From the Guidelines
Dopamine, dobutamine, and norepinephrine have distinct cardiac effects: Dopamine increases heart rate and contractility, dobutamine primarily increases contractility, and norepinephrine increases vascular tone with variable effects on heart rate and contractility 1.
Key Differences
- Dopamine acts through several receptors, stimulating β1-receptors at infusion rates of 2–15 μg/kg/min, increasing myocardial contractility at the cost of tachycardia and increased risk of arrhythmias 1.
- Dobutamine is a potent beta-adrenergic agonist, increasing contractility with minimal effect on heart rate, and is often used to treat low cardiac output 1.
- Norepinephrine has inconsistent and time-dependent effects on cardiac function and output, which may be related to baseline cardiovascular state, ventriculo-arterial coupling, and potential unmasking of myocardial depression with increased afterload 1.
Clinical Guidelines
- The Surviving Sepsis Campaign recommends norepinephrine as the first-choice vasopressor, with epinephrine as an alternative, and dopamine only in highly selected patients 1.
- Dobutamine may be added to norepinephrine in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor therapy 1.
Important Considerations
- Norepinephrine and epinephrine have similar effects on shock reversal and survival, but epinephrine may be associated with a higher risk of tachycardia and arrhythmias 1.
- Dopamine is not recommended for renal protection, and its use is associated with an increased risk of arrhythmias and mortality compared to norepinephrine 1.
From the Research
Cardiac Effects of Dopamine, Dobutamine, and Norepinephrine
- Dopamine and dobutamine are both potent cardiac stimulants, although their hemodynamic profiles are different 2
- Dobutamine appears to be the more appropriate choice in cardiac failure due to its additional benefit of preload reduction, while dopamine is preferred in cases of severe hypotension 2
- Dopamine can increase cardiac output more than norepinephrine, and has the potential advantage of increasing renal and hepatosplanchnic blood flow 3
- Norepinephrine is more powerful than dopamine in increasing blood pressure in shock states 3
Comparison of Dobutamine and Dopamine
- Dobutamine produced a distinct increase in cardiac index, while lowering left ventricular end-diastolic pressure and leaving mean aortic pressure unchanged 4
- Dopamine also significantly improved cardiac index, but at the expense of a greater increase in heart rate than occurred with dobutamine 4
- Dobutamine may be of special value in patients with the low output syndrome associated with coronary heart disease due to its comparatively little effect on heart rate and aortic pressure 4
Effects of Norepinephrine and Dobutamine in Septic Shock
- The addition of norepinephrine to treatment of patients with septic shock unresponsive to dobutamine significantly improves mean arterial pressure, cardiac index, stroke volume index, and left ventricular stroke work index 5
- Norepinephrine used alone in patients with septic shock and high cardiac index does not modify cardiac index or stroke volume index, but improves mean arterial pressure and left ventricular stroke work index 5
Inotropic Therapy for Cardiac Low Output Syndrome
- There is no significant difference in the hemodynamic effects of dopamine/dobutamine versus dopamine/dopexamine in patients with profound cardiogenic shock 6
- Dopexamine may have a beneficial effect on myocardial oxygen consumption and renal and splanchnic functions, but this does not translate to a superior clinical outcome 6