Optimal Drug Regimen for Cardiogenic Shock: How to Handle Inopressors and Inodilators

Abstract

Cardiogenic shock mortality remains a significant issue despite substantial improvements in the treatment of acute coronary syndromes. Cardiogenic shock treatment aims at restoring adequate end-organ perfusion. This treatment essentially relies on inotropes and/or vasopressors but the optimal combination is still unknown. While it seems clear that dopamine should not be used in this indication, there is also upcoming evidence showing that inopressors alone (norepinephrine, epinephrine, high-dose dopamine) are associated with a higher mortality. On the contrary, there is a strong rationale for the use of inodilators (dobutamine, levosimendan, phosphodiesterase III inhibitors), that at the same time, improve cardiac contractility and decrease left ventricular afterload. In patients with most severe conditions, a combination of inopressors and inodilators seems to be associated with a better outcome than inopressor alone. Although levosimendan seems to offer an appealing alternative to dobutamine, there is no evidence showing an improved long-term survival with levosimendan. However, because levosimendan is a calcium sensitizer and thus shunts the beta-adrenergic receptor, it seems to be the drug of choice for cardiogenic shock in patients under beta-blockers. Hence, the management of cardiogenic shock should rely first on inodilators, preferably dobutamine. An inopressor, preferably norepinephrine, should be used in case of persistent or initial significant hypotension, but always in association with an inodilator.