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Arquivos Brasileiros de Cardiologia Aug 2010Congestive heart failure (CHF) is a rather prevalent condition with a high mortality rate. Levosimendan is one among the new drugs that have been tested for its... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Congestive heart failure (CHF) is a rather prevalent condition with a high mortality rate. Levosimendan is one among the new drugs that have been tested for its management.
OBJECTIVE
To undertake a systematic review and meta-analysis of the morbidity and mortality reduction associated with levosimendan in the treatment of CHF.
METHODS
A bibliographic search was conducted in the Medline database for all randomized controlled trials (RCTs) that assessed the use of levosimendan in CHF. The outcomes were death from all causes, length of hospital stay, and hospital readmission for CHF. All RCTs with outcomes of interest were included. Methodological quality criteria, such as blinding and confidentiality of the list of allocation, were evaluated in sensitivity analysis. The main calculation was done with random effects.
RESULTS
Of the 179 articles identified, 48 were RCTs, 19 of them with outcomes of interest. In the comparison with placebo (7 trials, 1,652 patients), the relative risk (RR) for overall death was 0.87 (95% confidence interval [CI]: 0.65 to 1.18). In comparison with dobutamine (10 trials, 2,067 patients), the RR was 0.87 (95% CI: 0.75-1.02). Three studies had data on length of stay, in which levosimendan showed a decrease of 2.27 and 2.30 days compared to placebo and dobutamine, respectively (p < 0.05 for both). No article presented data on readmission alone.
CONCLUSION
The evidence available so far has shown no benefit in terms of mortality in association with the use of levosimendan, which only showed a small benefit in the time of hospitalization.
Topics: Brazil; Heart Failure; Hospitalization; Humans; Hydrazones; Pyridazines; Randomized Controlled Trials as Topic; Risk Factors; Simendan; Treatment Outcome; Vasodilator Agents
PubMed: 20549133
DOI: 10.1590/s0066-782x2010005000072 -
Critical Care (London, England) 2007Severe sepsis and septic shock are common problems in the intensive care unit and carry a high mortality. Endotoxin, one of the principal components on the outer... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Severe sepsis and septic shock are common problems in the intensive care unit and carry a high mortality. Endotoxin, one of the principal components on the outer membrane of gram-negative bacteria, is considered important to their pathogenesis. Polymyxin B bound and immobilized to polystyrene fibers (PMX-F) is a medical device that aims to remove circulating endotoxin by adsorption, theoretically preventing the progression of the biological cascade of sepsis. We performed a systematic review to describe the effect in septic patients of direct hemoperfusion with PMX-F on outcomes of blood pressure, use of vasoactive drugs, oxygenation, and mortality reported in published studies.
METHODS
We searched PubMed, the Cochrane Collaboration Database, and bibliographies of retrieved articles and consulted with experts to identify relevant studies. Prospective and retrospective observational studies, pre- and post-intervention design, and randomized controlled trials were included. Three authors reviewed all citations. We identified a total of 28 publications - 9 randomized controlled trials, 7 non-randomized parallel studies, and 12 pre-post design studies - that reported at least one of the specified outcome measures (pooled sample size, 1,425 patients: 978 PMX-F and 447 conventional medical therapy).
RESULTS
Overall, mean arterial pressure (MAP) increased by 19 mm Hg (95% confidence interval [CI], 15 to 22 mm Hg; p < 0.001), representing a 26% mean increase in MAP (range, 14% to 42%), whereas dopamine/dobutamine dose decreased by 1.8 microg/kg per minute (95% CI, 0.4 to 3.3 microg/kg per minute; p = 0.01) after PMX-F. There was significant intertrial heterogeneity for these outcomes (p < 0.001), which became non-significant when analysis was stratified for baseline MAP. The mean arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio increased by 32 units (95% CI, 23 to 41 units; p < 0.001). PMX-F therapy was associated with significantly lower mortality risk (risk ratio, 0.53; 95% CI, 0.43 to 0.65). The trials assessed had suboptimal method quality.
CONCLUSION
Based on this critical review of the published literature, direct hemoperfusion with PMX-F appears to have favorable effects on MAP, dopamine use, PaO2/FiO2 ratio, and mortality. However, publication bias and lack of blinding need to be considered. These findings support the need for further rigorous study of this therapy.
