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Inotropes and vasopressors use in cardiogenic shock

when, which and how much?

Levy, Brunoa,b,c; Buzon, Juliea,b,c; Kimmoun, Antoinea,b,c

Current Opinion in Critical Care: August 2019 - Volume 25 - Issue 4 - p 384–390
doi: 10.1097/MCC.0000000000000632
CARDIOGENIC SHOCK: Edited by Holger Thiele

Purpose of review Data and interventional trials regarding vasopressor and inotrope use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In this article, we review the current use of vasopressor and inotrope agents during cardiogenic shock.

Recent findings Two recent Cochrane analyses concluded that there was not sufficient evidence to prove that any one vasopressor or inotrope was superior to another in terms of mortality. A recent RCT and a meta-analysis on individual data suggested that norepinephrine may be preferred over epinephrine in patients with cardiogenic shock . For inotrope agents, when norepinephrine fails to restore perfusion, dobutamine represents the first-line agent. Levosimendan is a calcium sensitizer agent, which improves acute hemodynamics, albeit with uncertain effects on mortality.

Summary When blood pressure needs to be restored, norepinephrine is a reasonable first-line agent. Dobutamine is the first-line inotrope agent wheraes levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers. Current information regarding comparative effective outcomes is nonetheless sparse and their use should be limited as a temporary bridge to recovery, mechanical circulatory support or heart transplantation.

aService de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical

bINSERM U1116, Faculté de Médecine

cUniversité de Lorraine, Nancy, France

Correspondence to Bruno Levy, Hopital Brabois, Vandoeuvre les Nancy, France. Tel: +33 383154469; fax: +33 383153080; e-mail:

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