From the Guidelines
Norepinephrine is the recommended first-line vasopressor for cardiogenic shock. The typical starting dose is 0.1-0.2 mcg/kg/min, titrated to a mean arterial pressure (MAP) of 65-70 mmHg, with a maximum dose of 3.3 mcg/kg/min. This recommendation is based on the most recent and highest quality study available, which suggests that norepinephrine is associated with fewer arrhythmias and is likely the vasoactive drug of choice for most patients with cardiogenic shock 1.
Key Considerations
- Norepinephrine provides potent vasoconstriction through alpha-1 adrenergic effects while also offering modest beta-1 adrenergic inotropic support, which helps maintain cardiac output.
- If additional inotropic support is needed, dobutamine (starting at 2.5-5 mcg/kg/min) can be added to norepinephrine.
- For refractory cases, epinephrine (0.05-0.5 mcg/kg/min) or vasopressin (0.01-0.04 units/min) may be considered as second-line agents.
- It's essential to remember that vasopressors are temporary measures while addressing the underlying cause of cardiogenic shock, and mechanical circulatory support should be considered early if the patient is not responding to pharmacological therapy.
Supporting Evidence
- The SOAP II trial reported a statistically significant higher risk of mortality with dopamine compared to norepinephrine in the pre-defined sub-group of patients with cardiogenic shock 1.
- A network meta-analysis of 33 randomised trials of vasoactive agents in septic shock reported that levosimendan, dobutamine, epinephrine, vasopressin, and norepinephrine with dobutamine were all significantly associated with survival, with levosimendan and dobutamine affording the greatest benefit 1.
- The European Society of Cardiology guidelines recommend norepinephrine as the first-line vasopressor for cardiogenic shock 1.
Clinical Implications
- Norepinephrine should be used as the first-line vasopressor for cardiogenic shock due to its balanced profile of vasoconstriction and inotropic support.
- Close monitoring of the patient's hemodynamic status and adjustment of the vasopressor dose as needed is crucial to optimize outcomes.
- Early consideration of mechanical circulatory support is essential in patients who are not responding to pharmacological therapy.
From the FDA Drug Label
Dopamine Hydrochloride in 5% Dextrose Injection, USP is indicated for the correction of hemodynamic imbalances present in shock due to myocardial infarction, trauma, endotoxic septicemia, open heart surgery, renal failure and chronic cardiac decompensation as in refractory congestive failure The best vasopressor for cardiogenic shock is dopamine, as it is indicated for the correction of hemodynamic imbalances present in shock due to myocardial infarction, and has a direct inotropic effect on the myocardium which increases cardiac output at low or moderate doses. Key benefits of dopamine include:
- Increased cardiac output
- Increased urine flow
- Improved perfusion of vital organs 2
From the Research
Vasopressor Options for Cardiogenic Shock
- Norepinephrine is often considered a first-line vasopressor for cardiogenic shock due to its effectiveness in achieving adequate arterial pressure with a lower risk of adverse events compared to other catecholamine vasopressors 3, 4, 5
- The combination of norepinephrine and dobutamine may be a more reliable and safer strategy than epinephrine for hemodynamic support in cardiogenic shock patients 6
- Vasopressin or angiotensin-II can be added to norepinephrine if it is inadequate to achieve an adequate arterial pressure 3
Comparison of Vasopressors
- A study comparing norepinephrine-dobutamine to epinephrine in cardiogenic shock patients found that both regimens increased cardiac index and oxygen-derived parameters, but epinephrine was associated with a higher heart rate, arrhythmias, and inadequate gastric mucosa perfusion 6
- Another study found that norepinephrine use in cardiogenic shock patients was associated with increased 30-day mortality, but no significant difference in long-term mortality 7