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Blank AE, Zajonz T, Gruschwitz I, Neuhäuser C, Akintürk H, Jux C, Backhoff D. Efficacy and Safety of Esmolol in Neonatal Cardiac Surgery with Cardiopulmonary Bypass (CPB) for d-Transposition of the Great Arteries (d-TGA). Pediatr Cardiol 2024:10.1007/s00246-024-03671-x. [PMID: 39384584 DOI: 10.1007/s00246-024-03671-x] [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] [Received: 03/29/2024] [Accepted: 09/28/2024] [Indexed: 10/11/2024]
Abstract
OBJECTIVE D-Transposition of the great arteries (d-TGA) is the most common congenital heart disease requiring surgical correction within the neonatal period. Sinus tachycardia often persists postoperatively, potentially affecting cardiac function. This study aimed to investigate the efficacy and safety of the short-acting beta-1-selective beta-blocker esmolol in controlling heart rate in neonatal cardiac surgery with cardiopulmonary bypass (CPB). METHODS A retrospective cohort study was conducted on neonates undergoing surgery for d-TGA. The study cohort included 112 patients, divided into an esmolol intervention group (n = 57) and a control group (n = 55). Baseline characteristics, hemodynamic parameters and outcome measures were assessed. RESULTS In the esmolol group, median heart rate at ICU admission was significantly higher compared to the control group (155 vs. 147 bpm, p = 0.018). After a median time of 11 h, heart rate was lower among the esmolol patients (135 vs. 144 bpm, p < 0.001). There were no differences in other hemodynamic parameters between the two groups. Patients treated with esmolol required longer catecholamine support while no difference regarding survival, duration of invasive ventilation and ICU stay were noticed. CONCLUSION No relevant hemodynamic difference was seen between neonates treated with perioperative esmolol and the control group and outcome did not differ. This indicates non-inferiority of perioperative betablocker therapy in young age. Prospective and placebo-controlled assessment of perioperative esmolol therapy in neonates is needed.
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Affiliation(s)
- Anna-Eva Blank
- Pediatric Cardiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany.
- Department of Pediatric Cardiology, Intensive Care Medicine and Congential Heart Disease, Pediatric Heart Center, Justus-Liebig University Giessen, Feulgenstr. 10-12, 35392, Giessen, Germany.
| | - Thomas Zajonz
- Pediatric Anesthesiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
| | - Inga Gruschwitz
- Pediatric Cardiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
| | - Christoph Neuhäuser
- Pediatric Cardiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
| | - Hakan Akintürk
- Pediatric Cardiac Surgery, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
| | - Christian Jux
- Pediatric Cardiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
| | - David Backhoff
- Pediatric Cardiology, Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
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2
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Suero OR, Ali AK, Barron LR, Segar MW, Moon MR, Chatterjee S. Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review. J Thorac Dis 2024; 16:1503-1520. [PMID: 38505057 PMCID: PMC10944787 DOI: 10.21037/jtd-23-1626] [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: 10/24/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.
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Affiliation(s)
- Orlando R. Suero
- Divisions of Cardiovascular Anesthesia & Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed K. Ali
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lauren R. Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Matthew W. Segar
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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3
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Barron LK, Moon MR. Medical Therapy After CABG: the Known Knowns, the Known Unknowns, and the Unknown Unknowns. Cardiovasc Drugs Ther 2024; 38:141-149. [PMID: 36881214 DOI: 10.1007/s10557-023-07444-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Medical therapies play a central role in secondary prevention after surgical revascularization. While coronary artery bypass grafting is the most definitive treatment for ischemic heart disease, progression of atherosclerotic disease in native coronary arteries and bypass grafts result in recurrent adverse ischemic events. The aim of this review is to summarize the recent evidence regarding current therapies in secondary prevention of adverse cardiovascular outcomes after CABG and review the existing recommendations as they pertain to the CABG subpopulations. RECENT FINDINGS There are many pharmacologic interventions recommended for secondary prevention in patients after coronary artery bypass grafting. Most of these recommendations are based on secondary outcomes from trials which include but did not focus on surgical patients as a cohort. Even those designed with CABG in mind lack the technical and demographic scope to provide universal recommendations for all CABG patients. CONCLUSION Recommendations for medical therapy after surgical revascularization are chiefly based on large-scale randomized controlled trials and meta-analyses. Much of what is known about medical management after surgical revascularization results from trials comparing surgical to non-surgical approaches and important characteristics of the operative patients are omitted. These omissions create a group of patients who are relatively heterogenous making solid recommendations elusive. While advances in pharmacologic therapies are clearly adding to the armamentarium of options for secondary prevention, knowing what patients benefit most from each therapeutic option remains challenging and a personalized approach is still required.
