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International Journal of Cardiology Jan 2017Available pharmacological options for rhythm control strategy in atrial fibrillation (AF) are limited by sub-optimal efficacy and potentially serious adverse events. The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/OBJECTIVES
Available pharmacological options for rhythm control strategy in atrial fibrillation (AF) are limited by sub-optimal efficacy and potentially serious adverse events. The aim of the present meta-analysis is to determine the efficacy and safety of ranolazine for AF management.
METHODS
The present meta-analysis was conducted according to current recommendations (CRD42016039000). Two large medical databases (MEDLINE and Scopus) were systematically searched and from that eight randomized clinical trials and two non-randomized observational studies were identified. The primary endpoint was to determine the efficacy of ranolazine to prevent AF episodes. Secondary efficacy endpoints were: efficacy in converting AF to sinus rhythm, time to conversion, and reduction in AF burden. Safety endpoints included death, serious adverse events, and QTc prolongation.
RESULTS
Ranolazine was found to be effective in reducing the risk of AF when compared to control (OR 0.47; 95% CI 0.29-0.76; p=0.003). Subgroup analysis showed a larger effect size in post-operative AF (OR 0.29; 95% CI 0.11-0.77; p=0.03) when compared to no post-operative AF (OR 0.70; 95% CI 0.54-0.83; p=0.005). Ranolazine increased the chances of successful cardioversion when added to amiodarone over amiodarone alone (OR 3.11; 95% CI 1.42-6.79; p=0.004) while significantly reducing time to conversion (SMD -2.83h; 95% CI -4.69--0.97h; p<0.001). Overall risks of death, adverse events, and QTc prolongation were comparable between ranolazine and control group.
CONCLUSIONS
Ranolazine is an effective option when used for rhythm control strategy in AF. The use of ranolazine seems to be safe and associated with few adverse events.
Topics: Atrial Fibrillation; Cardiovascular Agents; Humans; Ranolazine
PubMed: 27839812
DOI: 10.1016/j.ijcard.2016.11.103 -
Current Cardiology Reviews 2022Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction.
OBJECTIVE
The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery.
METHODS
This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.
RESULTS
Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P<0.00001); 95% CI 0.21-0.52. Magnesium: risk ratio 0.50; I2= 24%; Z=5.08 (P<0.00001); 95% CI 0.39-0.66].
CONCLUSION
All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.
Topics: Cardiac Surgical Procedures; Dexmedetomidine; Humans; Postoperative Complications; Tachycardia, Ectopic Junctional
PubMed: 34082685
DOI: 10.2174/1573403X17666210603113430 -
Europace : European Pacing,... Jun 2020We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF). (Meta-Analysis)
Meta-Analysis
AIMS
We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF).
METHODS AND RESULTS
We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low.
CONCLUSION
For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.
Topics: Amiodarone; Anti-Arrhythmia Agents; Atrial Fibrillation; Bayes Theorem; Electric Countershock; Humans; Network Meta-Analysis; Treatment Outcome
PubMed: 32176779
DOI: 10.1093/europace/euaa024 -
Frontiers in Cardiovascular Medicine 2022Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment...
INTRODUCTION
Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment of refractory ventricular fibrillation (RVF). This review aims to compare the advantages of DSED with standard defibrillation in the treatment of refractory ventricular fibrillation.
MATERIALS AND METHODS
PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to May 1, 2022. Studies included adult patients who developed RVF. The study used random-effects and fixed-effects models for meta-analysis, which was reported by risk ratio (RR) with 95% confidence interval (CI), mean difference (MD), or standardized mean difference (SMD). The risk of bias in individual studies was assessed using the Robins-I tool for observational studies and the Cochrane Risk of Bias 2 (ROB-2) tool for clinical trials. Primary outcomes included the termination of RVF, prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological recovery. Secondary outcomes included age, total defibrillation attempts, emergency medical system arrival time, and dose of epinephrine and amiodarone used.
