Disclosure(s): No relevant financial relationship(s) to disclose.
First Author: Quincy K. Tran, MD, PhD – University of Maryland Medical Center, R. Adams Cowley Shock Trauma Center Co-Author: Rohan Vanga, N/A – Student, Research Associate Program in Emergency Medicine and Critical Car, Department of Emergency Medicine, University of Maryland School of Medicine Co-Author: Martin Borrisov, MD – Resident Physician, University of Maryland Medical Center Co-Author: Sooyoung Hwang, MD – Resident Physician, University of Maryland Medical Center Co-Author: Daniel Najafali, BS – Student, Carle Illinois College of Medicine Co-Author: Jennifer Walker, MD – Emergency Medicine, Critical Care Medicine, Baylor Scott & White Health Co-Author: Angie Chan, BS – Student, Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine Co-Author: Maie Abdel-Wahab, BS – Hackensack Meridian Health Hackensack University Medical Center Co-Author: Ali Pourmand, MD MPH – Attending physician, George Washington University school of medicine and Health Sciences
Introduction: For patients with septic shock, norepinephrine (NE) is the recommended vasopressor. However, among patients who develop cardiomyopathy, the Surviving Sepsis Guidelines recommends an inotrope. However, there are no large randomized trials (RCTs) to compare the efficacy of NE+Dobu versus epinephrine (EPI) for cardiomyopathy in septic shock. In our study, we hypothesized that EPI alone might have similar efficacy as the NE+Dobu combination for patients with septic shock and pre-existing cardiomyopathy.
Methods: This is a retrospective study, utilizing the global real-world database TriNetX, which involves 130 contributing organizations and 130 million patients. We followed the PICO format. Eligible patients were adult patients with septic shock between August 2005 to August 2025 and any cardiomyopathy at the index ED visit. Intervention was treatment with EPI on the same day or one day after the index ED visit. The control group was composed of patients who received NE+Dobu at similar time frames. Outcomes were 30-day all-cause mortality, rates of dialysis, and any arrhythmia. Control and EPI groups were matched via propensity score matching using demographic, vital signs and laboratory values at index visit. Sample size calculation suggested a sample size of 152 patients per group to detect a 15% difference of 30-day mortality.
Results: Our study analyzed 452 patients (226 [50%] per group). Mean age (+/- SD) was 67.3 (SD 13) for control and 68.2 (SD 14, P=0.49) for EPI groups. Serum lactate was 2.3 (SD 1.7) mmol/dL for control vs. 1.7 (SD 1.3, P< 0.01) for EPI group. Mortality rate was 99 (43.8%) and 67 (29.6%) for control and EPI groups, (Risk difference [RD] 14%, 95% CI 0.054, 0.23, P=0.002), respectively. Prevalence of dialysis was 27 (11.9%) and 28 (12.4%) for control and EPI patients (RD -0.4%, 95% CI -0.065, 0.056, P=0.89). Arrhythmias occurred in 112 (49.6%) of control vs. 117 (51.8%) in EPI group (RD -2.2%, 95% CI -0.11, 0.070, P=0.64).
Conclusions: Among patients with septic shock and pre-existing cardiomyopathy, treating patients with epinephrine was not associated with higher 30-day mortality. There were similar rates of dialysis and arrhythmias. Further studies are needed to confirm our observation.
