Author + information
- Received February 4, 2018
- Revision received April 9, 2018
- Accepted April 15, 2018
- Published online July 2, 2018.
- Bruno Levy, MD, PhDa,∗ (, )@CHRU_de_Nancy@Inserm,
- Raphael Clere-Jehl, MDb,
- Annick Legras, MDc,
- Tristan Morichau-Beauchant, MDd,
- Marc Leone, MD, PhDe,
- Ganster Frederique, MDf,
- Jean-Pierre Quenot, MD, PhDg,
- Antoine Kimmoun, MD, PhDa,
- Alain Cariou, MD, PhDd,
- Johan Lassus, MD, PhDh,
- Veli-Pekka Harjola, MD, PhDh,
- Ferhat Meziani, MD, PhDb,
- Guillaume Louis, MDi,
- Patrick Rossignol, MD, PhDj,
- Kevin Duarte, PhDj,
- Nicolas Girerd, MD, PhDj,
- Alexandre Mebazaa, MD, PhDk,
- Philippe Vignon, MD, PhDl,
- aService 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
- bUniversité de Strasbourg (UNISTRA), Faculté de médecine, Hôpitaux Universitaires de Strasbourg, Service de réanimation, Nouvel Hôpital Civil, Strasbourg, France
- cMédecine Intensive Réanimation, CHRU Bretonneau, Tours, France
- dMedical ICU, Cochin University Hospital (APHP), Paris, France, and Paris Descartes University, Paris, France
- eSurgical ICU, Hôpital Nord, AP-HM, Aix Marseille Université, Marseille, France
- fService de Réanimation Médicale, Groupement Hospitalier Mulhouse Sud Alsace–Hôpital Emile Muller, Mulhouse, France
- gDepartment of Intensive Care, François Mitterrand University Hospital, Dijon, Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, and INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- hHeart and Lung Center, Cardiology, Helsinki University and Helsinki University Hospital, Helsinki, Finland
- iService de Réanimation, Hôpital Mercy, Metz, France
- jINSERM CIC1433, Nancy University Hospital, Nancy, France
- kInserm UMR-S 942, Hôpital Lariboisière, Paris, Department of Anaesthesiology and Intensive Care, Lariboisière Hospital, and Université Paris Diderot-Sorbonne Paris Cité, Paris, France
- lMedical-Surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, and INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
- ↵∗Address for correspondence:
Dr. Bruno Levy, Réanimation Médicale Brabois, CHRU Nancy, 1 Rue du Morvan, Vandoeuvre-les Nancy, Meurthe-et-Moselle (54) 54500, France.
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)
The study was supported by a grant from INSERM-DHOS. Dr. Levy has received lecture fees from Pulsion, Baxter, Orion, and Lilly; and has received consultant fees from Novartis, Orion, and Baxter. Dr. Leone has served as a consultant for Aguettant. Dr. Kimmoun has received fees from Baxter, Merck Sharp & Dohme, and Gilead. Dr. Rossignol has received personal fees (consulting) from Novartis, Relypsa, AstraZeneca, Grünenthal, Stealth Peptides, Fresenius, Vifor Fresenius Medical Care Renal Pharma, Vifor, and CTMA; lecture fees from Bayer and CVRx; and is cofounder of CardioRenal. Dr. Girerd has received board fees from Novartis; and honoraria from Servier. Dr. Mebazaa has received speakers honoraria from Abbott, Orion, Roche, and Servier; and has received fees as a member of advisory boards and/or steering committees, and/or research grants from Bristol-Myers Squibb, Adrenomed, Neurotronik, Roche, Sanofi, and Sphyngotec. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 4, 2018.
- Revision received April 9, 2018.
- Accepted April 15, 2018.
- 2018 American College of Cardiology Foundation
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