OBJECTIVE: Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients. DESIGN: We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality. MEASUREMENTS AND RESULTS: Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17-76%) and short-term mortality rate was 49% (21-69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8-3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4-6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0-6.0]). CONCLUSIONS: In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.

AMC Heart Center Academic Medical Center University of Amsterdam Amsterdam The Netherlands

Australian and New Zealand Intensive Care Research Centre School of Public Health and Preventive Medicine Monash University Melbourne Australia

Cardiology Department University Hospital Brno and Faculty of Medicine Masaryk University Brno Czech Republic

Cardiology Department University Hospital of Nancy Vandoeuvre lès Nancy France

Cardiovascular Department Hôpital de la Tour Meyrin Geneva Switzerland

CIC Plurithématique INSERM University Hospital of Nancy Nancy France

Department of Anesthesiology and Critical Care APHP Saint Louis Lariboisière University Hospitals University Paris Diderot and INSERM UMR S 942 Paris France

Department of Anesthesiology and Critical Care Medicine Hôpital Européen Georges Pompidou Paris France

Department of Anesthesiology and Critical Care Medicine PhyMedExp University of Montpellier INSERM CNRS Montpellier France

Department of Intensive Care Austin Hospital Melbourne Australia

Department of Intensive Care Royal Melbourne Hospital Melbourne Australia

Department of Internal Medicine 3 University of Cologne Cologne Germany

Department of Medicine Cardiology Heart Center Dresden University of Technology Dresden Germany

Division of Cardiology Henry Ford Hospital 2799W Grand Blvd K14 Detroit MI 48202 USA

Division of Nephrology National University Health System University Medicine Cluster Singapore Singapore

Emergency Department University Hospital of Nancy Nancy France

Emergency Medicine University of Helsinki and Department of Emergency Medicine and Services Helsinki University Hospital Helsinki Finland

Heart and Lung Center University of Helsinki and Helsinki University Hospital Helsinki Finland

INSERM U1116 University of Lorraine Nancy France

Intensive Cardiac Care Unit Florence University Hospital Careggi Florence Italy

Intensive Care Unit Faculty of Medicine University Hospital of Nancy France and U1116 Vandoeuvre lès Nancy France

Intensive Care Unit University Hospital Félix Guyon Saint Denis France

Investigation Network Initiative Cardiovascular and Renal Clinical Trialists INI CRCT Nancy France

Medical Intensive Care Unit University Medical Centre Maribor Ljubljanska Maribor Slovenia

Praxisklinik Herz und Gefaesse Dresden Germany

School of Medicine The University of Melbourne Melbourne Australia

Med Klin Intensivmed Notfmed. 2018 Nov;113(8):681-684. doi: 10.1007/s00063-018-0471-5. PubMed

Intensive Care Med. 2018 Nov;44(11):2022-2023. doi: 10.1007/s00134-018-5372-9. PubMed

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