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deSouza IS, Shrestha P, Allen R, Koos J, Thode H. Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07552-6. [PMID: 38324103 DOI: 10.1007/s10557-024-07552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48 h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department. METHODS We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48 h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4 h and 24 h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s). RESULTS The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4 h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24 h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision. CONCLUSIONS Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4 h; flecainide is definitely among the most effective for cardioversion within 24 h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY, 11203, USA.
| | - Pragati Shrestha
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Robert Allen
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
| | - Jessica Koos
- Health Sciences Library, Stony Brook University, Stony Brook, NY, USA
| | - Henry Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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Ray L, Geier C, DeWitt KM. Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias. Am J Health Syst Pharm 2023; 80:1039-1055. [PMID: 37227130 DOI: 10.1093/ajhp/zxad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias. SUMMARY Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated. CONCLUSION Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.
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Affiliation(s)
- Lance Ray
- Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Curtis Geier
- San Francisco General Hospital, San Francisco, CA, USA
| | - Kyle M DeWitt
- University of Vermont Medical Center, Burlington, VT, USA
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Antiarrhythmic Drug Therapy in the Treatment of Acute and Chronic Atrial Flutter. Card Electrophysiol Clin 2022; 14:533-545. [PMID: 36153132 DOI: 10.1016/j.ccep.2022.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the present article, we will focus on the pharmacologic treatment of atrial flutter aimed either at restoring/maintaining sinus rhythm or controlling the ventricular response during tachyarrhythmia. To provide a comprehensive description we will start discussing the electroanatomic substrate underlying the development of atrial flutter and the complex relationship with atrial fibrillation. We will then describe the available drugs for the treatment of atrial flutter on the bases of their electrophysiological effects and data from available clinical studies. We will conclude by discussing the general principles of rhythm and rate control treatment during atrial flutter.
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Antiarrhythmic Agents: a Review and Comment on Relevance in the Current Era—Part 2. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00944-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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5
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 272] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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Tisdale JE, Chung MK, Campbell KB, Hammadah M, Joglar JA, Leclerc J, Rajagopalan B. Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e214-e233. [PMID: 32929996 DOI: 10.1161/cir.0000000000000905] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many widely used medications may cause or exacerbate a variety of arrhythmias. Numerous antiarrhythmic agents, antimicrobial drugs, psychotropic medications, and methadone, as well as a growing list of drugs from other therapeutic classes (neurological drugs, anticancer agents, and many others), can prolong the QT interval and provoke torsades de pointes. Perhaps less familiar to clinicians is the fact that drugs can also trigger other arrhythmias, including bradyarrhythmias, atrial fibrillation/atrial flutter, atrial tachycardia, atrioventricular nodal reentrant tachycardia, monomorphic ventricular tachycardia, and Brugada syndrome. Some drug-induced arrhythmias (bradyarrhythmias, atrial tachycardia, atrioventricular node reentrant tachycardia) are significant predominantly because of their symptoms; others (monomorphic ventricular tachycardia, Brugada syndrome, torsades de pointes) may result in serious consequences, including sudden cardiac death. Mechanisms of arrhythmias are well known for some medications but, in other instances, remain poorly understood. For some drug-induced arrhythmias, particularly torsades de pointes, risk factors are well defined. Modification of risk factors, when possible, is important for prevention and risk reduction. In patients with nonmodifiable risk factors who require a potentially arrhythmia-inducing drug, enhanced electrocardiographic and other monitoring strategies may be beneficial for early detection and treatment. Management of drug-induced arrhythmias includes discontinuation of the offending medication and following treatment guidelines for the specific arrhythmia. In overdose situations, targeted detoxification strategies may be needed. Awareness of drugs that may cause arrhythmias and knowledge of distinct arrhythmias that may be drug-induced are essential for clinicians. Consideration of the possibility that a patient's arrythmia could be drug-induced is important.
