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BMJ Open Oct 2020Postoperative atrial fibrillation (POAF) is a potentially lethal and morbid complication after open heart surgery. This systematic review and meta-analysis aimed to... (Meta-Analysis)
Meta-Analysis
PURPOSE
Postoperative atrial fibrillation (POAF) is a potentially lethal and morbid complication after open heart surgery. This systematic review and meta-analysis aimed to investigate metoprolol compared with other treatments for prophylaxis against POAF.
METHODS
We searched CENTRAL, MEDLINE, EMBASE and trial registries for randomised controlled trials that evaluated metoprolol for preventing the occurrence of POAF after surgery against other treatments or placebo. Random-effects model was used for estimating the risk ratios (RRs) and mean differences with 95% CIs.
RESULTS
Nine trials involving 1570 patients showed metoprolol reduced POAF compared with placebo (416 patients; RR 0.46, 95% CI 0.33 to 0.66; I²=21%; risk difference (RD) -0.19, 95% CI -0.28 to -0.10). However, metoprolol increased the risk of POAF compared with carvedilol (159 patients; RR 1.59, 95% CI 1.20 to 2.12; I²=4%; RD 0.13, 95% CI 0.06 to 0.20). There was no difference when compared with sotalol or amiodarone. The occurrence of cardiovascular conditions after drugs administration or death between the groups was not different. The overall quality of evidence was moderate to high. Subgroup analysis and funnel plot were not performed.
CONCLUSIONS
Metoprolol is effective in preventing POAF compared with placebo and showed no difference with class III antiarrhythmic drugs. Death and thromboembolism are associated with open heart surgery, but not significant in relation to the use of metoprolol.
PROSPERO REGISTRATION NUMBER
CRD42019131585.
Topics: Amiodarone; Anti-Arrhythmia Agents; Atrial Fibrillation; Cardiac Surgical Procedures; Humans; Metoprolol; Postoperative Complications
PubMed: 33130564
DOI: 10.1136/bmjopen-2020-038364 -
The American Journal of Emergency... Oct 2020Although available studies have not demonstrated that antiarrhythmic drugs could increase long-term survival or survival with favorable neurological outcome, some... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Although available studies have not demonstrated that antiarrhythmic drugs could increase long-term survival or survival with favorable neurological outcome, some studies have shown that the rate of hospital admission is higher with amiodarone or lidocaine than with placebo. To study the effects of antiarrhythmic drugs during cardiac arrest, a meta-analysis was conducted to assess the efficacy of amiodarone and/or lidocaine.
METHODS
We searched studies from inception until Jan 21, 2020. The primary endpoint was survival to hospital discharge in cardiac arrest, and the secondary endpoints were survival to hospital admission/24 h and favorable neurological outcome.
RESULTS
A total of 9 studies were included. In head-to-head studies, amiodarone (odds ratio [OR] 2.96, 95% credible interval [CrI] 1.02-8.53) and lidocaine (OR 3.12, 95% CrI 1.08-9.98) had superior effects on survival to hospital admission/24 h compared to the combination of the two drugs. In terms of survival to hospital discharge, amiodarone (OR 1.18, 95% CrI 1.03-1.35) and lidocaine (OR 1.22, 95% CrI 1.06-1.41) were more effective than placebo. Amiodarone (OR 1.20, 95% CrI 1.02-1.41) was significantly better than placebo in favorable neurological outcome. However, there was no significant difference in other pairwise comparisons. The surface under cumulative ranking curve (SUCRA) revealed that lidocaine was the most effective therapy for survival to hospital admission (84.1%) and discharge (88.4%), while amiodarone was associated with a more favorable neurological outcome (88.2%).
CONCLUSIONS
Lidocaine had the best effect on both survival to hospital admission and discharge, while amiodarone was associated with a more favorable neurological outcome.
TRIAL REGISTRATION
This study is registered with PROSPERO, number CRD42020171049.
Topics: Amiodarone; Anti-Arrhythmia Agents; Bayes Theorem; Heart Arrest; Humans; Lidocaine; Network Meta-Analysis; Survival Analysis
PubMed: 33071078
DOI: 10.1016/j.ajem.2020.06.074 -
Optometry and Vision Science : Official... Jul 2020Amiodarone is an excellent antiarrhythmic medication; however, it has numerous systemic and ocular adverse effects. (Meta-Analysis)
Meta-Analysis
SIGNIFICANCE
Amiodarone is an excellent antiarrhythmic medication; however, it has numerous systemic and ocular adverse effects.