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Affiliation(s)
- Lauren K Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Heart Institute, Houston, TX, USA.
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Heart Institute, Houston, TX, USA
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4
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Puscas A, Harpa MM, Brinzaniuc K, Al-Hussein H, Al-Hussein H, Banceu C, Opris C, Ghiragosian C, Flamind S, Balan R, Voidazan S, Suciu H. Evaluation of Perioperative Beta-Blockers and Factors Associated with Postoperative Atrial Fibrillation in Cardiac Surgery: A Single Center Experience. Rev Cardiovasc Med 2023; 24:370. [PMID: 39077087 PMCID: PMC11272838 DOI: 10.31083/j.rcm2412370] [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] [Received: 08/03/2023] [Revised: 09/04/2023] [Accepted: 09/14/2023] [Indexed: 07/31/2024] Open
Abstract
Background Postoperative atrial fibrillation (AF) has a complex etiology, and beta-blockers are commonly recommended for its pharmacological prevention. This study aims to assess the impact of beta-blocker therapy on postoperative AF occurrence in patients undergoing aortic valve replacement, mitral valve replacement, surgical revascularization of the myocardium, or a combination of these procedures. Methods The study encompassed 472 patients who received aortic valve replacement, mitral valve replacement, surgical revascularization, or their combination. We evaluated the efficacy of preoperative and one-month postoperative beta-blocker administration in preventing postoperative AF, and the associated risk factors involved in the development of postoperative AF. Results Of the total patient population, 36% experienced postoperative AF. Our study demonstrated a significant reduction in postoperative AF incidence among patients receiving beta-blocker treatment (all p-values < 0.05). Additionally, one-month post-surgery, beta-blocker treatment exerted a protective effect by maintaining the sinus rhythm (p = 0.0001). Regarding the risk factors involved in the development of postoperative AF, both age and left atrium (LA) sizeassessed pre-and postoperatively-were positively correlated with the occurrence of postoperative AF (p = 0.006). No relationship was found between leukocyte counts and AF incidence. Notably, C-reactive protein (CRP) levels were significantly elevated on the fifth postoperative day in patients with AF (p < 0.007). The duration of ischemia was significantly longer in patients with AF (p = 0.009). Conclusions This study establishes the efficacy of perioperative beta-blocker treatment in mitigating postoperative AF. One month post-surgery, most patients under beta-blocker therapy maintained sinus rhythm, suggesting a potential long-term protective effect of beta-blockers against late-onset AF.