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Malviya A, Kapoor M, Sivam RKN, Khan SA, Pandey R, Kumar U, Ete T, Mishra A. Ibutilide with magnesium for conversion of atrial fibrillation or flutter in rheumatic heart disease patients: Ibutilide with magnesium for chemical cardioversion of atrial fibrillation or flutter. Indian Heart J 2020; 72:283-288. [PMID: 32861384 PMCID: PMC7474117 DOI: 10.1016/j.ihj.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/15/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Data on adjunctive use of magnesium with ibutilide for conversion of persistent rheumatic atrial fibrillation and flutter to sinus rhythm is lacking. Aim We aimed to study the efficacy of adjunctive supplementation of intravenous magnesium with ibutilide for conversion of persistent rheumatic atrial fibrillation and flutter to sinus rhythm and to define a definite level of serum magnesium which leads to significant increase in rates of such conversion. Methods and results This was a prospective study including 33 Rheumatic heart disease patients (13 males and 20 females) with mean age of 49.27 ± 11.4 years and persistent AF or AFl. All patients received intravenous magnesium to raise serum magnesium level in range of 4 mg/dl to 4.5 mg/dl prior to administration of Ibutilide. 25 out of 33 (76%) patients converted to sinus rhythm. Upon univariate analysis, presence of background beta blocker therapy, serum potassium and magnesium at time of Ibutilide injection were found to have significant relation with conversion to sinus rhythm. Upon multivariate analysis serum magnesium level at the time of Ibutilide injection was found to have significant contribution on post injection rhythm reversal (p-value = 0.006). The level of magnesium at 3.8 mg/dl was found to have maximum sensitivity of 96% and specificity of 62.5% for conversion to sinus rhythm by ibutilide with magnesium (p-value< 0.05). Conclusions Ibutilide is highly effective in cardioversion of persistent rheumatic atrial fibrillation/flutter patients. Raising Serum Magnesium levels above 3.8 mg/dl significantly improves efficacy of ibutilide.
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Affiliation(s)
- Amit Malviya
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Manish Kapoor
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Rondeep Kumar Nath Sivam
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Shakeel Ahamad Khan
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Ruchi Pandey
- Department of Community Medicine, Al-Falah School of Medical Science & Research Centre, Dhauj, Faridabad, Haryana, India
| | - Utpal Kumar
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Tony Ete
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| | - Animesh Mishra
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India.
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8
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Le DD, Levis JT, Lugovskaya N, Vinson DR. ECG Diagnosis: Ibutilide-induced Torsade de Pointes. Perm J 2019; 23:18-187. [PMID: 30939273 DOI: 10.7812/tpp/18-187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Daphne D Le
- Department of Molecular & Environmental Biology, University of California, Berkeley
| | - Joel T Levis
- Department of Emergency Medicine, Santa Clara Medical Center, CA.,Department of Emergency Medicine (Surgery), Stanford University, CA.,Foothill College Paramedic Program, Los Altos, CA
| | | | - David R Vinson
- Department of Emergency Medicine, Sacramento Medical Center, CA.,CREST (Clinical Research on Emergency Services and Treatment) Network, Sacramento, CA.,Division of Research, Oakland, CA.,Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento
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Modeling of Amiodarone Effect on Heart Rate Control in Critically Ill Patients with Atrial Tachyarrhythmias. Clin Pharmacokinet 2017; 55:991-1002. [PMID: 26946135 DOI: 10.1007/s40262-016-0372-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIMS Amiodarone is the gold-standard medication to control heart rate in critically ill patients with atrial tachyarrhythmias (ATs); however, effective doses and covariates influencing its efficacy remain unknown. We therefore performed pharmacodynamic modeling of heart rate reduction induced by amiodarone in these patients. METHODS AND RESULTS This observational study included 80 consecutive severely ill patients receiving amiodarone to treat ATs. A total of 1348 time-heart rate observations with 361 amiodarone dose administrations were analyzed during a period of up to 6 days after hospital treatment initiation using a nonlinear mixed-effect model. Pretreatment with amiodarone before intensive care administration, paroxysmal versus persistent AT, catecholamine infusion, and fluid and magnesium loading were among the covariates assessed in the model. In case of paroxysmal AT in a patient not pretreated with amiodarone, a 300 mg intravenous loading dose combined with an 800 mg oral dose on the first day, followed by 800 mg/day orally for 4 days was effective in achieving a heart rate between 80 and 115 bpm within the first day, and to maintain it during the next 4 days. Corresponding doses were twice as high in patients with persistent AT. Use of intravenous magnesium (p < 0.02) and fluid loading (p < 0.02) was associated with an earlier and greater heart rate decrease, while use of dobutamine had an opposite influence (p < 0.05). CONCLUSIONS In critically ill patients with AT, the dose of amiodarone required to control heart rate is influenced by the type of AT and by other easily measurable conditions which may allow better individualization of amiodarone dosing.
