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Inotropes,vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis |
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| Authors: | Fernando Shannon M Mathew Rebecca Sadeghirad Behnam Brodie Daniel Belley-Côté Emilie P Thiele Holger van Diepen Sean Fan Eddy Di Santo Pietro Simard Trevor Russo Juan J Tran Alexandre Lévy Bruno Combes Alain Hibbert Benjamin Rochwerg Bram |
| Institution: | 1.CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada ;2.Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada ;3.Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada ;4.Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada ;5.Department of Anesthesia, McMaster University, Hamilton, ON, Canada ;6.Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA ;7.Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA ;8.Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada ;9.Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada ;10.Population Health Research Institute, Hamilton, ON, Canada ;11.Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig and Leipzig Heart Institute, Leipzig, Germany ;12.Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada ;13.Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada ;14.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada ;15.Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada ;16.Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada ;17.School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada ;18.Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada ;19.Division of Cardiology, Mayo Clinic, Rochester, MN, USA ;20.Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Nancy, France ;21.NSERM U1116, Faculté de Médecine, Université de Lorraine, Nancy, France ;22.Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM Unite Mixte de Recherche (UMRS) 1166, Paris, France ;23.Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Paris, France ; |
| 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. SourceWe 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 findingsWe 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. ConclusionThe 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 registrationCenter for Open Science (https://osf.io/ky2gr); registered 10 November 2020 |
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