Lower risk of atrial fibrillation with addition of vasopressin to catecholamines for treatment of shock

Reference

McIntyre WF, Um KJ, Alhazzani W, et al. Association of vasopressin plus catecholamine vasopressors vs. catecholamines alone with atrial fibrillation in patients with distributive shock. JAMA 2018;319(18):1889-1900.

Synopsis

Catecholamines such as norepinephrine, epinephrine, dopamine, and dobutamine are used for the treatment of shock but are associated with adverse cardiac events, including arrhythmias and myocardial ischemia. Vasopressin is a hormone that can also be used for the treatment of shock but does not have the same cardiac side effects. These investigators searched multiple databases, including MEDLINE and EMBASE, as well as trial registries and conference proceedings to find randomized controlled trials that compared vasopressin with and without catecholamines versus catecholamines alone for the treatment of distributive shock. The primary outcome of interest was incidence of atrial fibrillation. Two authors independently screened studies for eligibility, abstracted data from individual studies, and assessed the risk of bias of each included study. Ultimately, 23 studies that compared vasopressin with catecholamines versus catecholamines alone (N = 3088 patients) were included in the review. Data pooled from 13 studies showed a decreased risk of atrial fibrillation with the addition of vasopressin (relative risk [RR] 0.77; 95% CI 0.67 - 0.88; P <.001; number needed to treat [NNT] = 15). The result remained the same when the 7 studies at high risk of bias were excluded. Pooled data also showed a reduction in mortality (RR 0.89; 0.82 - 0.97; P = .009; NNT = 23), but the result was no longer statistically significant when limited to the 2 studies at low risk of bias. Finally, findings regarding the need for renal replacement therapy were mixed—no effect was seen when all data were combined, but a significant reduction was noted when only results from 2 low risk of bias trials were included (RR 0.70; 0.53 - 0.92; P = .01). There were no statistically significant differences detected in myocardial injury, ventricular arrhythmias, stroke, or length of hospital stay. A post-hoc analysis showed an increased risk of digital ischemia with the use of vasopressin, with consistent results across several subgroup analyses (RR 2.38; 1.37 - 4.12; P = .002; NNT=42).