What is the preferred treatment for bradycardia and hypotension: dobutamine plus levophed (Levophed is a brand name for norepinephrine) or epinephrine (Epi)?

From the Guidelines

For a patient who is bradycardic and hypotensive, epinephrine is generally preferred over the combination of dobutamine plus levophed (norepinephrine). This preference is based on the most recent and highest quality evidence available, which suggests that epinephrine provides a more straightforward and effective approach to managing both bradycardia and hypotension simultaneously 1. Epinephrine at doses of 0.01-0.1 mcg/kg/min offers both alpha and beta adrenergic effects, thereby increasing heart rate, contractility, and vascular tone at the same time.

Key Considerations

• The dobutamine (starting at 2-5 mcg/kg/min) plus levophed (starting at 0.01-0.3 mcg/kg/min) combination can be effective but requires titrating two separate medications, which may have competing effects at the vascular level.
• Epinephrine works rapidly to address both the bradycardia through its beta-1 effects and hypotension through alpha-1 vasoconstriction, making it a simpler and more efficient choice in acute situations.
• However, in specific scenarios such as cardiogenic shock with severe bradycardia, the dobutamine-levophed combination might be preferred as it allows more precise control of chronotropy and vascular tone separately, as suggested by guidelines for the management of acute and chronic heart failure 1.

Management Approach

• Regardless of the choice between epinephrine and the dobutamine-levophed combination, addressing the underlying cause of bradycardia and hypotension (such as beta-blocker overdose, heart block, or sepsis) remains essential while providing vasopressor support.
• The use of other medications like norepinephrine, dopamine, and milrinone may also be considered based on the patient's specific condition and response to initial treatment, as outlined in guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
• Continuous monitoring of organ perfusion and hemodynamics is crucial in guiding the pharmacologic management of patients with cardiogenic shock, with considerations for invasive monitoring and device therapy as needed 1.

From the Research

Comparison of Dobutamine plus Levo and Epi for Brady and Hypotensive Patients

• The use of dobutamine plus levosimendan versus epinephrine (epi) for treating bradycardia and hypotension is not directly compared in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that levosimendan may have benefits over dobutamine in certain cases, such as reducing short-term mortality in patients with cardiogenic shock or low cardiac output syndrome 3.
• Levosimendan has been shown to improve cardiac output and reduce pulmonary capillary wedge pressure in patients with acute, decompensated heart failure 4.
• Dobutamine, on the other hand, can cause hypotensive responses in some patients, particularly those with well-functioning left ventricles 5.
• The combination of dobutamine and levosimendan has been studied, but the results are mixed, with one study showing no benefit over levosimendan alone 2.
• Epinephrine is not directly compared to dobutamine plus levosimendan in the provided studies, but it is mentioned as a comparison to other inotropic agents in one study 3.

Mechanisms and Effects

• The mechanisms of action of levosimendan and dobutamine are different, with levosimendan increasing cardiac contractility without increasing oxygen demand, and dobutamine increasing contractility and heart rate 4.
• The effects of these drugs on B-type natriuretic peptide (BNP) levels have been studied, with decreases in BNP levels associated with improved survival in patients with severe acutely decompensated heart failure 6.
• The choice of inotropic agent may depend on the individual patient's condition and response to treatment, with levosimendan potentially being a better option for patients with certain characteristics, such as those with well-functioning left ventricles 5.