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Liu Y, Hong Y. Amiodarone vs. metoprolol succinate in HFrEF complicated with persistent atrial fibrillation with rapid ventricular response: A prospective observational study. Front Cardiovasc Med 2023; 9:1029012. [PMID: 36698920 PMCID: PMC9868854 DOI: 10.3389/fcvm.2022.1029012] [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: 08/26/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Background β-blockers have been recommended for patients with heart failure (HF) and atrial fibrillation (AF), but studies have shown that β-blockers do not reduce all-cause mortality or cardiovascular mortality in patients with HF and AF. Objective To investigate the difference in efficacy between oral amiodarone and metoprolol succinate for patients with HF with reduced ejection fraction (HFrEF) and persistent atrial fibrillation (pAF) with rapid ventricular response (RVR). Methods Patients with HFrEF complicated with pAF with RVR treated in the People's Hospital of Chongqing Hechuan between March 2018 and March 2019 were enrolled in this prospective observational study. The primary outcomes were cardiovascular mortality and the first hospitalization for HF rate. The secondary outcomes were type B pro-brain natriuretic peptide (NT-proBNP) before/after treatment, left ventricular ejection fraction (LVEF) before/after treatment, average heart rate (AhR), and the rate of sinus rhythm after 1 year of follow-up. Results A total of 242 patients with HFrEF complicated with pAF with RVR were enrolled and divided into amiodarone + perindopril + spironolactone+ routine drug (amiodarone group, n = 121) and metoprolol succinate + perindopril + spironolactone +routine drug (metoprolol succinate group, n = 121) according to their treatment strategy. Cardiovascular mortality (4.9 vs. 12.4%, HR: 2.500, 95%CI: 1.002-6.237, P = 0.040) and first hospitalization for HF (52.9 vs. 67.8%, HR: 1.281, 95%CI: 1.033-1.589, P = 0.024) were significantly lower in the amiodarone group than in the metoprolol group. The mean ventricular rate in the amiodarone group was significantly lower than in the metoprolol group (64.5 ± 3.2 vs. 72.4 ± 4.2, P < 0.001). After 1 year of follow-up, the sinus rhythm rate was significantly higher in the amiodarone group than in the metoprolol group (38.8 vs. 7.4%, HR: 0.191, 95%CI: 0.098-0.374, P < 0.001). The difference in proBNP (3,914.88 vs. 2,558.07, P < 0.001) and LVEF (-6.89 vs. -0.98, P < 0.001) before and after treatment was significantly higher in the amiodarone group than in the metoprolol group. Conclusion In conclusion, in this prospective observational study, the amiodarone group had lower risk of cardiovascular death and the first hospitalization for HF than metoprolol in HFrEF and persistent atrial fibrillation (pAF) with RVR. The mechanism may be related to improved cardiac function, rhythm control and ventricular rate control. Registration number ChiCTR2200057816; Registered 7 March 2022-Retrospectively registered: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=4222.
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Affiliation(s)
- Yongrong Liu
- Department of Cardiovascular Medicine, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yali Hong
- Department of Cardiovascular Medicine, People's Hospital of Chongqing Hechuan, Chongqing, China
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Martínez-Sellés M, Elosua R, Baranchuk A. The "Bayés Spirit" as a guide for new generations: How to combine one's personal life and friendships with science and profession. J Electrocardiol 2023; 78:17-20. [PMID: 36709528 DOI: 10.1016/j.jelectrocard.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/14/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023]
Abstract
Recent studies suggest that up to a quarter of physicians in training suffer from burnout and psychological disorders. Scientist-physicians, cardiologists, cardiology residents, and first-year medical residents seem to be more prone to developing varying degrees of emotional distress. Concerned about the new generations of clinicians and researchers, the authors aim to provide guidelines for reconciling professional success with a fulfilling and satisfying personal life. The figure of Antonio Bayés de Luna (cardiology and electrocardiology guru) is used as the ideal example to learn how to combine one's personal life, family, and friendships with science and their professional career. This can be done in a healthy and balanced way, prioritizing the former while continuing to have an intense dedication to the latter.
