Rochester Regional Health, Rochester, NY.
Westchester Medical Center at New York Medical College, Valhalla, NY.
Curr Probl Cardiol. 2023 Aug;48(8):101245. doi: 10.1016/j.cpcardiol.2022.101245. Epub 2022 May 8.
This study aims to evaluate the difference between dobutamine and milrinone in patients presenting with acute decompensated heart failure (AHF). Inotropes are indicated for treating AHF, especially in patients with concomitant hypoperfusion indicative of cardiogenic shock. However, previous studies have not identified the optimal inotrope. We sought to compare outcomes associated with milrinone versus dobutamine in patients with AHF. A systematic literature search was performed to identify relevant trials from inception to August 2021. Our primary outcome of interest was mortality. Analysis was sub-categorized according to subpopulation, including AHF, AHF with cardiogenic shock (AHF-shock), AHF with a bridge to transplantation, and AHF with destination therapy. Summary effects were calculated using a fixed-effects model as risk ratio or mean difference with 95% confidence intervals for all the clinical endpoints. Ten studies, including one randomized controlled trial with 21,106 patients, were included in the analysis (4918 patients were in the Milrinone group, while 15188 were in the Dobutamine group). Milrinone was associated with a lower risk of mortality in patients with AHF (relative risk 0.87; confidence interval :0.79-0.97; P < 0.05, heterogeneity I² = 0%) with event rates of 9.4% vs 9.8% (number needed to treat of 250). Milrinone was also associated with improved mortality with relative risk 0.76 (0.79-0.95; P < 0.05) in patients with AHF with destination therapy. There was a non-significant trend towards improved mortality in AHF-shock patients. However, AHF with a bridge to transplantation patients had a non-significant trend towards improved mortality with dobutamine. There was no difference between the 2 strategies for the outcomes of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay in the overall population. Intensive care unit length of hospital stay was lower in AHF-shock patients in the milrinone group, whereas dobutamine was associated with a lower length of intensive care unit stay in AHF patients. The cumulative data comparing milrinone with dobutamine indicate an overall marginal benefit of milrinone compared to dobutamine in the totality of patients with AFH with or without cardiogenic shock, and whether or not they are bridged to transplantation or destination assist device. More appropriately powered prospective studies are needed to identify a conclusive benefit of one inotrope over another.
本研究旨在评估多巴酚丁胺和米力农在急性失代偿性心力衰竭（AHF）患者中的差异。正性肌力药物用于治疗 AHF，特别是在伴有提示心源性休克的低灌注的患者中。然而，先前的研究并未确定最佳的正性肌力药物。我们旨在比较米力农与多巴酚丁胺在 AHF 患者中的治疗结局。进行了系统的文献检索，以确定从开始到 2021 年 8 月的相关试验。我们感兴趣的主要结局是死亡率。根据亚组（包括 AHF、伴有心源性休克的 AHF（AHF-shock）、桥接移植的 AHF 和有目的地治疗的 AHF）进行分析。使用固定效应模型计算所有临床终点的风险比或均数差值作为汇总效应，置信区间为 95%。纳入了 10 项研究，其中包括一项包含 21106 例患者的随机对照试验（米力农组 4918 例，多巴酚丁胺组 15188 例）。米力农可降低 AHF 患者的死亡率（相对风险 0.87；置信区间：0.79-0.97；P < 0.05，异质性 I²=0%），其死亡率分别为 9.4%和 9.8%（需要治疗的患者数为 250 例）。米力农在有目的地治疗的 AHF 患者中，死亡率的相对风险也降低了 0.76（0.79-0.95；P < 0.05）。在伴有心源性休克的 AHF 患者中，死亡率呈改善趋势，但无统计学意义。然而，桥接移植的 AHF 患者，使用多巴酚丁胺死亡率呈改善趋势，但无统计学意义。在总体人群中，急性肾损伤、开始肾脏替代治疗、机械通气、心律失常、症状性低血压和住院时间的结局方面，两种策略之间没有差异。在伴有心源性休克的 AHF 患者中，米力农组的 ICU 住院时间较短，而在 AHF 患者中，多巴酚丁胺组的 ICU 住院时间较短。比较米力农和多巴酚丁胺的累积数据表明，米力农与多巴酚丁胺相比，在伴有或不伴有心源性休克的所有 AHF 患者中，以及是否桥接移植或接受目的地辅助设备治疗，均有一定的优势。需要进行更多的、设计更合理的前瞻性研究，以确定一种正性肌力药物优于另一种药物。
