Patients with pulmonary hypertension (PH) who developed right ventricular (RV) failure with hypoperfusion had higher survival with milrinone than with dobutamine in a retrospective cohort analysis presented at the ACC.26 conference. The findings also showed a higher rate of atrial and ventricular arrhythmias with milrinone use.
The retrospective cohort study evaluated adult patients with PH who presented with RV failure and evidence of hypoperfusion, defined as lactic acid levels >2 mmol/L, between January 1, 2015, and September 1, 2025. Data were derived from the TriNetX database, which includes records from approximately 115 million patients across five countries. Patients treated with either milrinone or dobutamine were included, while those with left-sided heart failure, newly diagnosed pulmonary embolism, or exposure to both vasoactive agents were excluded.
Among 391 eligible patients, propensity score matching generated two balanced cohorts of 168 patients each. Overall survival at longest follow-up was significantly higher in the milrinone group than the dobutamine group (41.97% vs 22.55%; HR 0.56; 95% CI 0.43-0.73). Mean follow-up duration was 145 days with milrinone and 101 days with dobutamine.
Milrinone use was also associated with a lower likelihood of requiring mechanical ventilation (18.5% vs 28.0%; OR 0.58; 95% CI 0.35-0.98). However, atrial or ventricular arrhythmias occurred more frequently in the milrinone cohort compared with the dobutamine cohort (32.7% vs 19.0%; OR 2.07; 95% CI 1.25-3.42). No significant differences were observed in all-cause readmission rates or the need for additional vasoactive medications.
RV failure remains a leading cause of hospitalization in patients with PH, yet evidence guiding vasoactive therapy selection remains limited. These findings suggest milrinone may be associated with improved survival in this high-risk population. The analysis supports the need for randomized controlled trials to clarify the comparative efficacy and safety of vasoactive therapies in PH-related RV failure.
