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Kamsani SH, Middeldorp ME, Chiang G, Stefil M, Evans S, Nguyen MT, Shahmohamadi E, Zhang JQ, Roberts-Thomson KC, Emami M, Young GD, Sanders P. Safety of outpatient commencement of sotalol. Heart Rhythm O2 2024; 5:341-350. [PMID: 38984365 PMCID: PMC11228273 DOI: 10.1016/j.hroo.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
Background Inpatient monitoring is recommended for sotalol initiation. Objective The purpose of this study was to assess the safety of outpatient sotalol commencement. Methods This is a multicenter, retrospective, observational study of patients initiated on sotalol in an outpatient setting. Serial electrocardiogram monitoring at day 3, day 7, 1 month, and subsequently as clinically indicated was performed. Corrected QT (QTc) interval and clinical events were evaluated. Results Between 2008 and 2023, 880 consecutive patients who were commenced on sotalol were evaluated. Indications were atrial fibrillation/flutter in 87.3% (n = 768), ventricular arrhythmias in 9.9% (n = 87), and other arrhythmias in 2.8% (n = 25). The daily dosage at initiation was 131.0 ± 53.2 mg/d. The QTc interval increased from baseline (431 ± 32 ms) to 444 ± 37 ms (day 3) and 440 ± 33 ms (day 7) after sotalol initiation (P < .001). Within the first week, QTc prolongation led to the discontinuation of sotalol in 4 and dose reduction in 1. No ventricular arrhythmia, syncope, or death was observed during the first week. Dose reduction due to asymptomatic bradycardia occurred in 3 and discontinuation due to dyspnea in 3 within the first week. Overall, 1.1% developed QTc prolongation (>500 ms/>25% from baseline); 4 within 3 days, 1 within 1 week, 4 within 60 days, and 1 after >3 years. Discontinuation of sotalol due to other adverse effects occurred in 41 patients within the first month of therapy. Conclusion Sotalol initiation in an outpatient setting with protocolized follow-up is safe, with no recorded sotalol-related mortality, ventricular arrhythmias, or syncope. There was a low incidence of significant QTc prolongation necessitating discontinuation within the first month of treatment. Importantly, we observed a small incidence of late QT prolongation, highlighting the need for vigilant outpatient surveillance of individuals on sotalol.
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Affiliation(s)
- Suraya H. Kamsani
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- National Heart Institute, Kuala Lumpur, Malaysia
| | - Melissa E. Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glenda Chiang
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
| | - Maria Stefil
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Shaun Evans
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mau T. Nguyen
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Elnaz Shahmohamadi
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica Qingying Zhang
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
| | - Kurt C. Roberts-Thomson
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Glenn D. Young
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Carnevale Miino M, Macsek T, Halešová T, Chorazy T, Hlavínek P. Is the reliability of wastewater-based epidemiology affected by season? Comparative analysis with pharmaceuticals prescriptions. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2024; 31:16426-16436. [PMID: 38316739 DOI: 10.1007/s11356-024-32110-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
Wastewater-based epidemiology (WBE) has been already proposed by several authors for estimating the consumption of drugs, mainly the illicit ones. However, not much information is available about the actual reliability of this tool given the absence of comparison with the actual consumption. This work aims to evaluate the reliability of the WBE as a tool for estimating the consumption of pharmaceuticals in urban area. Measured consumption back-calculated with a WBE approach was compared with prescription of pharmaceutical products as "control." Moreover, seasonal influence on (i) pharmaceutical consumption, (ii) load of pharmaceutical products in the sewer system, and (iii) reliability of WBE was evaluated. Ciprofloxacin, sulfamethoxazole, metoprolol, carbamazepine, and citalopram were estimated by WBE with a difference respect to the "control" value lower than 0.2 order of magnitude while only trimethoprim and sotalol exceeded the 0.5 order of magnitude of difference but below the 1 order of magnitude. Sedatives were the best represented by WBE (on average 0.15 order of magnitude of difference compared to prescription data). However, further studies are suggested to fully estimate the influence of the type of APs on the reliability of the WBE. Seasonal patterns were found for the load of ciprofloxacin in the sewer and for the consumption of sulfamethoxazole and trimethoprim by population but seasonal changes did not have a significant impact (p > 0.05) on the reliability of WBE. Despite some gaps remained to optimize the reliability of the tool, WBE can be considered a valid method to estimate the consumption of prescribed drugs from the analysis of the sewer system.
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Affiliation(s)
- Marco Carnevale Miino
- AdMaS Research Centre, Faculty of Civil Engineering, Brno University of Technology, Purkyňova 651/139, 612 00, Brno, Czech Republic.