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Affiliation(s)
- Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Spain; CIBERCV, Madrid, Spain; CIBERCV, Universidad Europea. Madrid, Spain; Universidad Complutense. Madrid, Spain.
| | - Roberto Elosua
- CIBERCV, Universidad Europea. Madrid, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Facultad de Medicina, Universidad de Vic-Universidad Central de Catalunya, Vic, Barcelona, Spain
| | - Adrián Baranchuk
- Division of Cardiology, Kingston Health Sciences Center, Kingston, Ontario, Canada
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Abstract
BACKGROUND Meta-analyses from randomized outcome-based trials have challenged the role of beta-blockers for the treatment of hypertension. However, because they often include trials on diseases other than hypertension, the role of these drugs in the choice of the blood pressure (BP)-lowering treatment strategies remains unclear. METHODS Electronic databases were searched for randomized trials that compared beta-blockers vs. placebo/no-treatment/less-intense treatment (BP-lowering trials) or beta-blockers vs. other antihypertensive agents in patients with or without hypertension (comparison trials). Among BP-lowering trials and according to baseline comorbidity, we separately considered trials in hypertension, trials without chronic heart failure or acute myocardial infarction, and trials with either chronic heart failure or acute myocardial infarction. Seven fatal and nonfatal outcomes were calculated (random-effects model) for BP-lowering or comparison trials. RESULTS A total of 84 BP-lowering or comparison trials (165 850 patients) were eligible. In 67 BP-lowering trials (68 478 patients; mean follow-up 2.5 years; baseline SBP/DBP, 136/82 mmHg), beta blockers were associated with a lower incidence of major cardiovascular events [risk ratio 0.85 and 95% confidence interval (95% CI) 0.78-0.92] and all-cause death (risk ratio 0.81 and 95% CI 0.75-0.86). Restriction of the analysis to five trials recruiting exclusively hypertensive patients (18 724 patients; mean follow-up 5.1 years; baseline SBP/DBP 163/94 mmHg), a -10.5/-7.0 mmHg BP decrease was accompanied by reduction of major cardiovascular events by 22% (95% CI, 6-34). In 24 comparison trials (103 764 patients, 3.92 years of mean follow-up), beta-blockers compared with other agents were less protective for stroke and all-cause death in all trials and in trials conducted exclusively in hypertensive patients (averaged risk ratio increase 20 and 6%, respectively, for both cases). CONCLUSION Compared with other antihypertensive agents, beta-blockers appear to be substantially less protective against stroke and overall mortality. However, they exhibit a substantial risk-reducing ability for all events when prescribed to lower BP in patients with modest or more clear BP elevations, and therefore can be used as additional agents in hypertensive patients.
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Siemers LA, MacGillivray J, Andrade JG, Turgeon RD. Chronic Amiodarone Use and the Risk of Cancer: A Systematic Review and Meta-analysis. CJC Open 2021; 3:109-114. [PMID: 33458637 PMCID: PMC7801211 DOI: 10.1016/j.cjco.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/16/2022] Open
Abstract
Background Observational studies have identified inconsistent associations between chronic use of amiodarone and cancer-related outcomes. We performed a systematic review and meta-analysis to evaluate cancer risk among patients receiving amiodarone. Methods We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) to May 1, 2020. We included randomized controlled trials (RCTs) with follow-up ≥2 years that compared amiodarone (any dose) to any comparator (placebo, active pharmacologic or interventional comparator, or usual care), and reported ≥1 outcome of interest. We contacted authors of published chronic amiodarone trials for potentially unreported cancer outcomes. The primary outcome was cancer incidence. Secondary outcomes were cancer-related death and site-specific cancers. We determined risk ratios and 95% confidence intervals using a fixed-effect model, and statistical heterogeneity using I2. We conducted prespecified subgroup and sensitivity analyses for amiodarone indication, amiodarone dose, duration of therapy, and trial-level risk of bias. Results From 1439 articles, we included 5 RCTs (n = 4357). Mean follow-up duration ranged from 21 to 37 months. We included previously unpublished cancer outcome data from 1 RCT. Our primary outcome was not reported in any RCT. There was no significant difference in cancer-related death between amiodarone (1.69%) and the comparator (1.75%) (risk ratio 0.96, 95% confidence interval 0.57-1.63; I2 = 0%). There were no significant interactions from our subgroup or sensitivity analyses. Conclusions Chronic amiodarone use did not increase cancer-related deaths. Data from RCTs do not support an increased risk of cancer-related harms with amiodarone use, and these concerns should not deter use of amiodarone when indicated.
