The role of inotropes in cardiogenic shock: to help, to harm or do nothing at all?
Notice bibliographique
Résumé
Cardiogenic shock (CS) is characterized by low cardiac output, resulting in end-organ hypoperfusion. Despite therapeutic advances, mortality remains high at upwards of 40%.1 Current guidelines recommend consideration of inotropes in patients with CS, with purported benefits of augmented cardiac output and contractility, improved lusitropy, and reduced afterload through vasodilation of the systemic and pulmonary circulations.1 In the first head-to-head comparison of inotrope therapy in CS, our research group demonstrated no difference in clinical outcomes between milrinone and dobutamine.2 While inotropes are widely used, uncertainties remain regarding their safety and efficacy in CS. A recent network meta-analysis evaluating the relative efficacy of inotropes in CS showed that milrinone and dobutamine may have no effect on mortality compared with placebo; however, the low certainty evidence does not rule out the possibility of benefit or harm.3 Trials to date have been limited by the enrolment of patients with pre-shock, predominantly SCAI class A and/or B, limiting generalizability.3,4 Moreover, inotrope therapy has been associated with a concerning signal of harm, including prolonged intensive care unit and hospital stays and increased in-hospital mortality among decompensated heart failure patients.5 Finally, no randomized trials have yet investigated the efficacy of single-agent inotrope therapy against placebo in the initial resuscitation of patients with CS, a significant gap in the current literature. The CAPITAL DOREMI2 trial is a multi-centre, randomized controlled trial comparing single-agent inotrope therapy against placebo in patients with SCAI class C–D CS. This trial will be the first of its kind to establish the safety and efficacy of inotrope therapy during the initial resuscitation of patients with CS, carrying the potential to change the standard care. A total of 346 participants will be randomized to single inotrope or placebo therapy for up to 12 h. Participants will then continue open-label therapies at the discretion of the treating team and be followed for the duration of their index hospitalization. Primary and secondary outcomes are detailed in Table 1. Study recruitment commenced in March 2022, and we have successfully enrolled 159 patients (46% of the total study cohort). The trial is anticipated to recruit participants over a 3-year period, with additional sites across North America currently in the process of starting recruitment. Primary and secondary outcomes in CAPITAL DOREMI2 In summary, little evidence exists to support the use of inotrope therapy in CS. The CAPITAL DOREMI2 trial aims to establish the safety and efficacy of inotrope therapy compared to placebo in patients with CS, holding the potential to reshape the standard care provided to this population. The data underlying this article will be shared on reasonable request to the corresponding author. Conflict of interest: The authors have no conflict of interest to declare.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,004 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,001 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
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