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Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department. Ann Emerg Med 2017; 71:96-108.e2. [PMID: 28969929 DOI: 10.1016/j.annemergmed.2017.07.481] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/22/2017] [Accepted: 07/21/2017] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success. METHODS Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion. RESULTS Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (>480 ms) in 29.4% of patients, and 3.1% were hypokalemic (<3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion. CONCLUSION The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.
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Abstract
Atrial fibrillation (AF) is the most frequently encountered arrhythmia. Prevalence increases with advancing age and so as its associated comorbidities, like heart failure. Choice of pharmacologic therapy depends on whether the goal of treatment is maintaining sinus rhythm or tolerating AF with adequate control of ventricular rates. Antiarrhythmic therapy and conversion of AF into sinus rhythm comes with the side effect profile, and we should select best antiarrhythmic therapy, individualized to the patient. New antiarrhythmic drugs are being tested in clinical trials. Drugs that target remodeling and inflammation are being tested for their use as prevention of AF or as upstream therapy.
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Affiliation(s)
- Muhammad Rizwan Sardar
- Department of Cardiology, Cooper University Hospital, 3rd Floor Dorrance, One Cooper Plaza, Camden, NJ 08103, USA; Lankenau Institute for Medical Research (LIMR), Wynnewood, PA 19096, USA; Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Wajeeha Saeed
- Albert Einstein College of Medicine, Bronx Lebanon Hospital Center, Bronx, NY 10457, USA
| | - Peter R Kowey
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA; Lankenau Institute for Medical Research (LIMR), Lankenau Medical Center, Wynnewood, PA 19096, USA
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Baker WL. Treating arrhythmias with adjunctive magnesium: identifying future research directions. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2016:pvw028. [DOI: 10.1093/ehjcvp/pvw028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199-267. [PMID: 24682347 PMCID: PMC4676081 DOI: 10.1161/cir.0000000000000041] [Citation(s) in RCA: 900] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.03.021] [Citation(s) in RCA: 508] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zamani P, Verdino RJ. Management of Atrial Fibrillation. J Intensive Care Med 2014; 30:484-98. [PMID: 24828991 DOI: 10.1177/0885066614534603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/03/2014] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation remains the most prevalent cardiac arrhythmia, and its incidence is increasing as the population ages. Common conditions associated with an increased incidence include advanced age, hypertension, heart failure, and valvular heart disease. Patients with atrial fibrillation may complain of palpitations, fatigue, and decreased exercise tolerance or may be completely asymptomatic. Options for treating patients who experience atrial fibrillation include rate-controlling drugs such as digoxin, β-blockers, and calcium channel blockers or a rhythm-controlling strategy with agents such as sodium channel blockers and potassium channel blockers. Atrial fibrillation increases the risk of stroke due to atrial thrombus formation and embolization. Anticoagulation with the vitamin K antagonist, warfarin, remains the most widely prescribed treatment option to decrease stroke risk. Several other antithrombotic agents have recently become available and offer excellent alternatives to warfarin. Catheter ablation can be undertaken as a nonpharmacologic rhythm control option with varying degrees of success depending on duration of atrial fibrillation and follow-up time from the procedure. This review article further describes the management options for patients presenting with atrial fibrillation.
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Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ralph J Verdino
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Abu-El-Haija B, Giudici MC. Predictors of long-term maintenance of normal sinus rhythm after successful electrical cardioversion. Clin Cardiol 2014; 37:381-5. [PMID: 24700327 DOI: 10.1002/clc.22276] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/25/2014] [Indexed: 11/05/2022] Open
Abstract
Electrical cardioversion (EC) for atrial fibrillation (AF) is a common procedure performed in an attempt to restore normal sinus rhythm (NSR). Many factors predict long-term maintenance of NSR and the risk of AF recurrence. The duration of AF, cardiac size and function, rheumatic heart disease, significant mitral valve disease, left atrial enlargement, and older age are among the most common recognized factors. A number of interventions can potentially decrease the AF recurrence rate. Identifying and treating reversible causes and the use of antiarrhythmic medications in certain situations can help decrease the risk of AF recurrence. The role of the newer anticoagulants is expanding, and wider application is expected in the near future. We hope that this summary will serve as a guide to physicians and healthcare providers to address the question of who should undergo cardioversion, as there are patients who are most likely to benefit from this procedure and others that will revert back into AF within a short period. To identify who would benefit most from EC and have a reasonable chance of long-term maintenance of NSR, a thorough evaluation of each individual patient should be performed to tailor the best therapy to each individual.
