Norepinephrine or Epinephrine in Cardiogenic Shock: Is One Better?

Which should be the first-line vasopressor between norepinephrine and epinephrine in cardiogenic shock?
Your patient had an MI and is now in cardiogenic shock.
They are hypotensive and need a vasopressor.
To clarify, The Crit Doc of Tik Tok aka CriticalCareNow aka Haney Mallemat likes epinephrine as an inotrope, not a vasopressor.
This was a pilot study, meaning that more was to come, until the results forced the authors to stop.
This is not medical advice. Read the full free article for yourself.
The authors enrolled 57 patients into this double-blind trial.
Before you say “oh that’s not a lot”, recognize that they had to stop because of harm.
You see, there is prior data that epinephrine may have deleterious effects on the heart.
This is why they attempted this study in the first place.
The authors measured several parameters. (and did their statistical jumping jacks).
With regards to their MAP, CI, and SVI, they were the same.
As one would expect, the HR for the patients on epi was higher.
Also expected, as epi hits more of the beta receptors, there was an increase in lactate in these patients This does NOT mean the patients needed more fluids.
The problem was that 37% of the patients on epi went into refractory shock.
Just 7% of the patients on NE did the same.
It wasn’t statistically significant but 48% of the epinephrine group did not make it vs. 27% in the norepinephrine group.
Epinephrine could be a good choice as an inotrope but not a vasopressor.
I discuss this paper in more detail in my Vasopressors post.

Citation for Cardiogenic Shock: norepinephrine vs. epinephrine

Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Frederique G, Quenot JP, Kimmoun A, Cariou A, Lassus J, Harjola VP, Meziani F, Louis G, Rossignol P, Duarte K, Girerd N, Mebazaa A, Vignon P; Collaborators. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol. 2018 Jul 10;72(2):173-182. doi: 10.1016/j.jacc.2018.04.051. PMID: 29976291.
Link to Article

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