Vasopressin plus catecholamines lowers risk of atrial fibrillation in distributive shock

Originally Published By 2 Minute Medicine®. Reused on MPR with permission.

1. In this meta-analysis, addition of vasopressin to catecholamine vasopressors was associated with a lower risk of atrial fibrillation when compared to catecholamine monotherapy.

2. While there was decreased mortality with vasopressin plus catecholamines, this difference was not seen when restricting analysis to studies with a low risk of bias.

Evidence Rating Level: 1 (Excellent)

Study Rundown: In distributive shock, widespread vasodilation leads to decreased systemic resistance and mean arterial pressure, and vasopressor infusions are often used acute care. However, myocardial ischemia and arrhythmias are a common complication of vasopressor treatment in shock, and it is unclear which regimen reduces dangerous sequelae most optimally. In this systematic review and meta-analysis, treatment with vasopressin plus a catecholamine vasopressor was significantly associated with a lower risk of atrial fibrillation when compared to catecholamine vasopressors alone. In addition, while there was decreased mortality with vasopressin plus catecholamines, this difference was not seen when restricting analysis to studies with a low risk of bias. Other outcomes, including requirement for renal replacement therapy, myocardial injury, ventricular arrhythmia, and stoke, did not reach statistical significance.

This review does provide evidence to suggest that addition of vasopressin to catecholamines may offer a clinical advantage for prevention of atrial fibrillation, but a few limitations should be noted. First, while vasopressin may have contributed to a reduction in atrial fibrillation by reducing the adrenergic stimulation provided by catecholamine vasopressors, it may have simply reduced the duration of atrial fibrillation without affecting its incidence. Second, the approach to monitoring patients who are acutely ill for atrial fibrillation affects the detection of this outcome. Third, there are likely differences in the way vasopressors were initiated, titrated, and weaned between studies and approaches were infrequently described in detail, making generalizability of these results difficult.

Click to read the study, published in JAMA

Relevant Reading: Surviving Sepsis Guidelines

In-Depth [meta-analysis]: This review examined 23 studies that included 3088 patients (mean age, 61.1 years, women, 45.3%) with distributive shock. Included studies had to compare the administration of vasopressin (or analogous therapies) with or without concomitant catecholaminergic vasopressors with the administration of catecholaminergic vasopressors alone, irrespective of dose, duration, or co-intervention. More intensive therapy with vasopressin plus catecholamines demonstrated a significant reduction in the risk of atrial fibrillation associated with the administration of vasopressin (RR 0.77; CI95 0.67-0.88). The absolute effect is that 68 fewer people per 1000 patients (CI95 36-98) will experience atrial fibrillation when vasopressin is added to catecholamine vasopressors. When pooled, the administration of vasopressin in addition to catecholamines was associated with a reduction in mortality (RR 0.89; CI95 0.82-0.97). This translates to 45 lives (CI95 12-73) per 1000 patients treated with vasopressin. However, when limited to the 2 trials with low risk of bias, the results were not statistically significant (RR 0.96; CI95 0.84-1.11). Other outcomes, including requirement for renal replacement therapy, myocardial injury, ventricular arrhythmia, and stoke, did not reach statistical significance.

Image: PD

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