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Affiliation(s)
- Basil Abu-El-Haija
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76. [PMID: 24685669 DOI: 10.1016/j.jacc.2014.03.022] [Citation(s) in RCA: 2832] [Impact Index Per Article: 283.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071-104. [PMID: 24682348 DOI: 10.1161/cir.0000000000000040] [Citation(s) in RCA: 1523] [Impact Index Per Article: 152.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Management of late arrhythmias in adults with repaired congenital heart disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:615-31. [PMID: 23775510 DOI: 10.1007/s11936-013-0254-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OPINION STATEMENT As survival of patients with congenital heart disease improves with surgery and the population of patients with repaired adult congenital heart disease (ACHD) age, understanding complications such as arrhythmias has become more important. Arrhythmias account for significant morbidity and mortality in the ACHD population. Atrial arrhythmias occur in 15 % of patients with ACHD and, in patients with severe congenital heart disease (CHD), more than 50 % develop atrial arrhythmias by the age of 65 years [1]. This article aims to give an overview of arrhythmias seen in the ACHD population and the treatment modalities available now.
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Ganga HV, Noyes A, White CM, Kluger J. Magnesium adjunctive therapy in atrial arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1308-18. [PMID: 23731344 DOI: 10.1111/pace.12189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/02/2013] [Accepted: 04/10/2013] [Indexed: 11/30/2022]
Abstract
Magnesium (Mg) is an important intracellular ion with cardiac metabolism and electrophysiologic properties. A large percentage of patients with arrhythmias have an intracellular Mg deficiency, which is out of line with serum Mg concentrations, and this may explain the rationale for Mg's benefits as an atrial antiarrhythmic agent. A current limitation of antiarrhythmic therapy is that the potential for cardiac risk offsets some of the benefits of therapy. Mg enhances the balance of benefits to harms by enhancing atrial antiarrhythmic efficacy and reducing antiarrhythmic proarrhythmia potential as well as providing direct antiarrhythmic efficacy when used as monotherapy in patients undergoing cardiothoracic surgery.
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Affiliation(s)
- Harsha V Ganga
- The Henry Low Heart Center, Hartford Hospital, Hartford, Connecticut
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Prasad D, Snyder C, Ashwath R. Ibutilide therapy in the conversion of atrial flutter in neonates. Heart Rhythm 2013; 10:1231-3. [PMID: 23624161 DOI: 10.1016/j.hrthm.2013.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Deepa Prasad
- Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio 44106, USA
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Abstract
INTRODUCTION Atrial fibrillation (AF) is associated with increased mortality and morbidity. Although stroke prevention is the only way to improve prognosis, antiarrhythmic drugs (AADs) are of primary importance both in the conversion to sinus rhythm and in the long-term control of rhythm and rate. AREAS COVERED We searched the Cochrane Library and Medline Database for articles published in English concerning efficacy and safety of AADs in AF. Particular attention was paid to the recently published European Society of Cardiology guidelines. This review provides an overview of the currently available drugs used in AF, with a particular emphasis on their comparative efficacy and safety in different kind of patients. Recent important findings, and advantages and disadvantages of recently approved drugs such as vernakalant and dronedarone, are also discussed. EXPERT OPINION AADs remain fundamental in the acute and long-term management of AF, to control symptoms and to reduce the negative impact of the arrhythmia on QoL. The choice of a rate- over rhythm-control strategy should be individualized and based on accurate evaluation of patient medical history and symptoms. New agents will contribute to improve treatment efficacy together with the guarantee of better safety profiles.
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Affiliation(s)
- Alessandro Marinelli
- Clinica di Cardiologia , Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Italy.
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