Can epinephrine (adrenaline) be used in cardiogenic shock?

Can Epinephrine Be Used in Cardiogenic Shock?

Epinephrine can be used in cardiogenic shock, but norepinephrine should be preferred as the first-line vasopressor due to superior safety outcomes. 1, 2

First-Line Vasopressor Choice

Norepinephrine is recommended as the first-line vasopressor in cardiogenic shock, particularly in patients with persistent hypotension and tachycardia 1. The 2018 international guideline on vasoactive agents explicitly states that in cardiogenic shock with persistent hypotension, norepinephrine is the advised agent 1.

When Epinephrine May Be Considered

Epinephrine can be used as a single agent combining both vasopressor and inotropic effects in patients with persistent hypotension and evidence of myocardial depression 1. However, this approach carries significant risks that must be weighed carefully.

Critical Safety Concerns with Epinephrine

The evidence against routine epinephrine use in cardiogenic shock is compelling:

• A 2018 randomized controlled trial comparing epinephrine versus norepinephrine in acute myocardial infarction-related cardiogenic shock was terminated early due to a dramatically higher incidence of refractory shock in the epinephrine group (37% vs. 7%, p=0.008) 2

• Epinephrine was independently associated with 5-fold increased 90-day mortality (OR 5.2,95% CI 1.88-14.7, p=0.002) in multivariable analysis 3

• Epinephrine causes significant metabolic derangements including:

  • Increased lactic acidosis from H2 to H24 (p<0.0001) 2
  • Elevated cardiac double product indicating increased myocardial oxygen demand (p=0.0002) 2
  • Worsening cardiac and renal biomarkers 3
  • Inadequate splanchnic perfusion with increased PCO2 gap 4

• Higher heart rates and increased arrhythmias compared to norepinephrine 2, 4

Recommended Approach

For Hypotensive Cardiogenic Shock:

1. Start with norepinephrine as first-line vasopressor 1, 5
2. Add an inotrope separately (dobutamine or milrinone) if myocardial depression persists 6, 1
3. Reserve epinephrine only for salvage situations when other combinations have failed

Special Considerations:

• In patients with bradycardia, dopamine may be considered instead 1
• In afterload-dependent states (aortic stenosis, mitral stenosis), phenylephrine or vasopressin is preferred 1
• For patients on beta-blockers, consider milrinone or levosimendan as they work independently of beta-adrenergic receptors 6

Dosing When Epinephrine Must Be Used

If epinephrine is absolutely necessary, the FDA-approved dosing for shock is 7:

• Initial rate: 0.05 mcg/kg/min
• Titrate up to 2 mcg/kg/min to achieve desired MAP
• Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min
• Use the lowest effective dose for the shortest duration 6
• Wean gradually over 12-24 hours once hemodynamically stable 7

Common Pitfalls to Avoid

• Do not use epinephrine as first-line therapy in cardiogenic shock—the evidence shows worse outcomes 2, 3
• Avoid attributing lactic acidosis solely to poor perfusion in patients on epinephrine—the drug itself causes lactate elevation through metabolic effects 2, 4
• Do not continue epinephrine if refractory shock develops—consider escalating to mechanical circulatory support instead 5
• Monitor closely for arrhythmias, particularly in patients with underlying coronary disease 6, 2

Bottom Line

While epinephrine is pharmacologically capable of supporting blood pressure and cardiac output in cardiogenic shock, the combination of norepinephrine plus dobutamine (or milrinone) is safer and more effective 1, 4, 5. Epinephrine should be reserved for exceptional circumstances when preferred agents have failed, and patients should be monitored intensively for metabolic complications, arrhythmias, and progression to refractory shock.