Vasoactive support in cardiogenic shock: a systematic review of randomised controlled trials
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McGuigan P.
McNamee E.R.
Wardman C.
Boyle A.
Warren A.
Proudfoot A.
Blackwood B.
McAuley, D.
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2025
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Cardiogenic shock is a multifactorial heterogeneous syndrome in which disorders of the cardiovascular system impair cardiac output leading to inability to sustain end-organ perfusion.1,2 It is complex and carries a high mortality rate. The purpose of this systematic review was to evaluate whether use of vasoactive agents vs placebo or usual care in adults with cardiogenic shock improves the outcomes of mortality, escalation to mechanical circulatory support, heart transplant, or neurological outcomes. We searched MEDLINE and Embase using the OVID platform. CENTRAL was used to search CT.Gov, ICTRP, and CINAHL registers using MeSH terms relating to cardiogenic shock and vasoactive drugs (PROSPERO registration number CRD42024614065). No date or language restrictions were set. Inclusion criteria were RCTs of adult patients with cardiogenic shock as defined in each trial. Exclusion criteria were case series, case-control studies, observational studies, post hoc analysis of previously conducted randomised controlled trials, studies which present duplicate data, studies not reporting mortality, studies that deliver vasoactive drugs for fixed durations assessing physiological response, trials of paediatric populations, and post-cardiac surgical populations. Risk of bias was assessed by two reviewers independently using the Cochrane Risk of Bias tool for randomised trials. Nineteen studies met inclusion criteria. Primary outcome measure was mortality (up to 30 days or hospital discharge); intervention was any vasoactive drug with the aim of increasing blood pressure or cardiac output; and comparator was placebo or usual care. Where norepinephrine was one of two drugs studied, it was considered usual care. For all classes of drugs studied, there was no evidence of an effect on 30-day mortality-catecholamines: n=62, relative risk (RR), 1.20 (confidence interval [CI], 0.44-3.29), I2=16%; phosphodiesterase-3 inhibitors: n=85, RR, 0.60 (CI, 0.22-1.63), I2=40%, majority of events from a single study; levosimendan: n=61, RR, 0.75 (CI, 0.43-1.31), I2=40%, high risk of bias in two studies; nitric oxide synthase inhibitors: n=274, RR, 0.92 (CI, 0.26-3.31), I2=56%, high risk of bias in one study; and adrenomedullin antibody: n=60, RR, 1.01 (CI, 0.68-1.50), data from a single study. There was low certainty of evidence for all interventions. There are no existing core outcome sets for trials of vasoactive agents in cardiogenic shock. Of the 4221 studies screened, a comparatively small number of studies (with a small number of participants) were included in the review, with a number of these including a patient population in a low cardiac output state. Further research is required into the use of vasoactive drugs in the setting of cardiogenic shock in order to draw conclusions of benefit and apply to apply these results to clinical practice. Funding Belfast Health and Social Care Trust, Research Charitable Funds. References 1. Sinha SS, Morrow DA, Kapur NK, et al. J Am Col Cardiol 2025; 85: 1618-41 2. Waksman, R Pahuja M, van Diepen S, et al. Circulation 2023; 148: 1113-26 Copyright © 2025
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British journal of anaesthesia