CAPITAL Research Group Division of Cardiology University of Ottawa Heart Institute Ottawa Ontario Canada.
Faculty of Medicine University of Ottawa Ontario Canada.
J Am Heart Assoc. 2021 Nov 2;10(21):e021570. doi: 10.1161/JAHA.121.021570. Epub 2021 Oct 29.
Background The randomized DOREMI (Dobutamine Compared to Milrinone) clinical trial evaluated the efficacy and safety of milrinone and dobutamine in patients with cardiogenic shock. Whether the results remain consistent when stratified by acute myocardial infarction remains unknown. In this substudy, we sought to evaluate differences in clinical management and outcomes of acute myocardial infarction complicated by cardiogenic shock (AMICS) versus non-AMICS. Methods and Results Patients in cardiogenic shock (n=192) were randomized 1:1 to dobutamine or milrinone. The primary composite end point in this subgroup analysis was all-cause in-hospital mortality, cardiac arrest, non-fatal myocardial infarction, cerebrovascular accident, the need for mechanical circulatory support, or initiation of renal replacement therapy (RRT) at 30-days. Outcomes were evaluated in patients with (n=65) and without (n=127) AMICS. The primary composite end point was significantly higher in AMICS versus non-AMICS (hazard ratio [HR], 2.21; 95% CI, 1.47-3.30; =0.0001). The primary end point was driven by increased rates of all-cause mortality, mechanical circulatory support, and RRT. No differences in other secondary outcomes including cardiac arrest or cerebrovascular accident were observed. AMICS remained associated with the primary composite outcome, 30-day mortality, and RRT after adjustment for age, sex, procedural contrast use, multivessel disease, and inotrope type. Conclusions AMI was associated with increased rates of adverse clinical outcomes in cardiogenic shock along with increased rates of mortality and initiation of mechanical circulatory support and RRT. Contrast administration during revascularization likely contributes to increased rates of RRT. Heterogeneity of outcomes in AMICS versus non-AMICS highlights the need to study interventions in specific subgroups of cardiogenic shock. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03207165.
随机 DOREMI（米力农与多巴酚丁胺）临床试验评估了米力农和多巴酚丁胺在心源性休克患者中的疗效和安全性。在急性心肌梗死（AMI）患者中分层时，这些结果是否仍然一致尚不清楚。在这项亚研究中，我们旨在评估伴有和不伴有 AMI 的心源性休克（ACS）患者的临床管理和结局差异。
心源性休克患者（n=192）按 1:1 随机分为多巴酚丁胺或米力农组。本亚组分析的主要复合终点为全因住院死亡率、心脏骤停、非致命性心肌梗死、脑血管意外、30 天内需要机械循环支持或开始肾脏替代治疗（RRT）。评估伴有（n=65）和不伴有（n=127）AMI 的患者的结局。主要复合终点在 AMI 患者中明显高于非 AMI 患者（危险比[HR]，2.21；95%CI，1.47-3.30；=0.0001）。主要终点是由全因死亡率、机械循环支持和 RRT 增加率驱动的。其他次要结局，包括心脏骤停或脑血管意外，没有差异。在调整年龄、性别、介入造影剂使用、多血管疾病和正性肌力药物类型后，AMI 仍与主要复合结局、30 天死亡率和 RRT 相关。
AMI 与心源性休克患者不良临床结局发生率增加相关，死亡率、机械循环支持和 RRT 的启动率增加。血管重建期间造影剂的使用可能导致 RRT 发生率增加。AMI 与非 AMI 患者的结局存在差异，突出了在心源性休克的特定亚组中研究干预措施的必要性。