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Affiliation(s)
- Alexandra Puscas
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
| | - Marius M. Harpa
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Klara Brinzaniuc
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Hussam Al-Hussein
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Hamida Al-Hussein
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Cosmin Banceu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Carmen Opris
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Claudiu Ghiragosian
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Sanziana Flamind
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Robert Balan
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
- Klinik für Herzchirurgie, Klinikum Passau, 94032 Passau, Germany
| | - Septimiu Voidazan
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
| | - Horatiu Suciu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Targu Mures, Romania
- The Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation Târgu Mureș, 540142 Targu Mures, Romania
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Meenashi Sundaram D, Vasavada AM, Ravindra C, Rengan V, Meenashi Sundaram P. The Management of Postoperative Atrial Fibrillation (POAF): A Systematic Review. Cureus 2023; 15:e42880. [PMID: 37664333 PMCID: PMC10474445 DOI: 10.7759/cureus.42880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) refers to new-onset atrial fibrillation (AF) that develops after surgery and is associated with an increased risk of mortality and thromboembolic events. The optimal management and treatment methods for POAF complications are not yet fully established. This systematic review aimed to evaluate the various treatment and management approaches currently available in terms of their suitability, efficacy, and side effects in handling POAF incidence post-surgery. Google Scholar and PubMed electronic databases were searched extensively for relevant articles examining the various management techniques currently used to manage POAF and published between 2018 and 2023. Data were collected on the type of surgery the patients underwent, POAF definition period, intervention, and outcome of interest. Following a systematic assessment guided by the inclusion criteria, 10 of the 579 studies retrieved were included in this study, and 293,417 POAF cases were recorded. Three of these studies used different rhythm control and rate control treatments to manage POAF cases, while seven studies used various anticoagulation therapies to manage POAF incidence. For asymptomatic patients within one to three days of surgery, rate control is sufficient to manage POAF, and routine rhythm control is not needed; rhythm control should be reserved for patients who develop complications such as hemodynamic instability. Anticoagulation was performed in patients whose POAF exceeded four days after surgery. Anticoagulation was associated with an increased risk of mortality, stroke, thromboembolic events, and major bleeding in patients who underwent coronary artery bypass graft (CABG) surgery. In contrast, in a few other studies, anticoagulation treatment led to improved outcomes in patients who developed POAF. A wide range of management methods are available for POAF after different types of surgery. However, there is only limited evidence to guide the clinical practice. The data available are mainly retrospective and insufficient to accurately evaluate the efficacy of the various management methods available for POAF. Future research should make efforts to standardize the treatment for this condition.
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6
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Bagateliya ZA, Grekov DN, Komarova AG, Kulushev VM, Sokolov NY, Kuts IN, Lebedko MS. [Integral scales in assessing the risk of postoperative morbidity and mortality]. Khirurgiia (Mosk) 2023:25-33. [PMID: 38010015 DOI: 10.17116/hirurgia202311125] [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] [Indexed: 11/29/2023]
Abstract
Annual number of surgeries exceeds 10 million In Russia, and this number is increasing every year. Searching for a scale or index determining the risk of postoperative complications and mortality is an important issue all over the world. The authors analyzed all available risk assessment scales for postoperative morbidity and mortality. The most significant ones in historical aspect and modern perspective grading systems were highlighted. We compared these indices with clinical recommendations and necessary preoperative preparation. Thus, these scales are valuable for surgeons and anesthesiologists to assess the risk, volume of surgical intervention and methods of preoperative management. However, they are not perfect and require improvement. Therefore, development of such scales is a priority objective of medicine in the foreseeable future.
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Affiliation(s)
| | - D N Grekov
- Botkin Clinical Hospital, Moscow, Russia
| | | | | | | | - I N Kuts
- Botkin Clinical Hospital, Moscow, Russia
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7
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Jiang F, Xu H, Shi X, Han B, Chu Z, Xu B, Liu X. Dynamic Electrocardiogram under P Wave Detection Algorithm Combined with Low-Dose Betaloc in Diagnosis and Treatment of Patients with Arrhythmia after Hepatocarcinoma Resection. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6034180. [PMID: 34697566 PMCID: PMC8541856 DOI: 10.1155/2021/6034180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
This work aimed to study the diagnostic value of dynamic electrocardiogram (ECG) based on P wave detection algorithm for arrhythmia after hepatectomy in patients with primary liver cancer, and to compare the therapeutic effect of different doses of Betaloc. P wave detection algorithm was introduced for ECG automatic detection and analysis, which can be used for early diagnosis of arrhythmia. Sixty patients with arrhythmia after hepatectomy for primary liver cancer were selected as the research objects. They were randomly divided into control group, SD group, MD group, and HD group, with 15 cases in each group. No Betaloc, low-dose (≤47.5 mg), medium-dose (47.5-95 mg), and high-dose (142.5-190 mg) Betaloc were used for treatment. As a result, P wave detection algorithms can mark P waves that may be submerged in strong interference. P waves from arrhythmia database were used to verify the performance of the proposed algorithm. The prediction precision (Pp) of ventricular arrhythmia and atrial arrhythmia was 98.53% and 98.76%, respectively. Systolic blood pressure (117.35 ± 7.33, 126.44 ± 9.38, and 116.02 ± 8.2) mmHg in SD group, MD group, and HD group was significantly lower than that in control group (140.3 ± 7.21) mmHg after two weeks of treatment. Moreover, those of SD group and HD group were significantly lower than MD group (P < 0.05). The effective rate of cardiac function improvement in SD group (72.35 ± 1.21%) was significantly higher than that in control group, MD group, and HD group (38.2 ± 0.98%, 65.12 ± 1.33%, and 60.43 ± 1.25%; P < 0.05). In short, dynamic ECG based on P wave detection algorithm had high diagnostic value for arrhythmia after hepatectomy in patients with primary liver cancer. It was safe and effective for patients to choose small dose of Betaloc.