Topics: Adult; Aged; Cardiotonic Agents; Dobutamine; Dopamine; Endotoxins; Hemoperfusion; Humans; Middle Aged; Polymyxin B; Sepsis; Survival Rate; Treatment Outcome
PubMed: 17448226
DOI: 10.1186/cc5780 -
The Cochrane Database of Systematic... Jan 2007Low systemic blood flow (SBF) is common in extremely premature infants in the first day after birth and has been associated with peri / intraventricular haemorrhage... (Review)
Review
BACKGROUND
Low systemic blood flow (SBF) is common in extremely premature infants in the first day after birth and has been associated with peri / intraventricular haemorrhage (PIVH), necrotising enterocolitis (NEC), mortality and developmental impairment.
OBJECTIVES
To determine the effect of specific inotropes on morbidity and mortality in preterm infants with low systemic blood flow
SEARCH STRATEGY
Searches were made of The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2006 ), MEDLINE (1966 - April 2006), EMBASE (1980 - April 2006) and CINAHL (1982 - April 2006), supplemented by searches of abstracts of conference proceedings, citations of reviews and expert informants.
SELECTION CRITERIA
Random and quasi-random controlled trials of inotropes enrolling preterm infants with low systemic or organ blood flow in the neonatal period.
DATA COLLECTION AND ANALYSIS
Independent assessment of trial eligibility, quality and data extraction by each review author. Synthesis of data using relative risk (RR) and weighted mean difference (WMD) using standard methods of the Cochrane Collaboration.
MAIN RESULTS
No studies that compared an inotrope to no treatment in preterm infants with low SBF were found. One study (Osborn 2002a) was found that compared dobutamine versus dopamine. The study was of adequate methodology. It enrolled 42 infants < 30 weeks gestation and < 12 hours after birth with low SVC flow. The trial compared the effect of dobutamine versus dopamine titrated 10 to 20 mug/kg/min with the goal of increasing and maintaining SVC flow > 40 ml/kg/min. No significant difference was reported in mortality to discharge (RR 1.41, 95% CI 0.79, 2.52), PIVH (RR 1.01, 95% 0.52, 1.97), grade 3 or 4 PIVH (RR 0.39, 95% CI 0.12, 1.31) or NEC. At three years, there was no significant difference in cerebral palsy, deafness, Developmental quotient > 2 sd below norm or combined disability (RR 0.10, 95% CI 0.01, 1.56). Surviving infants treated with dobutamine had a significantly higher development quotient (MD 35.00, 95% CI 17.68, 52.32). There was no significant difference in death or disability at the latest time reported (RR 0.95, 95% CI 0.66, 1.38). For secondary outcomes, there was no significant difference in periventricular leucomalacia, renal impairment, pulmonary haemorrhage, retinopathy of prematurity or CLD at 36 weeks. There was no significant difference in treatment failure. Dobutamine produced a significantly greater increase in SVC flow at the highest dose reached (MD 13.10, 95% CI 2.87, 23.33), whereas dopamine produced a significantly greater increase in mean BP at 10 and 20 mug/kg/min and at the highest dose reached (MD -7.20, 95% CI -11.41, -2.99).
AUTHORS' CONCLUSIONS
In preterm infants with low systemic blood flow, there is some evidence that dobutamine is better than dopamine at increasing and maintaining systemic blood flow. The only eligible trial did not demonstrate any consistent differences in clinical outcomes. However, this study was not sufficiently powered to prove or disprove effects on clinical outcomes. It is unclear what is the most effective strategy for improving the cardiovascular status of immature infants in the first day. Further trials are needed to determine effective strategies for preventing and improving low systemic and organ blood flow.
Topics: Blood Circulation; Blood Volume; Cardiotonic Agents; Dobutamine; Dopamine; Humans; Infant, Newborn; Infant, Premature; Morbidity; Regional Blood Flow
PubMed: 17253539
DOI: 10.1002/14651858.CD005090.pub2 -
Critical Care (London, England) Jun 2005Many adult patients require temporary inotropic support after cardiac surgery. We reviewed the literature systematically to establish, present and classify the evidence... (Review)
Review
Many adult patients require temporary inotropic support after cardiac surgery. We reviewed the literature systematically to establish, present and classify the evidence regarding choice of inotropic drugs. The available evidence, while limited in quality and scope, supports the following observations; although all beta-agonists can increase cardiac output, the best studied beta-agonist and the one with the most favourable side-effect profile appears to be dobutamine. Dobutamine and phosphodiesterase inhibitors (PDIs) are efficacious inotropic drugs for management of the low cardiac output syndrome. Dobutamine is associated with a greater incidence of tachycardia and tachyarrhythmias, whereas PDIs often require the administration of vasoconstrictors. Other catecholamines have no clear advantages over dobutamine. PDIs increase the likelihood of successful weaning from cardiopulmonary bypass as compared with placebo. There is insufficient evidence that inotropic drugs should be selected for their effects on regional perfusion. PDIs also increase flow through arterial grafts, reduce mean pulmonary artery pressure and improve right heart performance in pulmonary hypertension. Insufficient data exist to allow selection of a specific inotropic agent in preference over another in adult cardiac surgery patients. Multicentre randomized controlled trials focusing on clinical rather than physiological outcomes are needed.