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Affiliation(s)
- Lauren A Siemers
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jenny MacGillivray
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Keegan R, Yeung C, Baranchuk A. Sudden Cardiac Death Risk Stratification and Prevention in Chagas Disease: A Non-systematic Review of the Literature. Arrhythm Electrophysiol Rev 2021; 9:175-181. [PMID: 33437484 PMCID: PMC7788394 DOI: 10.15420/aer.2020.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Chagas disease is an important public health problem in Latin America. However, migration and globalisation have resulted in the increased presence of Chagas disease worldwide. Sudden cardiac death is the leading cause of death in people with Chagas disease, most often due to ventricular fibrillation. Although more common in patients with documented ventricular arrhythmias, sudden cardiac death can also be the first manifestation of Chagas disease in patients with no previous symptoms or known heart failure. Major predictors of sudden cardiac death include cardiac arrest, sustained and non-sustained ventricular tachycardia, left ventricular dysfunction, syncope and bradycardia. The authors review the predictors and risk stratification score developed by Rassi et al. for death in Chagas heart disease. They also discuss the evidence for anti-arrhythmic drugs, catheter ablation, ICDs and pacemakers for the prevention of sudden cardiac death in these patients. Given the widespread global burden, understanding the risk stratification and prevention of sudden cardiac death in Chagas disease is of timely concern.
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Affiliation(s)
- Roberto Keegan
- Electrophysiology Service, Hospital Privado del Sur and Hospital Español, Bahia Blanca, Argentina
| | - Cynthia Yeung
- Department of Cardiology, Queen's University, Kingston, Canada
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Zhang D, Tu H, Wadman MC, Li YL. Substrates and potential therapeutics of ventricular arrhythmias in heart failure. Eur J Pharmacol 2018; 833:349-356. [PMID: 29940156 DOI: 10.1016/j.ejphar.2018.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/30/2018] [Accepted: 06/19/2018] [Indexed: 12/30/2022]
Abstract
Heart failure (HF) is a clinical syndrome characterized by ventricular contractile dysfunction. About 50% of death in patients with HF are due to fetal ventricular arrhythmias including ventricular tachycardia and ventricular fibrillation. Understanding ventricular arrhythmic substrates and discovering effective antiarrhythmic interventions are extremely important for improving the prognosis of patients with HF and reducing its mortality. In this review, we discussed ventricular arrhythmic substrates and current clinical therapeutics for ventricular arrhythmias in HF. Base on the fact that classic antiarrhythmic drugs have the limited efficacy, side effects, and proarrhythmic potentials, we also updated some therapeutic strategies for the development of potential new antiarrhythmic interventions for patients with HF.