RESULTS
In this systematic review and meta-analysis, 10 studies containing 1347 patients with available data on treatment outcomes were included. The pooled estimate was (RR 1.03, 95% CI, 0.89 to 1.19; = 0.42, = 0.678 > 0.05) for Termination of RVF, (RR 0.84, 95% CI, 0.63 to 1.11; = 1.23, = 0.219 > 0.05) for ROSC, (RR 0.86, 95% CI, 0.69 to 1.06; = 1.4, = 0.162 > 0.05) for survival to hospital admission, (RR 0.77, 95%CI, 0.52 to 1.15; = 1.26, = 0.206 > 0.05) for survival to hospital discharge, (RR 0.65, 95%CI, 0.35 to 1.22; = 1.33, = 0.184 > 0.05) for good neurologic recovery, (MD -1.01, 95%CI, -3.07 to 1.06; = 0.96, = 0.34 > 0.05) for age, (MD 2.27, 95%CI, 1.80 to 2.73; = 9.50, = 0.001 < 0.05) for total defibrillation attempts, (MD 1.10, 95%CI, -0.45 to 66; = 1.39, = 0.16 > 0.05) for emergency medical system arrival time, (SMD 0.34, 95%CI, 0.17 to 0.50; = 4.04, = 0.001 < 0.05) for epinephrine, and (SMD -0.30, 95%CI, -0.65 to -0.05; = 1.66, = 0.1 > 0.05) for amiodarone.
CONCLUSION
We discovered no differences between DSED and standard defibrillation in termination of RVF, prehospital return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses in patients with RVF. There were some differences in the number of defibrillations and epinephrine doses utilized during resuscitation.
SYSTEMATIC REVIEW REGISTRATION
[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329354], identifier [CRD42022329354].
PubMed: 36505388
DOI: 10.3389/fcvm.2022.1017935 -
European Journal of Clinical... Nov 2022Postoperative atrial fibrillation/flutter (POAF) is one of the most common cardiac complications after lung surgery. We aimed to assess the safety and efficacy of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative atrial fibrillation/flutter (POAF) is one of the most common cardiac complications after lung surgery. We aimed to assess the safety and efficacy of pharmacological interventions for new-onset POAF prophylaxis in patients with lung cancer after lung surgery.
METHODS
PubMed, Embase, Web of Science, Scopus, and the Cochrane Library were searched to identify randomized controlled trials comparing the effects of pharmacological interventions to prevent POAF following lung surgery.
RESULTS
A total number of 19 studies with 2,922 participants were included. Pharmacological interventions significantly reduced the incidence of POAF (odds ratio [OR] 0.36, 95% confidence interval [95% CI] 0.26-0.52) while did not increase the incidence of severe pulmonary complications (OR 1.17, 95% CI 0.57-2.41) after lung surgery compared with placebo/usual care. Among different trials, beta-blockers appeared to be the most effective with an OR of 0.13 (95% CI, 0.07-0.27) and a number needed-to-treat (NNT) of 3.63 and was considered safe with no serious adverse events recorded. The risk of POAF decreased from 25.6 to 11.4% (P < 0.001) overall and from 34.2 to 6.7% (P < 0.001) with beta-blockers as monotherapy. Pharmacological interventions did not reduce the 30-day mortality (OR 0.89, 95% CI 0.43-1.84, I = 0%), but showed a trend toward reducing major cardiovascular complications including myocardial ischemia/infarction, cardiac arrest, heart failure, and stroke (OR 0.41, 95% CI 0.13-1.29, I = 0%).
CONCLUSION
Current clinical evidence supports the effectiveness of pharmacological intervention with beta-blockers, amiodarone, magnesium sulfate, or calcium-channel blockers to reduce the incidence of POAF after lung surgery in patients with lung cancer. In the absence of contraindications, prophylaxis with beta-blockers seems to be the most effective of the treatments studied.
Topics: Adrenergic beta-Antagonists; Amiodarone; Atrial Fibrillation; Calcium; Cardiac Surgical Procedures; Humans; Lung; Lung Neoplasms; Magnesium Sulfate; Myocardial Infarction; Postoperative Complications
PubMed: 36136141
DOI: 10.1007/s00228-022-03383-2 -
Journal of Clinical Pharmacy and... Feb 2018Amiodarone, a commonly used class III antiarrhythmic agent notable for a relatively long half-life of up to 6 months and its pronounced adverse effect profile, is used...