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Affiliation(s)
- Fenfen Jiang
- Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
| | - Haokai Xu
- Department of Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo 315199, Zhejiang, China
| | - Xiaowen Shi
- Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
| | - Bingjiang Han
- Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
| | - Zhenliang Chu
- Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
| | - Bin Xu
- Department of Cardiology, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
| | - Xiaorong Liu
- Department of Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang, China
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8
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Lix LM, Sobhan S, St-Jean A, Daigle JM, Fisher A, Yu OHY, Dell'Aniello S, Hu N, Bugden SC, Shah BR, Ronksley PE, Alessi-Severini S, Douros A, Ernst P, Filion KB. Validity of an algorithm to identify cardiovascular deaths from administrative health records: a multi-database population-based cohort study. BMC Health Serv Res 2021; 21:758. [PMID: 34332563 PMCID: PMC8325284 DOI: 10.1186/s12913-021-06762-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/14/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Cardiovascular death is a common outcome in population-based studies about new healthcare interventions or treatments, such as new prescription medications. Vital statistics registration systems are often the preferred source of information about cause-specific mortality because they capture verified information about the deceased, but they may not always be accessible for linkage with other sources of population-based data. We assessed the validity of an algorithm applied to administrative health records for identifying cardiovascular deaths in population-based data. METHODS Administrative health records were from an existing multi-database cohort study about sodium-glucose cotransporter-2 (SGLT2) inhibitors, a new class of antidiabetic medications. Data were from 2013 to 2018 for five Canadian provinces (Alberta, British Columbia, Manitoba, Ontario, Quebec) and the United Kingdom (UK) Clinical Practice Research Datalink (CPRD). The cardiovascular mortality algorithm was based on in-hospital cardiovascular deaths identified from diagnosis codes and select out-of-hospital deaths. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated for the cardiovascular mortality algorithm using vital statistics registrations as the reference standard. Overall and stratified estimates and 95% confidence intervals (CIs) were computed; the latter were produced by site, location of death, sex, and age. RESULTS The cohort included 20,607 individuals (58.3% male; 77.2% ≥70 years). When compared to vital statistics registrations, the cardiovascular mortality algorithm had overall sensitivity of 64.8% (95% CI 63.6, 66.0); site-specific estimates ranged from 54.8 to 87.3%. Overall specificity was 74.9% (95% CI 74.1, 75.6) and overall PPV was 54.5% (95% CI 53.7, 55.3), while site-specific PPV ranged from 33.9 to 72.8%. The cardiovascular mortality algorithm had sensitivity of 57.1% (95% CI 55.4, 58.8) for in-hospital deaths and 72.3% (95% CI 70.8, 73.9) for out-of-hospital deaths; specificity was 88.8% (95% CI 88.1, 89.5) for in-hospital deaths and 58.5% (95% CI 57.3, 59.7) for out-of-hospital deaths. CONCLUSIONS A cardiovascular mortality algorithm applied to administrative health records had moderate validity when compared to vital statistics data. Substantial variation existed across study sites representing different geographic locations and two healthcare systems. These variations may reflect different diagnostic coding practices and healthcare utilization patterns.