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Affiliation(s)
- Dongze Zhang
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Huiyin Tu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Michael C Wadman
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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Claro JC, Candia R, Rada G, Baraona F, Larrondo F, Letelier LM. Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death. Cochrane Database Syst Rev 2015; 2015:CD008093. [PMID: 26646017 PMCID: PMC8407095 DOI: 10.1002/14651858.cd008093.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) is one of the main causes of cardiac death. There are two main strategies to prevent it: managing cardiovascular risk factors and reducing the risk of ventricular arrhythmias. Implantable cardiac defibrillators (ICDs) constitute the standard therapy for both primary and secondary prevention; however, they are not widely available in settings with limited resources. The antiarrhythmic amiodarone has been proposed as an alternative to ICD. OBJECTIVES To evaluate the effectiveness of amiodarone for primary or secondary prevention in SCD compared with placebo or no intervention or any other antiarrhythmic drugs in participants at high risk (primary prevention) or who have recovered from a cardiac arrest or a syncope due to Ventricular Tachycardia/Ventricular Fibrillation, or VT/VF (secondary prevention). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO) and LILACS on 26 March 2015. We reviewed reference lists of included studies and selected reviews on the topic, contacted authors of included studies, screened relevant meetings and searched in registers for ongoing trials. We applied no language restrictions. SELECTION CRITERIA Randomised and quasi-randomised trials assessing the efficacy of amiodarone versus placebo, no intervention, or other antiarrhythmics in adults. For primary prevention we considered participants at high risk for SCD. For secondary prevention we considered participants recovered from cardiac arrest or syncope due to ventricular arrhythmias. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trials for inclusion and extracted relevant data. We contacted trial authors for missing data. We performed meta-analyses using a random-effects model. We calculated risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). Three studies included more than one comparison. MAIN RESULTS We included 24 studies (9,997 participants). Seventeen studies evaluated amiodarone for primary prevention and six for secondary prevention. Only three studies used an ICD concomitantly with amiodarone for the comparison (all of them for secondary prevention).For primary prevention, amiodarone compared to placebo or no intervention (17 studies, 8383 participants) reduced SCD (RR 0.76; 95% CI 0.66 to 0.88), cardiac mortality (RR 0.86; 95% CI 0.77 to 0.96) and all-cause mortality (RR 0.88; 95% CI 0.78 to 1.00). The quality of the evidence was low.Compared to other antiarrhythmics (three studies, 540 participants), amiodarone reduced SCD (RR 0.44; 95% CI 0.19 to 1.00), cardiac mortality (RR 0.41; 95% CI 0.20 to 0.86) and all-cause mortality (RR 0.37; 95% CI 0.18 to 0.76). The quality of the evidence was moderate.For secondary prevention, amiodarone compared to placebo or no intervention (two studies, 440 participants) appeared to increase the risk of SCD (RR 4.32; 95% CI 0.87 to 21.49) and all-cause mortality (RR 3.05; 1.33 to 7.01). However, the quality of the evidence was very low. Compared to other antiarrhythmics (four studies, 839 participants) amiodarone appeared to increase the risk of SCD (RR 1.40; 95% CI 0.56 to 3.52; very low quality of evidence), but there was no effect in all-cause mortality (RR 1.03; 95% CI 0.75 to 1.42; low quality evidence).Amiodarone was associated with an increase in pulmonary and thyroid adverse events. AUTHORS' CONCLUSIONS There is low to moderate quality evidence that amiodarone reduces SCD, cardiac and all-cause mortality when compared to placebo or no intervention for primary prevention, and its effects are superior to other antiarrhythmics.It is uncertain if amiodarone reduces or increases SCD and mortality for secondary prevention because the quality of the evidence was very low.
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Affiliation(s)
- Juan Carlos Claro
- Department of Internal Medicine and Evidence-Based Healthcare Program, Faculty of Medicine, Pontificia Universidad Católica de Chile, Lira 63, 1st floor, Santiago, Region Metropolitana, Chile
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Range FT, Hilker E, Breithardt G, Buerke B, Lebiedz P. Amiodarone-induced pulmonary toxicity--a fatal case report and literature review. Cardiovasc Drugs Ther 2013; 27:247-54. [PMID: 23397327 PMCID: PMC7101864 DOI: 10.1007/s10557-013-6446-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Amiodarone is a widely used and very potent antiarrhythmic substance. Among its adverse effects, pulmonary toxicity is the most dangerous without a causal treatment option. Due to a very long half-life, accumulation can only be prevented by strict adherence to certain dosage patterns. In this review, we outline different safe and proven dosing schemes of amiodarone and compare the incidence and description of pulmonary toxicity. Reason for this is a case of fatal pulmonary toxicity due to a subacute iatrogenic overdosing of amiodarone in a 74-year-old male patient with known severe coronary artery disease, congestive heart failure and ectopic atrial tachycardia with reduced function of kidneys and liver but without preexisting lung disease. Within 30 days, the patient received 32.2 g of amiodarone instead of 15.6 g as planned. Despite early corticosteroid treatment after fast exclusion of all other differential diagnoses, the patient died another month later in our intensive care unit from respiratory failure due to bipulmonal pneumonitis.