WHAT IS KNOWN AND OBJECTIVE
Amiodarone, a commonly used class III antiarrhythmic agent notable for a relatively long half-life of up to 6 months and its pronounced adverse effect profile, is used for both acute and chronic management of cardiac arrhythmias. Chronic use of amiodarone has been associated with asymptomatic hepatotoxicity; however, acute toxicity is thought to be uncommon. There are only six reported cases of acute liver failure (ALF) secondary to amiodarone. In all these cases the outcome of death during the same hospitalization resulted. We aimed to report the only case of acute liver failure secondary to amiodarone infusion in the existing literature where the patient survived.
CASE SUMMARY
A 79-year-old woman admitted with atrial flutter was being treated with intravenous (IV) amiodarone when she abruptly developed coagulopathy, altered mental status and liver enzyme derangement. She was diagnosed with acute liver failure (ALF) secondary to an amiodarone adverse drug reaction, with a calculated score of seven on the Naranjo adverse drug reaction probability scale. Amiodarone was immediately withheld, and N-acetylcysteine (NAC) was initiated. Clinical improvement was seen within 48 hours of holding the drug and within 24 hours of initiating NAC. On post-hospital follow-up visit she was reported to have complete recovery.
WHAT IS NEW AND CONCLUSION
This report emphasizes the importance of monitoring liver enzymes and mental status while a patient is being administered IV amiodarone. N-acetylcysteine administration may have possibly contributed to the early and successful recovery from ALF in our patient. To date, she is the only patient in the existing literature who has been reported to survive ALF secondary to amiodarone administration.
Topics: Aged; Female; Humans; Amiodarone; Anti-Arrhythmia Agents; Hospitalization; Infusions, Intravenous; Liver Failure, Acute
PubMed: 28714083
DOI: 10.1111/jcpt.12594 -
Pharmacology Research & Perspectives Oct 2022The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade....
The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.
Topics: Acetylcholinesterase; Aged; Antifungal Agents; Antipsychotic Agents; Calcium Channel Blockers; Cholinesterase Inhibitors; Cross-Sectional Studies; Drug-Related Side Effects and Adverse Reactions; Humans; Independent Living; Sodium Potassium Chloride Symporter Inhibitors; Thyroxine
PubMed: 36123967
DOI: 10.1002/prp2.1008 -
The Cochrane Database of Systematic... Jun 2024Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion).
OBJECTIVES
To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption.
MAIN RESULTS
We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled.
AUTHORS' CONCLUSIONS
Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.
Topics: Aged; Humans; Middle Aged; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Bias; Electric Countershock; Network Meta-Analysis; Randomized Controlled Trials as Topic; Tachycardia; Male; Female
PubMed: 38828867
DOI: 10.1002/14651858.CD013255.pub2 -
Journal of Cardiology Jun 2019Amiodarone, which inhibits CYP2C9 and P-glycoprotein, is commonly prescribed with non-vitamin K antagonist oral anticoagulants (NOACs) and polypharmacy in high-risk... (Meta-Analysis)
Meta-Analysis
Non-vitamin K antagonist oral anticoagulants with amiodarone, P-glycoprotein inhibitors, or polypharmacy in patients with atrial fibrillation: Systematic review and meta-analysis.
BACKGROUND
Amiodarone, which inhibits CYP2C9 and P-glycoprotein, is commonly prescribed with non-vitamin K antagonist oral anticoagulants (NOACs) and polypharmacy in high-risk atrial fibrillation (AF) patients. We studied efficacy and safety of NOACs in AF patients receiving amiodarone, P-glycoprotein inhibitor, or polypharmacy.
METHODS
After a systematic database search (Medline, EMBASE, CENTRAL, SCOPUS, and Web of Science), four phase-III randomized trials comparing NOACs and warfarin in "with/without amiodarone," "with/without P-glycoprotein inhibitors," or "with/without multiple (≥5, polypharmacy) concomitant drugs" subgroups were included. The outcomes were pooled using a random-effects model to determine the relative risks (RRs) for stroke/systemic thromboembolism (SSTE), major bleeding (MB), intracranial hemorrhage (ICH), and all-cause mortality.
