This week, De Backer et al. report on a multicenter clinical trial in which they randomly assigned 1679 patients with shock to receive either dopamine or norepinephrine to restore and maintain blood pressure. With regard to the primary endpoint of 28-day mortality, there was no difference between the two pressors. However, dopamine was unexpectedly associated with more cardiac arrhythmias, especially atrial fibrillation. Particularly worrisome was a higher mortality rate among a prespecified subgroup of patients with cardiogenic shock.
“Sometimes in medicine, practice is handed down from generation to generation without rigorous study,” executive editor, Dr. Gregory Curfman said. “Logic tells us that something works, so we keep using it.” But studies like this give us new evidence for a different approach.
Current guidelines recommend dopamine as the first-line agent in treating septic and cardiogenic shock. A common clinical perception, until now, has been that the use of norepinephrine in patients with shock might actually increase mortality. The new information from this controlled trial challenges that perception. With regard to cardiogenic shock, the new study suggests that treatment guidelines should be changed to designate norepinephrine as the pressor of choice to restore arterial pressure.
In the accompanying editorial, Treating Shock — Old Drugs, New Ideas, Dr. Jerrold Levy of Emory University School of Medicine says that these results should, “put an end to the outdated view that the use of norepinephrine increases the risk of death.”
Dopamine has been relied upon to treat shock in the ICU and CCU for decades; has it been your first line agent? Does this article make you think differently about customary treatments for shock in your practice?