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Affiliation(s)
- Felix T Range
- Department of Cardiology and Angiology, University Hospital of Muenster, Münster, Germany.
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Santangeli P, Di Biase L, Burkhardt JD, Bai R, Mohanty P, Pump A, Natale A. Examining the safety of amiodarone. Expert Opin Drug Saf 2012; 11:191-214. [PMID: 22324910 DOI: 10.1517/14740338.2012.660915] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Amiodarone is the most widely used antiarrhythmic agent, with demonstrated effectiveness against all the spectrum of cardiac tachyarrhythmias. The risk of adverse effects acts as a limiting factor to its utilization especially in the long term. This article systematically reviews the published evidence on amiodarone versus placebo to examine its safety as an antiarrhythmic drug. AREAS COVERED Authors collected data on adverse effects reported in 49 randomized placebo-controlled trials with amiodarone. Adverse effects were classified according to the organ/system involved. Pooled estimates of the number needed to treat (NNT) and to harm (NNH) versus placebo were calculated. EXPERT OPINION Amiodarone is effective for both the acute conversion of atrial fibrillation (AF) (11 trials, NNT = 4 at 24 h; p = 0.003) and the prevention of postoperative AF (18 trials, NNT = 8; p < 0.001), although with an increased risk of bradycardia, hypotension, nausea or phlebitis (pooled NNH = 4; p < 0.001). Amiodarone administration for the maintenance of sinus rhythm has a favorable net clinical benefit (pooled NNT = 3; p < 0.001 versus pooled NNH for either thyroid toxicity, gastrointestinal discomfort, skin toxicity or eye toxicity = 11; p < 0.001). Treatment with amiodarone for the prophylaxis of sudden cardiac death has less favorable net clinical benefit (15 trials, NNT = 38; p < 0.001 versus NNH for either thyroid toxicity, hepatic toxicity, pulmonary toxicity or bradycardia = 14; p < 0.001). Amiodarone treatment in this setting should be used in only selected cases.
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De Vuyst E, Boengler K, Antoons G, Sipido KR, Schulz R, Leybaert L. Pharmacological modulation of connexin-formed channels in cardiac pathophysiology. Br J Pharmacol 2011; 163:469-83. [PMID: 21265827 PMCID: PMC3101610 DOI: 10.1111/j.1476-5381.2011.01244.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 12/09/2010] [Accepted: 01/02/2011] [Indexed: 12/17/2022] Open
Abstract
Coordinated electrical activity in the heart is supported by gap junction channels located at the intercalated discs of cardiomyocytes. Impaired gap junctional communication between neighbouring cardiomyocytes contributes to the development of re-entry arrhythmias after myocardial ischaemia. Current antiarrhythmic therapy is hampered by a lack of efficiency and side effects, creating the need for a new generation of drugs. In this review, we focus on compounds that increase gap junctional communication, thereby increasing the conduction velocity and decreasing the risk of arrhythmias. Some of these compounds also inhibit connexin 43 (Cx43) hemichannels, thereby limiting adenosine triphosphate loss and volume overload following ischaemia/reperfusion, thus potentially increasing the survival of cardiomyocytes. The compounds discussed in this review are: (i) antiarrythmic peptide (AAP), AAP10, ZP123; (ii) GAP-134; (iii) RXP-E; and (vi) the Cx mimetic peptides Gap 26 and Gap 27. None of these compounds have effects on Na(+) , Ca(2+) and K(+) channels, and therefore have no proarrhythmic activity associated with currently available antiarrhythmic drugs. GAP-134, RXP-E, Gap 26 and Gap 27 are pharmalogical agents with a favorable clinical safety profile, as already confirmed in phase I clinical trials for GAP-134. These agents show an excellent promise for treatment of arrhythmias in patients with ischaemic cardiomyopathy.