- Department of Theoretical and Applied Sciences, University of Insubria, Via J.H. Dunant 3, 21100, Varese, Italy.
| | - Tomáš Macsek
- AdMaS Research Centre, Faculty of Civil Engineering, Brno University of Technology, Purkyňova 651/139, 612 00, Brno, Czech Republic
| | - Taťána Halešová
- AdMaS Research Centre, Faculty of Civil Engineering, Brno University of Technology, Purkyňova 651/139, 612 00, Brno, Czech Republic
- ALS Czech Republic S. R.O, Na Harfě 336/9, 190 00, Prague, Czech Republic
| | - Tomáš Chorazy
- AdMaS Research Centre, Faculty of Civil Engineering, Brno University of Technology, Purkyňova 651/139, 612 00, Brno, Czech Republic
| | - Petr Hlavínek
- AdMaS Research Centre, Faculty of Civil Engineering, Brno University of Technology, Purkyňova 651/139, 612 00, Brno, Czech Republic
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Font CM, Tran CT. Class III Antiarrhythmics and Periprocedural Torsades de Pointes. JACC Case Rep 2023; 23:101998. [PMID: 37954945 PMCID: PMC10635876 DOI: 10.1016/j.jaccas.2023.101998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 11/14/2023]
Abstract
This case series describes 2 women on prolonged therapy with class III antiarrhythmics who developed torsades de pointes polymorphic ventricular tachycardia in the setting of catheter ablation for atrial fibrillation as a result of QTc prolonging factors. Clinicians must exercise increased vigilance in the perioperative period in patients on QTc-prolonging medications. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Cristina M. Font
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Cao T. Tran
- Department of Medicine, Division of Cardiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Lakkireddy D, Ahmed A, Atkins D, Bawa D, Garg J, Bush J, Charate R, Bommana S, Pothineni NVK, Kabra R, Darden D, Koreber S, Tummala R, Vasamreddy C, Park P, Mohanty S, Gopinathannair R, Seo BW, Natale A, Kennedy R. Feasibility and Safety of Intravenous Sotalol Loading in Adult Patients With Atrial Fibrillation (DASH-AF). JACC Clin Electrophysiol 2023; 9:555-564. [PMID: 37014289 DOI: 10.1016/j.jacep.2022.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND Inpatient initiation of sotalol is recommended owing to its proarrhythmic effects. The DASH-AF (Feasibility and Safety of Intravenous Sotalol Administered as a Loading Dose to Initiate Oral Sotalol Therapy in Adult Patients With Atrial Fibrillation) trial evaluates the safety and feasibility of intravenous (IV) sotalol, achieving a steady state with maximum QTc prolongation within 6 hours instead of the traditional 5-dose inpatient oral (PO) titration. METHODS DASH-AF is a prospective, nonrandomized, multicenter, open-label trial consisting of patients who underwent IV sotalol loading dose to initiate rapid oral therapy for atrial arrhythmias. IV dose was calculated based on the target oral dose as indicated by baseline QTc and renal function. Patients' QTc (in sinus) was measured via electrocardiography at 15-minute intervals and after IV loading completion. Patients were discharged 4 hours after first oral dose. All patients were monitored via mobile cardiac outpatient telemetry for 72 hours. The control group was composed of patients admitted for the traditional 5 PO doses. Safety outcomes were assessed in both groups. RESULTS One hundred twenty patients from 3 centers were enrolled from 2021 to 2022 in the IV loading group (compared with type of AF- and renal function-matched patients in the conventional PO loading cohort). This study demonstrated no significant change in ΔQTc in both groups, with a significantly lower number of patients requiring dose adjustment in the IV arm compared with the PO arm (4.1% vs 16.6%; P = 0.003). This led to potential cost savings of up to $3,500.68 per admission. CONCLUSIONS The DASH-AF trial shows that rapid IV sotalol loading in atrial fibrillation/flutter patients for rhythm control is feasible and safe compared with conventional oral loading with significant cost reduction. (Feasibility and Safety of Intravenous Sotalol Administered as a Loading Dose to Initiate Oral Sotalol Therapy in Adult Patients With Atrial Fibrillation [DASH-AF]; NCT04473807).
