Finally, a Treatment for Cardiogenic Shock?

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Finally, a Treatment for Cardiogenic Shock?

Treatment with a nitric oxide synthase inhibitor increases survival.

Survival remains low in patients with cardiogenic shock, despite modest improvements derived from supportive treatment with the intra-aortic balloon pump (IABP) and urgent revascularization. Large myocardial infarctions trigger production of high levels of nitric oxide (NO), which acts as a profound vasodilator and myocardial depressant and may contribute to cardiogenic shock. These authors hypothesized that reducing production of NO might be beneficial. They evaluated treatment with L-NAME, an inhibitor of NO synthase, in 30 consecutive patients with hypotension and hypoperfusion due to acute left ventricular ischemia who were unresponsive to rapid revascularization, IABP, and dopamine.

Patients were randomized to receive supportive care plus L-NAME (1 mg/kg bolus plus a 1 mg/kg/hr IV drip for 5 hours) or supportive care alone in an open-label fashion. The 2 groups were clinically comparable at baseline. Survival at 30 days, the primary endpoint, was 73% in the L-NAME group and 33% in the control group (P=0.008). The survival advantage was apparent at 1 week. Mean arterial blood pressures at 24 hours were 86 mm Hg and 66 mm Hg, respectively (P=0.004). Hourly urine output at 24 hours had increased by 180% in the L-NAME group and decreased by 10% in the control group (P=0.001).

Comment: In this small, well-conducted study, inhibiting the production of NO had a surprising effect on hemodynamics and outcome. If these results can be replicated in a larger trial of similar design and in patients who do not have access to invasive revascularization, NO synthase inhibition will be one of the best therapeutic successes for cardiogenic shock in recent years.

— James M. Christenson, MD, FRCPC

Published in Journal Watch Emergency Medicine September 24, 2003

Citation(s):

Cotter G et al. LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock: A prospective randomized study. Eur Heart J 2003 Jul; 24:1287-95.

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