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Affiliation(s)
- Elke De Vuyst
- Department of Basic Medical Sciences – Physiology group, Faculty of Medicine and Health Sciences, Ghent UniversityGhent, Belgium
| | - Kerstin Boengler
- Institut für Pathophysiologie, Zentrum für Innere Medizin, Universitätsklinikum EssenEssen, Germany
| | - Gudrun Antoons
- Department for Experimental Cardiology, O & N1, K.U.LeuvenLeuven, Belgium
| | - Karin R Sipido
- Department for Experimental Cardiology, O & N1, K.U.LeuvenLeuven, Belgium
| | - Rainer Schulz
- Institut für Physiologie, Justus-Liebig Universität GießenGießen, Germany
| | - Luc Leybaert
- Department of Basic Medical Sciences – Physiology group, Faculty of Medicine and Health Sciences, Ghent UniversityGhent, Belgium
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Kramer DG, Trikalinos TA, Kent DM, Antonopoulos GV, Konstam MA, Udelson JE. Quantitative evaluation of drug or device effects on ventricular remodeling as predictors of therapeutic effects on mortality in patients with heart failure and reduced ejection fraction: a meta-analytic approach. J Am Coll Cardiol 2010; 56:392-406. [PMID: 20650361 DOI: 10.1016/j.jacc.2010.05.011] [Citation(s) in RCA: 349] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 05/03/2010] [Accepted: 05/18/2010] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The purpose of this study was to quantitatively assess the relationship between therapy-induced changes in left ventricular (LV) remodeling and longer-term outcomes in patients with left ventricular dysfunction (LVD). BACKGROUND Whether therapy-induced changes in left ventricular ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV) are predictors of mortality in patients with LVD is not established. METHODS Searches for randomized controlled trials (RCTs) were conducted to identify drug or device therapies for which an effect on mortality in patients with LVD was studied in at least 1 RCT of > or = 500 patients (mortality trials). Then, all RCTs involving those therapies were identified in patients with LVD that described changes in LVEF and/or volumes over time (remodeling trials). We examined whether the magnitude of remodeling effects is associated with the odds ratios for death across all therapies or associated with whether the odds ratio for mortality was favorable, neutral, or adverse (i.e., statistically significantly decreased, nonsignificant, or statistically significantly increased odds for mortality, respectively). RESULTS Included were 30 mortality trials of 25 drug/device therapies (n = 69,766 patients; median follow-up 17 months) and 88 remodeling trials of the same therapies (n = 19,921 patients; median follow-up 6 months). The odds ratio for death in the mortality trials was correlated with drug/device effects on LVEF (r = -0.51, p < 0.001), EDV (r = 0.44, p = 0.002), and ESV (r = 0.48, p = 0.002). In (ordinal) logistic regressions, the odds for neutral or favorable effects in the mortality RCTs increased with mean increases in LVEF and with mean decreases in EDV and ESV in the remodeling trials. CONCLUSIONS In patients with LVD, short-term trial-level therapeutic effects of a drug or device on LV remodeling are associated with longer-term trial-level effects on mortality.