PURPOSE
We aimed to improve our understanding of amiodarone and its ocular adverse effects by performing a systematic review and meta-analysis of published case reports.
METHODS
This systematic review was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We used the MEDLINE database, primarily through PubMed, and used keywords (amiodarone, eye, eye diseases, visual/ocular adverse effects/manifestations) to identify case reports of ocular adverse effects after amiodarone use. The initial search resulted in 92 total case reports. However, after excluding nonrelevant case reports, 25 cases were selected for the final analysis.
RESULTS
Among the patients in the 25 case reports, 18 were male (72%), and the median age was 66 ± 9.9 years. In 15 cases (60%), the patients reported halos around light and/or decrease in vision after amiodarone use. The most common ophthalmic examination findings were cornea verticillata/vortex keratopathy in 19 cases (76%), followed by different patterns of papilledema and retinal hemorrhages in 5 cases (20%). Discontinuation of amiodarone was the most common intervention, followed by application of topical heparin. Outcomes among case reports were variable.
CONCLUSIONS
Cornea verticillata/vortex keratopathy was the most common ocular adverse effect in cases where amiodarone was administered. Early recognition of amiodarone-induced ocular adverse effects is imperative to prevent worsening keratopathy or uncommon adverse effects. Collaboration between physicians prescribing amiodarone-to recognize the ocular symptoms-and referral to eye care physicians are important.
Topics: Aged; Aged, 80 and over; Amiodarone; Anti-Arrhythmia Agents; Case-Control Studies; Corneal Diseases; Drug-Related Side Effects and Adverse Reactions; Female; Humans; Male; Middle Aged; Papilledema; Retinal Hemorrhage; Vision Disorders
PubMed: 32697562
DOI: 10.1097/OPX.0000000000001534 -
Kardiologia Polska Oct 2020Appropriate pharmacotherapy during advanced resuscitation procedures may affect the return of spontaneous circulation. Current guidelines on cardiopulmonary... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Appropriate pharmacotherapy during advanced resuscitation procedures may affect the return of spontaneous circulation. Current guidelines on cardiopulmonary resuscitation recommend amiodarone for shock‑refractory cardiac arrest or when lidocaine is not available.
AIMS
The aim of this study was to systematically analyze the available literature and to conduct a meta‑‑analysis to determine the effect of amiodarone and lidocaine on survival and neurological outcome after shock‑refractory cardiac arrest.
METHODS
PubMed, Scopus, Embase, Web of Science, and Cochrane Library databases were searched. Two independent reviewers screened randomized and quasi‑randomized controlled trials as well as cohort and cross‑sectional trials evaluating amiodarone or lidocaine for the treatment of adults with cardiac arrest.
RESULTS
After screening 682 unique references, 8 were selected for this meta‑analysis. A higher number of cases with return of spontaneous circulation was observed in the amiodarone group compared with the lidocaine group (OR, 1.03; 95% CI, 0.87-1.21; P = 0.75). A similar relationship was observed for survival to hospital discharge (OR, 1.12; 95% CI, 0.92-1.38; P = 0.26), as well as survival with favorable neurological outcome (OR, 1.11; 95% CI, 0.89-1.39; P = 0.35).
CONCLUSIONS
We found no statistically significant survival benefit of resuscitation with amiodarone compared with lidocaine. Future randomized controlled trials are needed to identify which antiarrhythmic drug should be use in shock‑refractory cardiac arrest.
Topics: Amiodarone; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Cross-Sectional Studies; Humans; Lidocaine; Out-of-Hospital Cardiac Arrest
PubMed: 32627999
DOI: 10.33963/KP.15483 -
The Journal of Innovations in Cardiac... Apr 2020Amiodarone is commonly used for a variety of arrhythmias and, in some parts of the world, is the only available antiarrhythmic drug (AAD). Yet, amiodarone is known to...
