Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction

Background Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. Methods We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. Results We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require pre-intubation vasoactive medication and mechanical circulatory support (both, P<0.05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3 vs. 36.1%, P=0.01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% Confidence interval: -7.6% to -1.8%, P=0.002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P<0.001). Conclusions Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.