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Affiliation(s)
- Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Shamsia Sobhan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audray St-Jean
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jean-Marc Daigle
- Institut national d'excellence en santé et en services sociaux (INESSS), Quebec City, Quebec, Canada
| | - Anat Fisher
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Oriana H Y Yu
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Sophie Dell'Aniello
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Nianping Hu
- The Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Shawn C Bugden
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,School of Pharmacy, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Baiju R Shah
- ICES, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Silvia Alessi-Severini
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Manitoba Centre for Health Policy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Antonios Douros
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Pierre Ernst
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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9
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Zhang Q, Huang B, Xue H, Lin Z, Zhao J, Cai Z. Preparation, Characterization, and Selection of Optimal Forms of (S)-Carvedilol Salts for the Development of Extended-Release Formulation. Mol Pharm 2021; 18:2298-2310. [PMID: 34032449 DOI: 10.1021/acs.molpharmaceut.1c00100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
(S)-carvedilol (S-CAR) is the dominant pharmacodynamic conformation of carvedilol, but its further development for extended-release formulation is restricted by its poor solubility. This study aimed to prepare and screen S-CAR salts that could be used to improve solubility and allow extended release. Five salts of S-CAR with well-known acid counterions (i.e., phosphate, hydrochloride, sulfate, fumarate, and tartrate) were produced using similar processes. However, these salts were obtained with water contents of 1.60-12.28%, and their physicochemical properties differed. The melting points of phosphate, hydrochloride, and tartrate were 1.1-1.5 times higher than that of the free base. The solubility of S-CAR salts was promoted to approximately 3-32 times higher than that of the free base at pH 5.0-8.0. Typical pH-dependent solubilities were evidently observed in S-CAR salts, but considerable differences in solubility properties among these salts were observed. S-CAR phosphate and hydrochloride possessed high melting points, considerable solubility, and excellent chemical and crystallographic stabilities. Accordingly, S-CAR phosphate and hydrochloride were chosen for further pharmacokinetic experiments and pharmaceutical study. S-CAR phosphate and hydrochloride extended-release capsules were prepared using HPMC K15 as the matrix and presented extended release in in vitro and in vivo evaluations. Results implied that water molecules in the hydrated salt were a potential threat to the achievement of crystal stability and thermostability. S-CAR phosphate and hydrochloride are suitable for further development of the extended-release formulation.
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Affiliation(s)
- Qi Zhang
- Institute of Materia Medica, Hangzhou Medical College, 310013 Hangzhou, China.,NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China
| | - Baolin Huang
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China
| | - Hongjiao Xue
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China
| | - Zimin Lin
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China
| | - Jie Zhao
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China.,TCM-Integrated Hospital of Southern Medical University, 510515 Guangzhou, China
| | - Zheng Cai
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, School of Pharmaceutical Sciences, Southern Medical University, 510515 Guangzhou, China.,TCM-Integrated Hospital of Southern Medical University, 510515 Guangzhou, China
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Madsen BK, Zetner D, Møller AM, Rosenberg J. Melatonin for preoperative and postoperative anxiety in adults. Cochrane Database Syst Rev 2020; 12:CD009861. [PMID: 33319916 PMCID: PMC8092422 DOI: 10.1002/14651858.cd009861.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anxiety in relation to surgery is a well-known problem. Melatonin offers an alternative treatment to benzodiazepines for ameliorating this condition in the preoperative and postoperative periods. OBJECTIVES To assess the effects of melatonin on preoperative and postoperative anxiety compared to placebo or benzodiazepines. SEARCH METHODS We searched the following databases on 10 July 2020: CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science. For ongoing trials and protocols, we searched clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA We included randomized, placebo-controlled or standard treatment-controlled (or both) studies that evaluated the effects of preoperatively administered melatonin on preoperative or postoperative anxiety. We included adult patients of both sexes (15 to 90 years of age) undergoing any kind of surgical procedure for which it was necessary to use general, regional, or topical anaesthesia. DATA COLLECTION AND ANALYSIS