Amiodarone is commonly used for a variety of arrhythmias and, in some parts of the world, is the only available antiarrhythmic drug (AAD). Yet, amiodarone is known to have a wide range of potential side effects, many of which are dose- and duration-dependent. We sought to study the incidence of side effects leading to the discontinuation of low-dose amiodarone, arbitrarily defined as 200 mg/day or less, and very-low-dose amiodarone, defined as 100 mg/day or less. In this study, literature databases were searched through June 2019. Studies that reported the incidence or prevalence of side effects of amiodarone were included. Effect estimates from individual studies were extracted and combined using the random-effects generic inverse variance method of DerSimonian and Laird. A total of 10 observational cohort studies involving 901 patients were included in the analysis. The pooled estimated incidence of overall side effects for low-dose amiodarone was 0.17 [95% confidence interval (CI): 0.12-0.22]. In addition, the pooled estimated incidence of side effects requiring medication discontinuation was 0.06 (95% CI: 0.03-0.11). As compared with 200 mg/day of amiodarone, the pooled estimated incidence of overall side effects was 0.11 (95% CI: 0.04-0.27), while the incidence of side effects requiring medication discontinuation was 0.02 (95% CI: 0.01-0.06) for the dose of 100 mg/day. In conclusion, very-low-dose amiodarone displays a low incidence of significant side effects requiring medication discontinuation.
PubMed: 32368381
DOI: 10.19102/icrm.2020.110403 -
Journal of Cardiovascular Pharmacology Jul 2020Vernakalant is a novel, relatively atrial-selective antiarrhythmic agent. Despite its good efficacy profile and rapid onset of action, there was still controversial... (Meta-Analysis)
Meta-Analysis
Vernakalant is a novel, relatively atrial-selective antiarrhythmic agent. Despite its good efficacy profile and rapid onset of action, there was still controversial evidence regarding vernakalant-related adverse events. We searched PubMed and Embase for studies that compared intravenous vernakalant with placebo or antiarrhythmic agents in patients with recent-onset atrial fibrillation (AF) lasting no more than 7 days. Efficacy and safety outcomes were the treatment-induced cardioversion rate within 90 minutes and adverse events after first exposure to study drug respectively. Nine randomized controlled trials enrolling 1296 patients were analyzed. Quantitative synthesis showed that vernakalant was superior to placebo for cardioversion of recent-onset AF within 90 minutes [49.7% vs. 6.2%, risk ratio (RR) 8.13, 95% confidence interval (CI) 5.35-12.36, P < 0.00001], and it did not achieve statistical significance in cardioversion when vernakalant was compared with ibutilide (62.4% vs. 47.3%, RR 1.32, 95% CI 1.00-1.73, P = 0.05). As for safety assessment, no significant differences were found in occurring serious adverse events (9.9% vs. 10.4%, RR 0.91, 95% CI 0.67-1.25, P = 0.57) and hypotension (5.3% vs. 3.3%, RR 1.53, 95% CI 0.86-2.73, P = 0.15) between vernakalant and comparator (either placebo, ibutilide, or amiodarone). There were trends that patients receiving vernakalant experienced more drug discontinuation (2.5% vs. 1.0%, RR 2.21, 95% CI 0.96-5.11, P = 0.06) and less any ventricular tachycardia (6.1% vs. 8.1%, RR 0.70, 95% CI 0.49-1.00, P = 0.05) than those receiving comparator, but the differences were not statistically significant. Furthermore, vernakalant was associated with a higher risk of bradycardia in comparison with comparator (6.3% vs. 1.1%, RR 4.04, 95% CI 1.67-9.75, P = 0.002). Vernakalant is effective in converting recent-onset AF to sinus rhythm rapidly, while significantly more bradycardia events are related to vernakalant in our meta-analysis.
Topics: Anisoles; Anti-Arrhythmia Agents; Atrial Fibrillation; Bradycardia; Heart Rate; Humans; Injections, Intravenous; Pyrrolidines; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 32251022
DOI: 10.1097/FJC.0000000000000832 -
BMJ Open Mar 2020The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.
OBJECTIVES
The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.
PARTICIPANTS
Critically ill adult patients who developed NOAF during admission.
PRIMARY AND SECONDARY OUTCOMES
Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.
METHODS
We searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale.
RESULTS
Of 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies).
CONCLUSION
The reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.
Topics: Adrenergic beta-Antagonists; Adult; Amiodarone; Atrial Fibrillation; Calcium Channel Blockers; Critical Illness; Humans; Magnesium; Stroke
PubMed: 32209631
DOI: 10.1136/bmjopen-2019-034774 -
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 -
European Heart Journal. Cardiovascular... Sep 2021To compare flecainide and dronedarone for sinus rhythm (SR) maintenance following electrocardioversion of persistent atrial fibrillation (AF), in patients with minimal... (Meta-Analysis)
Meta-Analysis
Comparison of dronedarone vs. flecainide in the maintenance of sinus rhythm, following electrocardioversion in adults with persistent atrial fibrillation: a systematic review and meta-analysis.
AIMS
To compare flecainide and dronedarone for sinus rhythm (SR) maintenance following electrocardioversion of persistent atrial fibrillation (AF), in patients with minimal or no structural heart disease.
