Milrinone as Compared with Dobutamine in Cardiogenic Shock
NEJM, 2021 · Double-blind randomized clinical trial (n=192)
Clinical question
Is milrinone superior to dobutamine in reducing mortality and adverse events in cardiogenic shock?
What the trial found
Milrinone and dobutamine yielded identical outcomes in cardiogenic shock without significant differences in mortality, arrhythmias, or hospital stay.
Current guideline position
Supported in AHA and ESC heart failure / cardiogenic shock guidance.
Clinical interpretation
Validates inotrope selection based on physiologic context: dobutamine for renal dysfunction or hypotension; milrinone for RV afterload elevation or chronic beta-blocker therapy.
Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.
Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.
RV anatomy and ischemia spiral, ventricular interdependence (D-sign), echocardiographic metrics (TAPSE, S', PAPi, VExUS), and the 4-pillar resuscitation strategy.