Cardiogenic shock is associated with poor clinical outcomes. There is a paucity of prospective data examining the efficacy and safety of different inotropic agents in patients with cardiogenic shock and renal dysfunction. Although, the DOREMI trial demonstrated no difference between the two inotropic agents dobutamine and milrinone, but a recently conducted post hoc analysis of this trial shows that a potential clinical benefit of milrinone vs dobutamine in cardiogenic shock could be attenuated by development of AKI (acute kidney injury).

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The authors stratified the DOREMI trial population based on both baseline renal dysfunction and the development of AKI and examined clinical outcomes with milrinone compared to dobutamine after stratification based on baseline estimated glomerular filtration rate (eGFR) 60 ml/min/1.73 m2and AKI.
The primary outcome was the composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke, or initiation of renal replacement therapy.
Most patients had AKI—124 of the 192 subjects enrolled. Main clinical findings included the fact that, in the stratum of patients with cardiogenic shock without AKI, milrinone was associated with better outcomes than dobutamine.
Such an effect was not observed in cardiogenic shock patients with AKI, where there was no difference between the strategies.
Baseline renal function did not appear to modulate the treatment effect of milrinone compared to dobutamine. However, there was an interaction between AKI and the treatment effect of milrinone vs dobutamine on the primary outcome and death. This interaction was characterized by a lower risk of the primary outcome and death with milrinone compared to dobutamine in patients without, but not with, AKI. (Figure 1)
The present analysis suggests a possible heterogeneity in the treatment effect of milrinone compared to dobutamine on clinical outcomes in relation to AKI. Compared to dobutamine, milrinone was associated with reduced rates of the primary outcome and death in the stratum of patients without AKI.
Exploring the role of individualized patient care, including patients with renal dysfunction, to improve clinical outcomes in cardiogenic shock should be a research priority.
Source: JACC Advances: JACC Adv. 2023 Jul, 2 (5) 100393