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Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis
Open accessAbstract
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 (281-285).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [283]
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“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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Metadata
- 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 › Critical Care and Intensive Care Medicine › 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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