Treatment of

cardiogenic
shock: A patient
centered
approach
Liz Sutliff, BSN, CCRN
Youngstown State University
NURS 6901
Dr. Amy Weaver, Ph.D., RN, CNE
April 27, 2022
 Background

Cardiogenic shock is a life-threatening form of heart failure that occurs after a

severe myocardial infarction or prolonged, progressive heart failure. This
condition carries a high mortality rate and is accompanied by concomitant
conditions and patient comorbidities. Patients that present with this condition
are given positive inotropic medications to increase the cardiac output. The
most used medications are Dobutamine (Dobutrex) or Milrinone (Primacor).
Although these medications are in different drug classes and their mechanism
of actions differ, the end results are similar. Drug selection varies between
providers without logical explanation of why one is selected and not the other.
It appears that this decision is made based solely on provider preference,
rather than research. This brings up the question—Why choose one over the
other?
Objective

To evaluate the effectiveness of Dobutamine versus

Milrinone in the treatment of cardiogenic shock.
To determine which inotrope is superior in treating
cardiogenic shock.
To identify if one inotrope had an effect on mortality.
To identify if one inotrope influenced the development
concomitant conditions.
To assist in developing treatment algorithms for those
admitted with cardiogenic shock.
 PICOT QUESTION
IN PATIENTS THAT DEVELOP CARDIOGENIC SHOCK, HOW DOES
SELECTION OF POSITIVE INOTROPES DOBUTAMINE AND MILRINONE
AFFECT PATIENT MORTALITY DURING HOSPITALIZATION?
Method

A literature review was completed using six quantitative

research articles ranging from 2009-2021.
Electronic databases used included PubMed, CINAHL
Plus, and the academic database from Maag Library at
Youngstown State University.
Search terms included cardiogenic shock AND
dobutamine VS milrinone, cardiogenic shock treatment,
dobutamine AND milrinone AND cardiogenic shock,
dobutamine AND cardiogenic shock, and milrinone AND
cardiogenic shock, and cardiogenic shock AND patient
mortality.
Results
 Study 1
Gorodeski et al., (2009)
N=112: 56 Milrinone and 56
Dobutamine
Non-Randomized, Non-Controlled
Chart Review
Unequal Cohorts
**No statistical significance
related to patient mortality.**
Study 2
Kelly et al., (2020)
N=135; 40 Milrinone and 95
Dobutamine
Non-Randomized, Non-Controlled
Retrospective Chart Review
Unequal Cohorts
**No statistical significance
related to patient mortality**
 Study 3
King et al, (2017)
N=500: 306 Dobutamine and 194
Milrinone
Single Center, Retrospective Chart
Review
 Non-Randomized, Non-Controlled
 Followed for 180 days after
hospitalization
 Unequal cohorts
**Statistical significance in out of
hospital mortality in those patients
treated with Dobutamine**
Study 4
Lewis et al., (2019)
N=100; 50 Milrinone and 50
Dobutamine
Non-Randomized, Non-Controlled
Retrospective Chart Review
Unequal Cohorts
**No statistical significance
related to patient mortality**
**Similar adverse events Milrinone
hypotension; Dobutamine
arrythmias**
 Study 5 Study 6

Nandkeolyar et al., (2021)

Mathew et al., (2021)

N=192; 96 patients Dobutamine, N=342: multiple concurrent

96 patients Milrinone vasoactives including inotropes

Randomized, controlled, double Non-Randomized, Non-Controlled

blind Retrospective Chart Review
Unequal Cohorts, Concurrent use
**No statistical significance of other vasoactives
related to patient mortality.**
**No statistical significance **Dobutamines use was
related to adverse events.** independently associated with
patient mortality.**
Synthesis of Literature

Conflicting and inconclusive data regarding superiority of

Milrinone over Dobutamine and the effect on patient
mortality.
Retrospective chart reviews are lacking in control over
variables.
Additional randomized controlled trials would be
beneficial to determine risk of mortality, drug
effectiveness and superiority, and risk of developing
concomitant conditions.
 Recommendations

These studies point to prescribers giving thoughtful consideration of potential

adverse events such as, arrythmia, hypotension, renal function, and
anticoagulation when making a drug selection. 
For patients at risk for developing arrhythmias such as past or current cardiac
arrythmia, those at risk for arrythmia in presence of heart attack or AICD use
Milrinone rather than Dobutamine, due to the increased risk of developing
tachyarrythmias.
For those that have contraindications to anticoagulation, use Milrionone as it has
less effects on tachyarrythmias that would necessitate the use of anticoagulants.
For patients at risk for developing hypotension or have renal injury or chronic
renal disease use Dobutamine as it has less effects on hypotension, precipitating
the development or progression of renal disease due to Acute Tubular Necrosis
(ATN).
 REFERENCES

Gorodeski, E. Z., Chu, E. C., Reese, J. R., Shishehbor, M. H., Hsich, E., & Starling, R. C. (2009). Prognosis on chronic dobutamine or milrinone
infusions for stage D heart failure. Circulation: Heart failure, 2(4), 320–324.

Kelly, J., Cheng, J., Malloy, R., & Lupi, K. (2020). Comparison of positive inotropic agents in the management of acute decompensated heart
failure. Journal of Cardiovascular Pharmacology, 75(5), 455–459.

King, J. B., Shah, R. U., Sainski-Nguyen, A., Biskupiak, J., Munger, M. A., & Bress, A. P. (2017). Effect of inpatient Dobutamine versus Milrinone
on out-of-hospital mortality in patients with acute decompensated heart failure. Pharmacotherapy, 37(6), 662–672.

Lewis, T. C., Aberle, C., Altshuler, D., Piper, G. L., & Papadopoulos, J. (2019). Comparative effectiveness and safety between Milrinone or
Dobutamine as initial inotrope therapy in cardiogenic shock. Journal of Cardiovascular Pharmacology and Therapeutics, 24(2), 130–138.

Mathew, R., Di Santo, P., Jung, R. G., Marbach, J. A., Hutson, J., Simard, T., Ramirez, F. D., Harnett, D. T., Merdad, A., Almufleh, A., Weng, W.,
Abdel-Razek, O., Fernando, S. M., Kyeremanteng, K., Bernick, J., Wells, G. A., Chan, V., Froeschl, M., Labinaz, M., Le May, M. R., … Hibbert, B.
(2021). Milrinone as compared with Dobutamine in the treatment of cardiogenic shock. The New England Journal of Medicine, 385(6), 516–
525.

Nandkeolyar, S., Doctorian, T., Fraser, G., Ryu, R., Fearon, C., Tryon, D., Kagabo, W., Abramov, D., Hauschild, C., Stoletniy, L., Hilliard, A., & Sakr,
A. (2021). Predictors of in-hospital mortality in cardiogenic shock patients on vasoactive or inotropic support. Clinical Medicine Insights:
Cardiology, 15, 11795468211049449.