This week we’ll be talking about the DOREMI trial and inotrope selection in cardiogenic shock.
Background: The management of cardiogenic shock is complex, often requiring tandem use of vasopressors and inotropes to stabilize hemodynamics. But what inotrope is more effective, dobutamine or milrinone?
Paper: Mathew R, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021 Aug 5 https://www.nejm.org/doi/full/10.1056/NEJMoa2026845
What: double-blind trial where patients with cardiogenic shock (n = 192) were randomized to receive milrinone (n=96) or dobutamine (n=96)
Inclusion criteria: > 18 admitted to the ICU with a clear indication for inotropic therapy
Exclusion criteria: out of hospital cardiac arrest, pregnant, had already received inotropic therapy prior to randomization
Primary outcome: composite of in-hospital death, resuscitated cardiac arrest, received cardiac transplant or mechanical circulatory support, nonfatal MI, TIA or stroke, or initiation of renal replacement therapy.
Results: There was no statistically significant difference in primary composite outcome or important secondary endpoints between milrinone vs dobutamine (49% vs 54%, p=0.47) in patients with cardiogenic shock.
Implication: EP’s should tailor inotrope selection in cardiogenic shock to the individual patient. Remember milrinone has a longer half-life and is renally cleared, and as such may accumulate/be difficult to titrate in those with end organ dysfunction and AKI.
Written by:
Garrett Prince, M.D.
Cook County EM Residency | PGY3
@GarrettPrince8
Carlos Mikell, M.D.
Cook County EM Residency | PGY3
@CarlosMikellMD
Peer Reviewed By:
Mark Mycyk, M.D.
Chair of Division of Research
Department of Emergency Medicine | Cook County Health