肾上腺素与去甲肾上腺素治疗急性心肌梗死后心源性休克。

Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction.

机构信息

Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, and Université de Lorraine, Nancy, France.

Université de Strasbourg (UNISTRA), Faculté de médecine, Hôpitaux Universitaires de Strasbourg, Service de réanimation, Nouvel Hôpital Civil, Strasbourg, France.

出版信息

J Am Coll Cardiol. 2018 Jul 10;72(2):173-182. doi: 10.1016/j.jacc.2018.04.051.

DOI:10.1016/j.jacc.2018.04.051

PMID:29976291

Abstract

BACKGROUND

Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking.

OBJECTIVES

The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction.

METHODS

The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses.

RESULTS

Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p < 0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p < 0.0001).

CONCLUSIONS

In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743).

摘要

背景

血管加压剂在心肌梗死后心源性休克（CS）患者中可能具有某些特定作用，这可能会影响预后。虽然去甲肾上腺素和肾上腺素目前是最常用的药物，但尚无随机试验比较它们的效果，并且缺乏干预数据。

目的

本文旨在比较前瞻性、双盲、多中心、随机研究中肾上腺素和去甲肾上腺素在急性心肌梗死后 CS 患者中的疗效和安全性。

方法

主要疗效终点是心指数的演变，主要安全性终点是难治性 CS 的发生。难治性 CS 定义为 CS 伴有持续低血压、终末器官低灌注和高乳酸血症，以及高儿茶酚胺和血管加压剂剂量。

结果

57 例患者随机分为肾上腺素和去甲肾上腺素 2 个研究组。对于主要疗效终点，从基线（H0）到 H72，两组心指数的演变相似（p=0.43）。对于主要安全性终点，观察到肾上腺素组难治性休克的发生率较高（27 例中有 10 例[37%]，而 30 例中有 2 例[7%]；p=0.008），导致研究提前终止。肾上腺素组心率从 H2 到 H24 显著增加，而去甲肾上腺素组无变化（p<0.0001）。与去甲肾上腺素相比，肾上腺素引起的几种代谢变化对其不利，包括从 H2 到 H24 心脏双乘积增加（p=0.0002）和乳酸酸中毒（p<0.0001）。