Topics: Cardiac Output, Low; Cardiotonic Agents; Catecholamines; Coronary Artery Bypass; Dobutamine; Humans; Phosphodiesterase Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Ventilator Weaning
PubMed: 15987381
DOI: 10.1186/cc3024 -
Heart (British Cardiac Society) Nov 2003To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery.
DESIGN
Meta-analysis of published reports.
METHODS
Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests.
RESULTS
In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9).
CONCLUSIONS
On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.
Topics: Cardiotonic Agents; Dipyridamole; Dopamine; Echocardiography, Stress; Electrocardiography, Ambulatory; Exercise Test; False Positive Reactions; Heart Diseases; Humans; Intraoperative Complications; Prognosis; Radionuclide Ventriculography; Sensitivity and Specificity; Vascular Diseases; Vasodilator Agents
PubMed: 14594892
DOI: 10.1136/heart.89.11.1327 -
The Cochrane Database of Systematic... 2000Inotropes are widely used in preterm infants to treat systemic hypotension. The most commonly used drugs are dopamine and dobutamine. These agents have different modes... (Review)
Review
BACKGROUND
Inotropes are widely used in preterm infants to treat systemic hypotension. The most commonly used drugs are dopamine and dobutamine. These agents have different modes of action which may result in different haemodynamic effects.
OBJECTIVES
To compare the effectiveness and safety of dopamine and dobutamine in the treatment of systemic hypotension in preterm infants.
SEARCH STRATEGY
The standard search method of the Cochrane Neonatal Review Group was used. Searches of electronic and other databases were performed. Previous reviews were searched for references to relevant trials and leading authors in the field were contacted for information about other published and unpublished studies.
SELECTION CRITERIA
Randomised controlled trials where short and/or long term effects of treatment with dopamine and dobutamine for the treatment of systemic arterial hypotension were compared were selected for this review. Trials studying newborn infants born before 37 completed weeks gestation and less than 28 days of age were eligible for inclusion. Systemic arterial hypotension was not defined specifically, but accepted as defined in individual studies. Studies were not limited by birthweight, lower gestational age threshold or by route or duration of administration of inotropic agents. Study quality and eligibility were assessed independently by each reviewer.
DATA COLLECTION AND ANALYSIS
The standard method of the Cochrane Collaboration described in the Cochrane Collaboration Handbook was used to perform this systematic review. Data extraction was performed independently by each reviewer, with differences being resolved by discussion. The following outcomes were determined: mortality in the neonatal period, long term neurodevelopmental outcome, radiological evidence of severe neurological injury, short term haemodynamic changes and incidence of adverse effects. The effect of interventions is expressed either as Relative Risk (RR), Risk Difference (RD) or as Weighted Mean Difference (WMD) with their 95% Confidence Interval (CI).
MAIN RESULTS
Four trials met the pre-defined criteria for inclusion in this review. There was no evidence of a significant difference between dopamine and dobutamine in terms of neonatal mortality (RD 0.02 95% CI -0.12 to 0.16), incidence of periventricular leukomalacia (RD -0.08, 95% CI -0.19 to 0.04), or severe periventricular haemorrhage (RD -0.02, 95% CI -0.13 to 0.09). Dopamine was more successful than dobutamine in treating systemic hypotension, with fewer infants having treatment failure (RD -0.29, 95% CI -0.42 to -0.17; NNT = 3.5, 95% CI 2.4 to 5.9). There was no evidence of a significant difference in change in left ventricular output when dopamine was compared with dobutamine (WMD -83 ml/kg/min, 95% CI -174 to 8 ml/kg/min). There was no evidence of a significant difference between the two agents with respect to the incidence of tachycardia (RD -0.06, 95% CI -0.25 to 0.14). None of the studies reported the incidence of adverse long term neurodevelopmental outcome.
REVIEWER'S CONCLUSIONS
Dopamine is more effective than dobutamine in the short term treatment of systemic hypotension in preterm infants. There was no evidence of an effect on the incidence of adverse neuroradiological sequelae (severe periventricular haemorrhage and/or periventricular leucomalacia), or on the incidence of tachycardia. However, in the absence of data confirming long term benefit and safety of dopamine compared to dobutamine, no firm recommendations can be made regarding the choice of drug to treat hypotension.
