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Meta-Analysis
. 2018 May 8;319(18):1889-1900.
doi: 10.1001/jama.2018.4528.

Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis

William F McIntyre  1 , Kevin J Um  1 , Waleed Alhazzani  1 , Alexandra P Lengyel  1 , Ludhmila Hajjar  2 , Anthony C Gordon  3   4 , François Lamontagne  5 , Jeff S Healey  1 , Richard P Whitlock  1 , Emilie P Belley-Côté  1
Affiliations
Meta-Analysis

Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis

William F McIntyre et al. JAMA. .

Abstract

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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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr McIntyre reported receiving grant funding from the Canadian Stroke Prevention Intervention Network and being a trainee member of the Cardiac Arrhythmia Network of Canada. Dr Gordon reported receiving grant funding from the National Institute for Health Research and Tenax Therapeutics; personal fees and nonfinancial support from Orion Pharma, Tenax Therapeutics, Ferring Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb; and personal fees from Amomed Pharma. Dr Healey reported receiving grant funding from Medtronic and Bristol-Meyers Squibb/Pfizer. Dr Belley-Côté reported receiving grant funding from the Canadian Institutes of Health Research. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow of Study Selection for Trials Comparing Vasopressin + Catecholamines vs Catecholamines Alone for Patients With Distributive Shock
Figure 2.
Figure 2.. Relative Risks of All Trials Comparing Vasopressin + Catecholamines vs Catecholamines Alone for Patients With Distributive Shock
The relative risks were calculated using a random-effects model with Mantel-Haenszel weighting. The size of data markers indicates the weight of the study. Error bars indicate 95% CIs. aVasopressin (or analogue [ie, terlipressin, selepressin, or pituitrin]) + catecholamine vasopressors.
Figure 3.
Figure 3.. Relative Risks of All Trials Comparing Vasopressin + Catecholamines vs Catecholamines Alone for Patients With Distributive Shock
The relative risks were calculated using a random-effects model with Mantel-Haenszel weighting. The size of data markers indicates the weight of the study. Error bars indicate 95% CIs. aVasopressin (or analogue [ie, terlipressin, selepressin, or pituitrin]) + catecholamine vasopressors. bRisk of bias categories for requirement for renal replacement therapy are the same as those for atrial fibrillation, as summarized in Table 1.
See this image and copyright information in PMC

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