One review author conducted data extraction in duplicate. Data extracted included information about study design, country of origin, number of participants and demographic details, type of surgery, type of anaesthesia, intervention and dosing regimens, preoperative anxiety outcome measures, and postoperative anxiety outcome measures. MAIN RESULTS We included 27 randomized controlled trials (RCTs), involving 2319 participants, that assessed melatonin for treating preoperative anxiety, postoperative anxiety, or both. Twenty-four studies compared melatonin with placebo. Eleven studies compared melatonin to a benzodiazepine (seven studies with midazolam, three studies with alprazolam, and one study with oxazepam). Other comparators in a small number of studies were gabapentin, clonidine, and pregabalin. No studies were judged to be at low risk of bias for all domains. Most studies were judged to be at unclear risk of bias overall. Eight studies were judged to be at high risk of bias in one or more domain, and thus, to be at high risk of bias overall. Melatonin versus placebo Melatonin probably results in a reduction in preoperative anxiety measured by a visual analogue scale (VAS, 0 to 100 mm) compared to placebo (mean difference (MD) -11.69, 95% confidence interval (CI) -13.80 to -9.59; 18 studies, 1264 participants; moderate-certainty evidence), based on a meta-analysis of 18 studies. Melatonin may reduce immediate postoperative anxiety measured on a 0 to 100 mm VAS compared to placebo (MD -5.04, 95% CI -9.52 to -0.55; 7 studies, 524 participants; low-certainty evidence), and may reduce delayed postoperative anxiety measured six hours after surgery using the State-Trait Anxiety Inventory (STAI) (MD -5.31, 95% CI -8.78 to -1.84; 2 studies; 73 participants; low-certainty evidence). Melatonin versus benzodiazepines (midazolam and alprazolam) Melatonin probably results in little or no difference in preoperative anxiety measured on a 0 to 100 mm VAS (MD 0.78, 95% CI -2.02 to 3.58; 7 studies, 409 participants; moderate-certainty evidence) and there may be little or no difference in immediate postoperative anxiety (MD -2.12, 95% CI -4.61 to 0.36; 3 studies, 176 participants; low-certainty evidence). Adverse events Fourteen studies did not report on adverse events. Six studies specifically reported that no side effects were observed, and the remaining seven studies reported cases of nausea, sleepiness, dizziness, and headache; however, no serious adverse events were reported. Eleven studies measured psychomotor and cognitive function, or both, and in general, these studies found that benzodiazepines impaired psychomotor and cognitive function more than placebo and melatonin. Fourteen studies evaluated sedation and generally found that benzodiazepine caused the highest degree of sedation, but melatonin also showed sedative properties compared to placebo. Several studies did not report on adverse events; therefore, it is not possible to conclude with certainty, from the data on adverse effects collected in this review, that melatonin is better tolerated than benzodiazepines. AUTHORS' CONCLUSIONS When compared with placebo, melatonin given as premedication (as tablets or sublingually) probably reduces preoperative anxiety in adults (measured 50 to 120 minutes after administration), which is potentially clinically relevant. The effect of melatonin on postoperative anxiety compared to placebo (measured in the recovery room and six hours after surgery) was also evident but was much smaller, and the clinical relevance of this finding is uncertain. There was little or no difference in anxiety when melatonin was compared with benzodiazepines. Thus, melatonin may have a similar effect to benzodiazepines in reducing preoperative and postoperative anxiety in adults.
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Affiliation(s)
- Bennedikte K Madsen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Dennis Zetner
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Ann Merete Møller
- Cochrane Anaesthesia, Critical and Emergency Care Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
- Cochrane Colorectal Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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Blessberger H, Lewis SR, Pritchard MW, Fawcett LJ, Domanovits H, Schlager O, Wildner B, Kammler J, Steinwender C. Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2019; 9:CD013438. [PMID: 31556094 PMCID: PMC6761481 DOI: 10.1002/14651858.cd013438] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.
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Affiliation(s)
- Hermann Blessberger
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Lizzy J Fawcett
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Hans Domanovits
- Vienna General Hospital, Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustria1090
| | - Oliver Schlager
- Vienna General Hospital, Medical University of ViennaDepartment of Internal Medicine II, Division of AngiologyWähringer Gürtel 18‐20ViennaAustria1090
| | - Brigitte Wildner
- University Library of the Medical University of ViennaInformation Retrieval OfficeWähringer Gürtel 18‐20ViennaAustria1090
| | - Juergen Kammler
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Clemens Steinwender
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
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