Topics: Cardiotonic Agents; Dobutamine; Dopamine; Humans; Hypotension; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases
PubMed: 10796258
DOI: 10.1002/14651858.CD001242 -
Journal of the American College of... Nov 1997This study evaluated the relative merits of the most frequently used techniques for predicting improvement in regional contractile function after coronary... (Comparative Study)
Comparative Study Meta-Analysis
Accuracy of currently available techniques for prediction of functional recovery after revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease: comparison of pooled data.
OBJECTIVES
This study evaluated the relative merits of the most frequently used techniques for predicting improvement in regional contractile function after coronary revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease.
BACKGROUND
Several techniques have been proposed for predicting improvement in regional contractile function after revascularization, including thallium-201 (Tl-201) stress-redistribution-reinjection, Tl-201 rest-redistribution, fluorine-18 fluorodeoxyglucose with positron emission tomography, technetium-99m sestamibi imaging and low dose dobutamine echocardiography (LDDE).
METHODS
A systematic review of all reports on prediction of functional recovery after revascularization in patients with chronic coronary artery disease (published between 1980 and March 1997) revealed 37 with sufficient details for calculating the sensitivity and specificity of each imaging modality. From the pooled data, 95% and 99% confidence intervals were also calculated.
RESULTS
Sensitivity for predicting regional functional recovery after revascularization was high for all techniques. The specificity of both Tl-201 protocols was significantly lower (p < 0.05) and LDDE significantly higher (p < 0.01) than that of the other techniques.
CONCLUSIONS
Pooled analysis of 37 studies showed that although all techniques accurately identify segments with improved contractile function after revascularization, the Tl-201 protocols may overestimate functional recovery. The evidence available thus far indicates that LDDE appears to have the highest predictive accuracy.
Topics: Chronic Disease; Confidence Intervals; Coronary Disease; Dobutamine; Echocardiography; Female; Humans; Male; Middle Aged; Myocardial Contraction; Myocardial Revascularization; Predictive Value of Tests; Sensitivity and Specificity; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Tomography, Emission-Computed; Tomography, Emission-Computed, Single-Photon; Ventricular Dysfunction, Left
PubMed: 9362401
DOI: 10.1016/s0735-1097(97)00352-5 -
Journal of the American College of... Mar 1996This study evaluated the prognostic value of abnormal test results with pharmacologic stress with regard to perioperative and long-term outcomes in a large population of... (Meta-Analysis)
Meta-Analysis
Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery.
OBJECTIVES
This study evaluated the prognostic value of abnormal test results with pharmacologic stress with regard to perioperative and long-term outcomes in a large population of candidates for vascular surgery.
BACKGROUND
Although numerous studies have demonstrated the prognostic value of dipyridamole-thallium-201 myocardial perfusion and dobutamine echocardiography in vascular surgery candidates, a synopsis of predictive estimates is difficult because of individual study variability in pretest clinical risk, sample size and study design.
METHODS
A systematic review of published reports on preoperative pharmacologic stress risk stratification from the MEDLINE data base (1985 to 1994) identified 10 reports on dipyridamole-thallium-201 myocardial perfusion (1,994 patients) and 5 on dobutamine stress echocardiography (446 patients). Random effects models were used to calculate summary odds ratios and 95% confidence intervals.
RESULTS
Summary odds ratios for death or myocardial infarction and secondary cardiac end points were greater for dobutamine echocardiographic dyssynergy (14- to 27-fold) than for dipyridamole-thallium-201 redistribution (4-fold); wider confidence intervals were noted with dobutamine echocardiography. Pretest coronary disease probability was correlated with the positive predictive value of a reversible thallium-201 defect (r=0.70), increasing sixfold from low to high risk patient subsets. Cardiac event rates were low in patients without a history of coronary artery disease (1% in 176 patients) compared with patients with coronary disease and a normal or fixed-defect pattern (4.8% in 83 patients) and one or more thallium-201 redistribution abnormality (18.6% in 97 patients, p=0.0001).
CONCLUSIONS
Meta-analysis of 15 studies demonstrated that the prognostic value of noninvasive stress imaging abnormalities for perioperative ischemic events is comparable between available techniques but that the accuracy varies with coronary artery disease prevalence.
Topics: Adrenergic beta-Agonists; Aged; Dipyridamole; Dobutamine; Echocardiography; Exercise Test; Female; Heart; Heart Diseases; Humans; Infusions, Intravenous; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Preoperative Care; Prognosis; Radionuclide Imaging; Risk Assessment; Thallium Radioisotopes; Vascular Diseases; Vasodilator Agents
PubMed: 8613604
DOI: 10.1016/0735-1097(95)00549-8