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Published on: June 12, 2021
Arrhythmic Events and Mortality in Patients With Cardiogenic Shock on Inotropic Support: Results of the DOREMI
Richard G Jung1, Pietro Di Santo2, Rebecca Mathew3
1CAPITAL 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.
Insights
Clinically significant arrhythmias occur in half of cardiogenic shock patients on inotropes, equally with dobutamine and milrinone. Ventricular arrhythmias increase mortality risk, while supraventricular ones prolong hospital stays.
Area of Science:
- Cardiology
- Critical Care Medicine
- Pharmacology
Background:
- Inotropic support is crucial for managing cardiogenic shock (CS).
- Existing data on arrhythmias in CS patients on inotropes have high bias.
- The DOREMI trial aimed to clarify arrhythmic event incidence and significance.
Purpose of the Study:
- To compare arrhythmic events in CS patients receiving dobutamine versus milrinone.
- To identify factors associated with arrhythmic events.
- To examine the association between arrhythmic events and in-hospital mortality.
Main Methods:
- The Dobutamine Compared to Milrinone (DOREMI) trial randomized patients to dobutamine or milrinone.
- Patients were analyzed based on the presence or absence of arrhythmic events.
- Arrhythmic events were defined as those requiring intervention or sustained ventricular arrhythmias.
Main Results:
- Nearly half of patients (47.9%) experienced arrhythmic events, with equal incidence between dobutamine and milrinone.
- Vasopressor use and atrial fibrillation history predicted arrhythmic events; RV dysfunction, MI, and higher LVEF were protective.
- Ventricular arrhythmias were linked to increased mortality and cardiac arrests; supraventricular arrhythmias correlated with longer hospital stays.
Conclusions:
- Clinically relevant arrhythmias affect approximately 50% of CS patients on dobutamine or milrinone.
- Arrhythmic events are associated with adverse outcomes, including mortality and prolonged hospitalization.
- Five factors can help identify high-risk patients for arrhythmic events in cardiogenic shock.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
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