Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis
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Importance: Vasopressin is an alternative to catecholamine vasopressors for patients with distributive shock-a condition due to excessive vasodilation, most frequently from severe infection. Blood pressure support with a noncatecholamine vasopressor may reduce stimulation of adrenergic receptors and decrease myocardial oxygen demand. Atrial fibrillation is common with catecholamines and is associated with adverse events, including mortality and increased length of stay (LOS). Objectives: To determine whether treatment with vasopressin + catecholamine vasopressors compared with catecholamine vasopressors alone was associated with reductions in the risk of adverse events. Data Sources: MEDLINE, EMBASE, and CENTRAL were searched from inception to February 2018. Experts were asked and meta-registries searched to identify ongoing trials. Study Selection: Pairs of reviewers identified randomized clinical trials comparing vasopressin in combination with catecholamine vasopressors to catecholamines alone for patients with distributive shock. Data Extraction and Synthesis: Two reviewers abstracted data independently. A random-effects model was used to combine data. Main Outcomes and Measures: The primary outcome was atrial fibrillation. Other outcomes included mortality, requirement for renal replacement therapy (RRT), myocardial injury, ventricular arrhythmia, stroke, and LOS in the intensive care unit and hospital. Measures of association are reported as risk ratios (RRs) for clinical outcomes and mean differences for LOS. Results: Twenty-three randomized clinical trials were identified (3088 patients; mean age, 61.1 years [14.2]; women, 45.3%). High-quality evidence supported a lower risk of atrial fibrillation associated with vasopressin treatment (RR, 0.77 [95% CI, 0.67 to 0.88]; risk difference [RD], -0.06 [95% CI, -0.13 to 0.01]). For mortality, the overall RR estimate was 0.89 (95% CI, 0.82 to 0.97; RD, -0.04 [95% CI, -0.07 to 0.00]); however, when limited to trials at low risk of bias, the RR estimate was 0.96 (95% CI, 0.84 to 1.11). The overall RR estimate for RRT was 0.74 (95% CI, 0.51 to 1.08; RD, -0.07 [95% CI, -0.12 to -0.01]). However, in an analysis limited to trials at low risk of bias, RR was 0.70 (95% CI, 0.53 to 0.92, P for interaction = .77). There were no significant differences in the pooled risks for other outcomes. Conclusions and Relevance: In this systematic review and meta-analysis, the addition of vasopressin to catecholamine vasopressors compared with catecholamines alone was associated with a lower risk of atrial fibrillation. Findings for secondary outcomes varied.
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Restricting antimicrobial therapy to the shortest course associated with better outcomes is an important part of antimicrobial stewardship.
“Restricting antimicrobial therapy to the shortest course associated with better outcomes is an important part of antimicrobial stewardship (281-285).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [283]
The KeyPoints (p. 2) describe a meta-analysis of vasopressin and atrial fibrillation in distributive shock, not antimicrobial treatment. Searches for the claimed shortest-course recommendation and for antimicrobial stewardship or antibiotic duration found no passage addressing the claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredA meta-analysis of RCTs on distributive shock found lower risk of atrial fibrillation with vasopressin plus norepinephrine compared with norepinephrine alone.
“Another meta-analysis of RCTs on distributive shock showed a lower risk of atrial fibrillation with the combination of vasopressin and norepinephrine compared to norepinephrine alone [358].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [358]
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Vasopressin in Sepsis and Other Shock States: State of the Art
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Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery
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Vasopressor use in cardiogenic shock
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Emergency medicine updates: Management of sepsis and septic shock
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Alternatives to norepinephrine in septic shock: Which agents and when?
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Role of Ischemia/Reperfusion and Oxidative Stress in Shock State
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Terlipressin for septic shock patients: a meta-analysis of randomized controlled study
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Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock*
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How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock
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Cost-effectiveness of second-line vasopressors for the treatment of septic shock
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Association of Premorbid Blood Pressure with Vasopressor Infusion Duration in Patients with Shock
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Atrial fibrillation in critical illness: state of the art
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Methylene Blue in Septic Shock: A Systematic Review and Meta-Analysis
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Vasoplegia in Heart, Lung, or Liver Transplantation: A Narrative Review
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Vasoplegia: Mechanism and Management Following Cardiopulmonary Bypass
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Self-citationHaemodynamic management of septic shock
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Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art
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Angiotensin II (Giapreza): A Distinct Mechanism for the Treatment of Vasodilatory Shock
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Outcomes and Management of Stressor-Associated Atrial Fibrillation
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Therapeutic Dilemmas in Mixed Septic-Cardiogenic Shock
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ANGIOTENSIN II IN THE TREATMENT OF DISTRIBUTIVE SHOCK: A SYSTEMATIC-REVIEW AND META-ANALYSIS
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Terlipressin or norepinephrine, or both in septic shock?
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- Authors
- McIntyre, W. F., Um, K. J., Alhazzani, W., Lengyel, A. P., Hajjar, L., Gordon, A. C., Lamontagne, F., Healey, J. S., Whitlock, R. P., & Belley-Côté, E. P.
- Affiliations
- McMaster University (CA)
- Universidade de São Paulo (BR)
- Charing Cross Hospital (GB)
- Université de Sherbrooke (CA)
- McMaster University, Hamilton, Ontario, Canada
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2018-05-08
- Volume
- 319
- Issue
- 18
- Pages
- 1889
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC6583502
- OpenAlex
- W2802319261
- Cited by
- 225
- References
- 45
- Citations by year
- 2026: 27 · 2025: 28 · 2024: 28 · 2023: 27 · 2022: 29 · 2021: 20 · 2020: 37 · 2019: 20 · 2018: 9
- FWCI
- 16.77
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- JAMA (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Spiral (Imperial College London) (submittedVersion)
- Funders
- National Institute for Health and Care Research (NIHR/CS/009/007, PB-PG-0610-22350)
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Trauma, Hemostasis, Coagulopathy, Resuscitation
- Keywords
- vasopressin, distributive shock, septic shock, atrial fibrillation, mortality, renal replacement therapy, myocardial injury, ventricular arrhythmias, stroke, length of hospital stay, intensive care unit, sepsis, vasodilation, myocardial oxygen demand, fluid resuscitation, vasopressor combination
- MeSH terms
- Atrial Fibrillation, Catecholamines, Drug Therapy, Combination, Female, Humans, Length of Stay, Male, Shock, Vasoconstrictor Agents, Vasopressins, Publication Bias
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