RESULTS
Among patients taking amiodarone, superiority of NOACs over warfarin in non-amiodarone users disappeared in terms of SSTE (p=0.11), MB (p=0.95), ICH (p=0.26), and mortality (p=0.32). No safety benefit (MB) of NOACs compared to warfarin was shown in patients taking P-glycoprotein inhibitors (p=0.47), but SSTE prevention was still superior with NOACs compared to warfarin in the same patient group [RR=0.78 (0.61-0.99), p=0.04, I=11%]. In AF patients with polypharmacy, NOACs showed a lower risk of SSTE [RR=0.82 (0.71-0.96), p=0.01, I=0%] and mortality [RR=0.91 (0.83-0.99), p=0.04, I=0%], but not MB (p=0.81) compared to warfarin.
CONCLUSIONS
NOACs were equivalent to warfarin among AF patients with concomitant amiodarone use in terms of efficacy, safety, and mortality. There was no safety benefit of NOACs over warfarin in patients using polypharmacy or P-glycoprotein inhibitors.
SYSTEMATIC REVIEW REGISTRATION
The protocol of this meta-analysis was registered on PROSPERO under CRD42018104808 (https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42018104808).
Topics: ATP Binding Cassette Transporter, Subfamily B, Member 1; Administration, Oral; Adult; Aged; Amiodarone; Anticoagulants; Atrial Fibrillation; Clinical Trials, Phase III as Topic; Female; Hemorrhage; Humans; Male; Middle Aged; Polypharmacy; Randomized Controlled Trials as Topic; Stroke; Thromboembolism; Treatment Outcome
PubMed: 30770140
DOI: 10.1016/j.jjcc.2018.12.018 -
Journal of Cardiothoracic Surgery May 2024To evaluate the clinical efficacy and safety of intraoperative intravenous amiodarone for arrhythmia prevention in on-pump coronary artery bypass grafting (CABG)... (Meta-Analysis)
Meta-Analysis Review
The efficacy and safety of intraoperative intravenous amiodarone in patients undergoing on-pump coronary artery bypass grafting surgery: a systemic review and PRISMA-compliant meta-analysis.
BACKGROUND
To evaluate the clinical efficacy and safety of intraoperative intravenous amiodarone for arrhythmia prevention in on-pump coronary artery bypass grafting (CABG) patients.
METHODS
A meta-analysis of randomized controlled trials was conducted. Pubmed, Embase, Cochrane Library, Ovid, China National Knowledge Infrastructure, and the Wan Fang database until July 1th, 2023. The primary outcomes of interest included the incidences of intra- and post-operative atrial fibrillation (POAF), ventricular fibrillation, or any arrhythmia, including atrial fibrillation, ventricular fibrillation, ventricular tachycardia, premature ventricular contraction, and sinus bradycardia. For continuous and dichotomous variables, treatment effects were calculated as the weighted mean difference (WMD)/risk ratio (RR) and 95% confidence interval (CI).
RESULTS
A database search yielded 7 randomized controlled trials including 608 patients, where three studies, including three treatments (amiodarone, lidocaine, and saline), contributed to the clinical outcome of atrial fibrillation, ventricular fibrillation, or any arrhythmia. Meta-analysis demonstrated that amiodarone can significantly reduce the incidence of POAF (RR, 0.39; 95%CI: 0.20, 0.77; P = 0.007, I = 0%) in patients undergoing on-pump CABG; there was no statistically significant influence on intra-operative atrial fibrillation, intra- and post-operative ventricular fibrillation, or any arrhythmia.
CONCLUSIONS
The current study suggests that intraoperative administration of intravenous amiodarone may be safe and effective in preventing POAF in patients undergoing on-pump CABG. More well-designed clinical trials are needed to validate this result.
Topics: Humans; Amiodarone; Coronary Artery Bypass; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Intraoperative Care; Administration, Intravenous; Postoperative Complications; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 38702789
DOI: 10.1186/s13019-024-02732-9