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Affiliation(s)
- Daniel G Kramer
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts 02111, USA
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Piccini JP, Berger JS, O'Connor CM. Amiodarone for the prevention of sudden cardiac death: a meta-analysis of randomized controlled trials. Eur Heart J 2009; 30:1245-53. [DOI: 10.1093/eurheartj/ehp100] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Naccarelli GV, Wolbrette DL, Dell'Orfano JT, Patel HM, Luck JC. Amiodarone: what have we learned from clinical trials? Clin Cardiol 2009; 23:73-82. [PMID: 10676597 PMCID: PMC6655150 DOI: 10.1002/clc.4960230203] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Amiodarone is an antiarrhythmic agent commonly used in the treatment of supraventricular and ventricular tachyarrhythmias. This paper reviews clinical trials in which amiodarone was used in one of the treatment arms. Key post-myocardial infarction trials include EMIAT and CAMIAT, both of which demonstrated that amiodarone reduced arrhythmic but not overall mortality. In patients with congestive heart failure (CHF), amiodarone was associated with a neutral survival in CHF/STAT and improvement in survival in GESICA. In patients with nonsustained ventricular tachycardia, the MADIT trial demonstrated that therapy with an implantable cardioverter-defibrillator (ICD) improved survival compared with the antiarrhythmic drug arm in such patients, most of whom were taking amiodarone. In sustained VT/VF patients, the CASCADE trial demonstrated that empiric amiodarone lowered arrhythmic recurrence rates compared with other drugs guided by serial Holter or electrophysiologic studies. Several trials including AVID, CIDS, and CASH have demonstrated the superiority of ICD therapy compared with empiric amiodarone in improving overall survival. Clinical implications of these trials are discussed.
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Affiliation(s)
- G V Naccarelli
- Section of Cardiology, Penn State University College of Medicine, Milton S. Hershey Medical Center, PennState Geisinger Health System, Hershey 17033, USA
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Komoriya M, Imai S, Aoyama H, Yagi H, Nagashima M, Enomoto M, Suzuki K, Yamaji S, Takase H, Matsudaira K, Takahashi N, Saito F, Yagi H, Kushiro T, Nagao K, Hirayama A. Long-term Prognosis for Non-ischemic Heart Disease Patients with Premature Ventricular Contraction and Non-sustained Ventricular Tachycardia. J Arrhythm 2008. [DOI: 10.1016/s1880-4276(08)80003-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Amiodarone use after acute myocardial infarction complicated by heart failure and/or left ventricular dysfunction may be associated with excess mortality. Am Heart J 2008; 155:87-93. [PMID: 18082495 DOI: 10.1016/j.ahj.2007.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 09/24/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND We sought to assess the association of amiodarone use with mortality during consecutive periods in patients with post-acute myocardial infarction with left ventricular systolic dysfunction and/or HF treated with a contemporary medical regimen. METHODS This study used data from VALIANT, a randomized comparison of valsartan, captopril, or both in patients with acute myocardial infarction with HF and/or left ventricular systolic dysfunction. We compared baseline characteristics of 825 patients treated with amiodarone at randomization with 13,875 patients not treated with amiodarone. Using Cox models, we examined the association of amiodarone use with subsequent mortality during consecutive periods after randomization (days 1-16, 17-45, 46-198, and 199-1096). RESULTS Patients treated with amiodarone were older, had higher Killip class, and were more likely to have a history of diabetes mellitus and hypertension. Adjusting for baseline predictors of mortality, we found that amiodarone use was associated with a significant increase in mortality during 3 of the 4 periods: hazard ratio 1.5, 95% CI (1.1-2.0), P = .02, for days 1 to 16; 2.1 (1.5-2.9), P < .001, for days 17 to 45; 1.1 (0.83-1.46), P = .51, for days 46 to 198; and 1.4 (1.2-1.6), P < .001, for days 199 to 1096. CONCLUSION In this study, amiodarone use was associated with excess early and late all-cause and cardiovascular mortality. These observational findings are in contrast to earlier randomized trials of amiodarone and need to be validated prospectively.
