L’effet des inotropes chez les patients atteints d’insuffisance cardiaque avancée : Une méta-analyse d’essais randomisés
DOI :
https://doi.org/10.62438/tunismed.v103i9.6513Mots-clés :
Insuffisance cardiaque avancée, inotropes, dobutamine , lévosimendan , milrinone, méta-analyse , mortalitéRésumé
Introduction : L’insuffisance cardiaque avancée (ICA) demeure associée à une morbidité et une mortalité élevées. Les agents inotropes tels que la dobutamine, le lévosimendan et la milrinone sont utilisés pour améliorer le débit cardiaque, mais leur effet sur la mortalité reste incertain, faute de comparaisons directes.
Objectif : Évaluer l’efficacité des inotropes (dobutamine, lévosimendan, milrinone) par rapport au placebo ou entre eux sur la mortalité chez les patients atteints d’ICA.
Méthodes : Une revue systématique et méta-analyse a été menée selon les recommandations PRISMA et enregistrée sur PROSPERO (CRD42024584389). Les bases de données Scopus, CENTRAL, Google Scholar, PubMed et les registres d’essais cliniques ont été consultés jusqu’en décembre 2024. Ont été inclus les essais contrôlés randomisés (ECR) publiés depuis 2000 chez des adultes (≥18 ans) présentant une ICA avec syndrome cardio-rénal. Les différences de risque (DR) et leurs intervalles de confiance (IC) à 95 % ont été estimées à l’aide d’un modèle à effets aléatoires. L’hétérogénéité (Q, Tau², I²) et le biais de publication (diagramme en entonnoir, méthode trim-and-fill) ont été évalués.
Résultats : Vingt-quatre ECR totalisant 2 862 participants ont été inclus. La DR combinée pour la mortalité était de -0,023 (IC 95 % : -0,046 à 0,000 ; p = 0,055), sans différence significative. Les analyses de sous-groupes (inotropes vs placebo) et les méta-régressions (âge, fraction d’éjection, pression systolique) n’ont pas modifié ces résultats. Une asymétrie du diagramme en entonnoir suggère un biais de publication.
Conclusions : Les inotropes montrent une tendance non significative à la réduction de la mortalité dans l’ICA. L’hétérogénéité des études limite la robustesse des conclusions. Des essais de plus grande envergure sont nécessaires pour identifier les sous-groupes susceptibles d’en bénéficier.
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