Jung Richard G, Di Santo Pietro, Mathew Rebecca, Simard Trevor, Parlow Simon, Weng Willy, Abdel-Razek Omar, Malhotra Nikita, Cheung Matthew, Hutson Jordan H, Marbach Jeffrey A, Motazedian Pouya, Thibert Michael J, Fernando Shannon M, Nery Pablo B, Nair Girish M, Russo Juan J, Hibbert Benjamin, Ramirez F Daniel
CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario Canada.
CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
Can J Cardiol. 2023 Apr;39(4):394-402. doi: 10.1016/j.cjca.2022.09.013. Epub 2022 Sep 20.
Inotropic support is widely used in the management of cardiogenic shock (CS). Existing data on the incidence and significance of arrhythmic events in patients with CS on inotropic support is at high risk of bias.
The Dobutamine Compared to Milrinone (DOREMI) trial randomized patients to receive dobutamine or milrinone in a double-blind fashion. Patients with and without arrhythmic events (defined as arrhythmias requiring intervention or sustained ventricular arrhythmias) were compared to identify factors associated with their occurrence, and to examine their association with in-hospital mortality and secondary outcomes.
Ninety-two patients (47.9%) had arrhythmic events, occurring equally with dobutamine and milrinone (P = 0.563). The need for vasopressor support at initiation of the inotrope and a history of atrial fibrillation were positively associated with arrhythmic events, whereas predominant right ventricular dysfunction, previous myocardial infarction, and increasing left ventricular ejection fraction were negatively associated with them. Supraventricular arrhythmic events were not associated with mortality (relative risk [RR], 0.97; 95% confidence interval [CI], 0.68-1.40; P = 0.879) but were positively associated with resuscitated cardiac arrests and hospital length of stay. Ventricular arrhythmic events were positively associated with mortality (RR, 1.66; 95% CI, 1.13-2.43; P = 0.026) and resuscitated cardiac arrests. Arrhythmic events were most often treated with amiodarone (97%) and electrical cardioversion (27%), which were not associated with mortality.
Clinically relevant arrhythmic events occur in approximately one-half of patients with CS treated with dobutamine or milrinone and are associated with adverse clinical outcomes. Five factors may help to identify patients most at risk of arrhythmic events.
正性肌力支持广泛应用于心源性休克（CS）的治疗。现有关于接受正性肌力支持的CS患者心律失常事件的发生率及意义的数据存在高度偏倚风险。
多巴酚丁胺与米力农对比（DOREMI）试验将患者随机分为两组，以双盲方式分别接受多巴酚丁胺或米力农治疗。比较发生和未发生心律失常事件（定义为需要干预的心律失常或持续性室性心律失常）的患者，以确定与其发生相关的因素，并研究其与院内死亡率及次要结局的关联。
92例患者（47.9%）发生了心律失常事件，多巴酚丁胺组和米力农组的发生率相同（P = 0.563）。开始使用正性肌力药物时需要血管升压药支持以及有房颤病史与心律失常事件呈正相关，而主要为右心室功能障碍、既往心肌梗死以及左心室射血分数增加与心律失常事件呈负相关。室上性心律失常事件与死亡率无关（相对危险度[RR]，0.97；95%置信区间[CI]，0.68 - 1.40；P = 0.879），但与心脏骤停复苏及住院时间呈正相关。室性心律失常事件与死亡率（RR，1.66；95% CI，1.13 - 2.43；P = 0.026）及心脏骤停复苏呈正相关。心律失常事件最常使用胺碘酮（97%）和电复律（27%）治疗，这两种治疗与死亡率无关。
在接受多巴酚丁胺或米力农治疗的CS患者中，约一半会发生临床相关的心律失常事件，且与不良临床结局相关。五个因素可能有助于识别心律失常事件风险最高的患者。
