Efficacy and safety of dobutamine versus milrinone in cardiogenic shock: Systematic review and meta-analysis

Abstract

Background: Cardiogenic shock (CS) is a life-threatening condition requiring timely pharmacological support. Dobutamine and milrinone are commonly used inotropes, yet their comparative efficacy and safety in CS management remain uncertain. This systematic review and meta-analysis aims to evaluate the outcomes associated with dobutamine versus milrinone in CS patients.

Methods: A thorough literature search was conducted across databases including MEDLINE (via PubMed), CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus, spanning publications up to February 2025. Randomized controlled trials and observational studies comparing dobutamine and milrinone in adult patients diagnosed with CS were incorporated. Statistical analyses were performed employing a random-effects model. Effect measures comprised odds ratios (OR) for binary outcomes and standardized mean differences (SMD) for continuous outcomes, accompanied by 95% confidence intervals (CI), with heterogeneity evaluated using I² statistics.

Results: Dobutamine was associated with higher in-hospital mortality (OR 1.56, 95% CI 1.01–2.39; I²=93%; p=0.04), which was non-significant in RCTs (OR 1.24, 95% CI 0.70–2.19; I²=0%; p=0.46; moderate certainty) but significant in observational studies (OR 1.63, 95% CI 1.02–2.59; I²=94%; p=0.04; very low certainty). Mortality was markedly increased in ICU settings (OR 2.85, 95% CI 1.42–5.69; I²=93%; p<0.001; moderate certainty), whereas non-ICU settings showed no significant difference (OR 0.68, 95% CI 0.32–1.45; I²=84%; low certainty). Overall all-cause mortality was also higher with dobutamine (OR 1.54, 95% CI 1.07–2.21; I²=87%; p=0.02), remaining non-significant in RCT data (OR 1.30, 95% CI 0.73–2.32; moderate certainty) but significant in observational data (OR 1.58, 95% CI 1.06–2.35; I²=89%; low certainty). No significant differences were observed in ICU length of stay (SMD −0.13, 95% CI −0.99 to 0.73; I²=93%) or hospital length of stay (SMD −0.69, 95% CI −4.49 to 3.11; I²=98%), and significant arrhythmias were comparable (OR 0.88, 95% CI 0.40–1.93; I²=76%). However, acute renal failure was significantly more frequent with dobutamine (OR 1.22, 95% CI 1.01–1.47; I²=0%; p=0.03).

Conclusion: Dobutamine is associated with increased mortality particularly in ICU patients and a higher risk of acute renal failure compared with milrinone, with evidence certainty ranging from moderate to very low and substantial heterogeneity across mortality outcomes.