Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review

Am J Emerg Med. 2024 Mar:77:158-163. doi: 10.1016/j.ajem.2023.12.031. Epub 2023 Dec 21.


Purpose: The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support.

Methods: We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock.

Results: The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison.

Conclusion: The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.

Keywords: Cardiac arrest; Catecholamines; Post-resuscitation shock; Return of spontaneous circulation; Vasopressors.

Publication types

  • Meta-Analysis
  • Systematic Review
  • Review

MeSH terms

  • Adult
  • Epinephrine / therapeutic use
  • Heart Arrest* / complications
  • Heart Arrest* / drug therapy
  • Hemodynamics
  • Humans
  • Norepinephrine / therapeutic use
  • Prospective Studies
  • Retrospective Studies
  • Shock* / complications
  • Shock* / drug therapy
  • Shock, Cardiogenic / etiology
  • Vasoconstrictor Agents / therapeutic use


  • Norepinephrine
  • Epinephrine
  • Vasoconstrictor Agents