to Milrinone in the Treatment of Cardiogenic Shock) trial, we sought to confirm that LC is directly associated with survival in patients with CS and therefore may be a reasonable therapeutic target for clinicians and surrogate end points for researchers 8 , 22 (Figure 1 ).…”

Inotrope and vasopressor use in cardiogenic shock: what, when and why?

“…Lastly, as a beta-adrenergic agonist, concern has been raised about the efficacy of dobutamine with beta-blocker therapy on board. A secondary analysis of CAPITAL DOREMI trial ∗∗ found no difference in outcomes between dobutamine and milrinone among patients treated with beta-blocker in the 24 h preceding inotrope initiation [35 ▪▪ ]. In fact, the beta-blocker cohort demonstrated fewer resuscitated cardiac arrests and deaths, with a trend toward fewer ventricular arrhythmias.…”

Inotropic support in cardiogenic shock: who leads the battle, milrinone or dobutamine?

“…Where two intervention arms were established (mean arterial pressure ≥70 mmHg per 36 h vs. mean arterial pressure ≤70 mmHg per 36 h) Primary outcomes (all-cause mortality, resuscitated cardiac arrest, need for cardiac transplantation, stroke or initiation of renal therapy) were more frequent in the group with low mean arterial pressure (67.6% vs. 42.2%). In patients with cardiogenic shock under treatment with Milrinone or Dobutamine, low mean arterial pressure values are associated with worse outcomes Di Santo et al [ 35 ] To evaluate clinical and hemodynamic outcomes in the use of beta-blockers in patients with cardiogenic shock under treatment with Dobutamine or Milrinone Subgroup analysis of the DOREMI clinical trial. 192 patients were included, and primary outcomes (all-cause mortality, resuscitated cardiac arrest, need for cardiac transplantation, stroke or initiation of renal therapy, among others) were evaluated 93 patients received beta-blockers.…”

“…During the literature review, 4 randomized clinical trials were found that met the inclusion criteria [ 12 , [34] , [35] , [36] ], highlighting the most recent published one [ 12 ].…”