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Varela DL, Burnham TS, May HT, Bair TL, Steinberg BA, Muhlestein JB, Anderson JL, Knowlton KU, Jared Bunch T. Economics and Outcomes of Sotalol In-Patient Dosing Approaches in Patients with Atrial Fibrillation. J Cardiovasc Electrophysiol 2021; 33:333-342. [PMID: 34953091 PMCID: PMC9305518 DOI: 10.1111/jce.15342] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
Introduction There exists variability in the administration of in‐patient sotalol therapy for symptomatic atrial fibrillation (AF). The impact of this variability on patient in‐hospital and 30‐day posthospitalization costs and outcomes is not known. Also, the cost impact of intravenous sotalol, which can accelerate drug loading to therapeutic levels, is unknown. Methods One hundred and thirty‐three AF patients admitted for oral sotalol initiation at an Intermountain Healthcare Hospital from January 2017 to December 2018 were included. Patient and dosing characteristics were described descriptively and the impact of dosing schedule was correlated with daily hospital costs/clinical outcomes during the index hospitalization and for 30 days. The Centers for Medicare and Medicaid Services reimbursement for 3‐day sotalol initiation is $9263.51. Projections of cost savings were made considering a 1‐day load using intravenous sotalol that costs $2500.00 to administer. Results The average age was 70.3 ± 12.3 years and 60.2% were male with comorbidities of hypertension (83%), diabetes (36%), and coronary artery disease (53%). The mean ejection fraction was 59.9 ± 7.8% and the median corrected QT interval was 453.7 ± 37.6 ms before sotalol dosing. No ventricular arrhythmias developed, but bradycardia (<60 bpm) was observed in 37.6% of patients. The average length of stay was 3.9 ± 4.6 (median: 2.2) days. Postdischarge outcomes and rehospitalization rates stratified by length of stay were similar. The cost per day was estimated at $2931.55 (1. $2931.55, 2. $5863.10, 3. $8794.65, 4. $11 726.20). Conclusions In‐patient oral sotalol dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. In consideration of estimated costs, there is the potential for $871.55 cost savings compared to a 2‐day oral load and $3803.10 compared to a 3‐day oral load.
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Affiliation(s)
- Daniel L Varela
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Tyson S Burnham
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Heidi T May
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Tami L Bair
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Benjamin A Steinberg
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Joseph B Muhlestein
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
| | - Jeffrey L Anderson
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, 5169 Cottonwood, St #520, Murray, UT, USA, 84107
| | - T Jared Bunch
- University of Utah School of Medicine, Cardiology Division, 30 N 1900 E, Room 4A100, Salt Lake City, UT, USA, 84132
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Field ME. Intravenous sotalol-A shortcut to success? J Cardiovasc Electrophysiol 2021; 33:343-344. [PMID: 34951497 DOI: 10.1111/jce.15339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael E Field
- Medical University of South Carolina, Charleston, South Carolina, USA
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Mascarenhas DAN, Mudumbi PC, Kantharia BK. Outpatient Initiation of Sotalol in Patients with Atrial Fibrillation: Utility of Cardiac Implantable Electronic Devices for Therapy Monitoring. Am J Cardiovasc Drugs 2021; 21:693-700. [PMID: 34291437 PMCID: PMC8295005 DOI: 10.1007/s40256-021-00493-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
Background Antiarrhythmic drugs are often used in the management of patients with atrial fibrillation (AF). Sotalol is conventionally initiated in the inpatient setting for monitoring efficacy and adverse effects, including QTc interval prolongation and torsades de pointes (TdP) proarrhythmia. Objective We aimed to evaluate the efficacy and safety of outpatient initiation of sotalol for the treatment of AF in a select group of patients with cardiac implantable electronic devices (CIEDs): permanent pacemakers (PPMs), implantable cardioverter defibrillators (ICDs), and implantable loop recorders (ILRs) capable of continuous rhythm monitoring remotely. Methods We conducted our clinical study in a real-world practice setting with longitudinal follow-up of the study cohort. We included adult patients with symptomatic paroxysmal and persistent AF eligible for sotalol for rhythm control strategy and who had CIEDs in our study. Patients with a known contraindication to sotalol were excluded. After making a shared management decision with patients, sotalol was initiated as an outpatient, with regular clinical encounters with patients to assess the efficacy and safety of treatment, and monitoring cardiac rhythm and QTc intervals with CIEDs utilizing their remote monitoring platforms. Results The study cohort comprised 105 patients; 38 (36%) females, mean age ± standard deviation (SD) 73.9 ± 10.36 years, and with a CHA2DS2-VASc score of 3.26 ± 1.37 and left ventricular ejection fraction of 60.16 ± 9.10%. Twenty-six (24.8%) patients were implanted with PPMs, 10 (9.5%) with dual-chamber ICDs, and 69 (65.7%) with ILRs. Over a follow-up period of 23 ± 15 months, sotalol was continued at a steady median dose of 80 mg twice daily, 105 ± 42 mg (mean ± SD) in 77 (73%) patients who maintained sinus rhythm, and discontinued in 28 (27%) patients because of inefficacy or development of adverse effects. No adverse effects relating to QTc prolongation and TdP or mortality were observed during the study period. Conclusions Effective and safe outpatient initiation and maintenance of sotalol therapy is possible in select patients who have CIEDs for continuous remote monitoring and surveillance capabilities.
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Abstract
Beta adrenergic antagonists and antianginal drugs are used with the aim to ultimately decrease mortality and enable patients to lead an improved quality of life by avoidance of anginal episodes. Each class of medications used for this purpose have a variety of actual or potential side effects associated with their use. Side effects and drug interactions involving these medications are discussed in the following chapter. A special review is included that examines available evidence in the context of the current COVID-19 pandemic. Evidence presented should be used in the context of the patient populations described and may aid clinical decision making through avoidance or identification of actual or potential side effects. This review includes literature published from November 2019 to January 2021.
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network – Toronto General Hospital, Toronto, Canada
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