Clinical question: Is there a benefit to selecting milrinone over dobutamine for inotropic support in patients with cardiogenic shock?
Background: Inotropes, particularly milrinone and dobutamine, are a mainstay of treatment for cardiogenic shock, but there is little data to support using one over the other.
Study Design: Randomized, double-blind clinical trial.
Setting: Single quaternary care cardiac institute in Ottawa, Canada.
Synopsis: The 192 patients with cardiogenic shock (Society for Cardiovascular Angiography and Interventions shock stages B-E) were randomized to receive dobutamine or milrinone; doses were adjusted by the blinded treatment team. The primary outcome (composite of in-hospital death, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, TIA, stroke, and/or the initiation of renal replacement therapy) occurred in 49% with milrinone versus 54% with dobutamine treatment, with no statistically significant difference. No differences between the groups were found for secondary outcomes. Limitations include evaluation of only in-hospital outcomes, a single-center design, and dose adjustments by individual physicians rather than by protocol.
Bottom line: This study did not identify any advantages of milrinone over dobutamine for cardiogenic shock treatment.
Citation: Mathew R et al. Milrinone as compared with dobutamine in the treatment of cardiogenic shock. N Engl J Med. 2021;385(6): 516-524.
Dr. Winget is a clinical instructor at the University of Colorado School of Medicine hospital medicine section, Rocky Mountain Regional VA Medical Center, Aurora, Colo.