METHODS AND RESULTS
A systematic search of publications using EMBASE, CENTRAL, CINAHL, and MEDLINE (1989-2019), identified a total of 595 articles. No limitations were applied. Nine articles met the inclusion criteria [five randomized controlled trials (RCTs) and four cohort studies], encompassing 1349 persistent AF candidates. Two retrospective studies compared flecainide with dronedarone, indicating a 6% reduced risk of AF recurrence with flecainide; however, results were not statistically significant [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71-1.24; P = 0.66]. One RCT compared dronedarone to placebo, demonstrating a 28% reduced risk of AF recurrence at 6 months (RR 0.72, 95% CI 0.58-0.90; P = 0.004). Two RCTs compare flecainide to placebo, when a 16% decreased risk of AF recurrence at 6-12 months was indicated; however, these results were not statistically significant (RR 0.84, 95% CI 0.66-1.07; P = 0.16). Within a 6- to 12-month follow-up period, a combined recurrence rate of AF was examined, in which flecainide and dronedarone maintained SR in 50% and 42%, respectively. Four articles satisfied quality appraisal, one of which focused on flecainide data.
CONCLUSION
Dronedarone and flecainide displayed similar efficacy in maintaining SR in patients following electrocardioversion for persistent AF. The SR maintenance was numerically but not statistically significant in the flecainide group. Side effects uncovered similar pro-arrhythmic activity. However, in light of the deficiency of volume and quality of available evidence, the writer acknowledges the requirement for future research.
Topics: Adult; Anti-Arrhythmia Agents; Atrial Fibrillation; Cohort Studies; Dronedarone; Flecainide; Humans
PubMed: 32163173
DOI: 10.1093/ehjcvp/pvaa018 -
American Journal of Clinical Dermatology Apr 2020Idiopathic intracranial hypertension (IIH) is a condition with increased intracranial pressure of unknown etiology. Its presenting symptoms include persistent headache,...
BACKGROUND
Idiopathic intracranial hypertension (IIH) is a condition with increased intracranial pressure of unknown etiology. Its presenting symptoms include persistent headache, pulsatile tinnitus, and visual obscuration. It tends to occur in obese women of childbearing age, and its greatest risk is irreversible loss of vision. Some of the commonly used medications in dermatology, especially those for acne vulgaris, have been associated with IIH. However, the creation of specific risk categories for drugs as a guide for clinicians has never been performed.
OBJECTIVE
The aim of this study was to critically assess all published cases of IIH and identify high-risk drugs associated with drug-induced intracranial hypertension (DIIH), to assist dermatologists and other physicians with patient education and monitoring of symptoms of secondary intracranial hypertension.
METHODS
MEDLINE, EMBASE, and Cochrane Review Databases were searched for all cases of IIH thought to be drug-related between January 1900 and June 2019. A total of 5117 articles were identified, and 235 articles were found to be relevant. All cases were assessed to satisfy the modified Dandy criteria for diagnosis of IIH, and the likelihood of each case being a 'definite' adverse drug reaction (ADR) was determined using the Koh algorithm for ADR. An association category (from weakly associated [Category I] to strongly associated [Category V]) was assigned based on the number of cases meeting these two criteria.
RESULTS
There were 259 verifiable cases of DIIH. Vitamin A derivatives, tetracycline-class antibiotics, recombinant growth hormone, and lithium were found to be most strongly associated with DIIH (Categories IV and V). Corticosteroids were moderately associated with DIIH (Category III). Drugs that were weakly associated with DIIH (Categories I and II) include cyclosporine, progestin-only contraceptives, combined oral contraceptives, second- and third-generation fluoroquinolones, sulfenazone, gonadotropin-releasing hormones and luteinizing hormone-releasing hormone agonist, nalidixic acid, amiodarone, stanozolol, danazol, divalproic acid, sulfasalazine, ketoconazole, and ustekinumab.
CONCLUSION
We suggest using the term 'drug-induced intracranial hypertension' (DIIH) and propose a set of diagnostic criteria for DIIH. Our review attempts to identify DIIH-associated drugs based on a strict diagnostic and drug-causality algorithm, then stratify them into appropriate risks categories. This may ultimately assist physicians in counselling patients about the risk of DIIH when prescribing medications and recognizing this uncommon yet sight-threatening condition.
Topics: Dermatologic Agents; Humans; Intracranial Hypertension
PubMed: 31741184
DOI: 10.1007/s40257-019-00485-z