From the Guidelines
Epinephrine (EPI) is generally preferred over dobutamine for right ventricular (RV) support in acute settings. This preference is based on the most recent and highest quality evidence available, including the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) 1. Epinephrine provides more comprehensive hemodynamic support for the failing right ventricle by increasing cardiac contractility, heart rate, and maintaining systemic vascular resistance to support coronary perfusion pressure.
The key benefits of epinephrine in this context include:
- Increased cardiac contractility to overcome elevated pulmonary pressures
- Maintenance of systemic vascular resistance to support coronary perfusion pressure
- Appropriate for use in hypotensive states, where dobutamine may be less ideal due to its potential to cause peripheral vasodilation and reduce coronary perfusion pressure
In contrast, dobutamine, while effective for improving contractility through beta-1 stimulation, may not be the first choice in acute RV failure due to its potential to worsen RV function in hypotensive states 1. However, dobutamine may be considered in cases of RV failure with preserved blood pressure, starting at a dose of 2.5-5 mcg/kg/min. The choice between epinephrine and dobutamine should be guided by the patient's specific hemodynamic profile, with epinephrine being particularly valuable when both inotropic support and maintenance of systemic pressure are needed.
It's also important to consider the principles of acute right heart failure management, as outlined in the guidelines, which emphasize cautious volume loading, the use of vasopressors like norepinephrine, and the potential role of other therapies such as levosimendan and vasodilators in specific contexts 1. Ultimately, the decision between epinephrine and dobutamine for RV support should prioritize the patient's morbidity, mortality, and quality of life outcomes, based on the most current and high-quality evidence available.
From the Research
Comparison of EPi and Dobutamine for RV Support
- The choice between epinephrine (EPi) and dobutamine for right ventricular (RV) support depends on various factors, including the patient's condition and the desired outcome.
- Studies have shown that dobutamine can improve RV contractility and cardiac output in patients with RV failure 2, 3.
- However, dobutamine may not be as effective in reducing RV afterload as other agents, such as milrinone or levosimendan 3, 4.
- Epinephrine, on the other hand, has been shown to improve RV function in patients with severe septic shock and RV failure by increasing RV contractility and reducing RV afterload 5.
- A key difference between EPi and dobutamine is their effect on RV afterload, with EPi potentially reducing afterload and dobutamine having a more pronounced inotropic effect 2, 5.
Effects on RV Contractility and Afterload
- Dobutamine increases RV contractility and cardiac output, but may not significantly reduce RV afterload 2, 3.
- Epinephrine improves RV contractility and reduces RV afterload in patients with severe septic shock and RV failure 5.
- Levosimendan, another agent, has been shown to restore RV-PA coupling better than dobutamine due to its additional pulmonary vasodilatory effects 4.