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17
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Abstract
As the population ages and survival from ischaemic heart disease improves, the incidence and prevalence of congestive cardiac failure has increased dramatically. Medical treatments including ACE inhibitors, beta blockers, and aldosterone antagonists have improved the outlook for most patients. However, despite optimal medical treatment there is a significant group of patients who continue to suffer poor morbidity and mortality. Device based treatment consisting of implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy (CRT) devices offer new modes of treatment to patients with symptomatic heart failure despite optimal medical therapy. ICDs have been shown to reduce mortality in patients with severe heart failure while CRT leads to an improvement in functional class, quality of life scores, physiological measures such as peak Vo(2), and reduce hospitalisations. Combination devices, which provide both ICD and CRT functions, have now been seen to provide synergistic benefits in selected patients.
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Affiliation(s)
- A Y Patwala
- The Cardiothoracic Centre, Thomas Drive, Liverpool, UK.
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18
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Abstract
Beta-adrenergic blockers are one of the most frequently prescribed cardiovascular drugs. Numerous beta-blockers are available for clinical use. Although these agents differ substantially, it is not clear whether (and which) differences are clinically relevant. Most of the important differences among agents reflect the relative specificity for beta1-, beta2-, and alpha-adrenergic receptors. Selection of a particular agent and target dose is probably best guided by available trial data, even though data are limited. Nonselective agents (with or without alpha-blocking properties) devoid of intrinsic sympathetic activity (ISA) are most appropriate postinfarction. Evidence exists demonstrating a mortality benefit postinfarction for propranolol, timolol, metoprolol, and, in the presence of left ventricular dysfunction, carvedilol. In the setting of heart failure, the selective agents metoprolol and bisoprolol as well as the nonselective agent carvedilol (which possesses alpha-blocking properties) have a demonstrated mortality benefit. Not all tolerated beta-blockers are associated with a survival benefit and it is probably not advisable to extrapolate benefits to all drugs with similar (although probably not identical) properties. Carvedilol may possess advantages over other beta-blockers and a possible survival advantage, suggested by the recent Carvedilol or Metoprolol European Trial (COMET), although these findings are not universally accepted. Ultimately, selection of a specific agent avoids obvious contraindications and uses trial data to guide selection and dose as long as side effects are absent or tolerable.
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Affiliation(s)
- Michael J Reiter
- University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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19
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Krahn AD, Connolly SJ, Roberts RS, Gent M. Diminishing proportional risk of sudden death with advancing age: implications for prevention of sudden death. Am Heart J 2004; 147:837-40. [PMID: 15131539 DOI: 10.1016/j.ahj.2003.12.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Advances in primary and secondary prevention of sudden death have led to a wide array of potentially beneficial therapies. Identification of patients most likely to benefit would be of use when considering costly interventions such as an implantable defibrillator. We sought to determine the effect of advancing age on the mode of death in the Amiodarone Trialists Metanalysis. METHODS AND RESULTS Patients (n = 6252; age, 61.2+/-10.5 years; 83% men) were included in an analysis of predictors of sudden death (SD) and all-cause death (ACD), based on baseline variables at enrollment. Patients were divided into 5 age groups: < or =50 years, 51 to 60 years, 61 to 70 years, 71 to 80 years, and >80 years. During a mean of 16.8+/-10.3 months of follow-up, there were 1023 deaths, with an annual overall mortality rate of 11.7%. Both sudden death and nonsudden death rates increased with age, although the increase of nonsudden death with age was more dramatic. The overall proportion of death that was sudden (SD/ACD ratio) was 0.41, falling from 0.51 before age 50 years to 0.26 after age 80 years (P =.002 for trend). The SD/ACD ratio was not affected by sex, New York Heart Association Class, or left ventricular ejection fraction. CONCLUSIONS Although the incidence of sudden death increases with age, the proportion of death that is sudden diminishes markedly. This finding may influence the yield of interventions targeted at prevention of sudden death.
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Affiliation(s)
- Andrew D Krahn
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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20
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Somberg JC. Arrhythmia therapy. Am J Ther 2002; 9:537-42. [PMID: 12424515 DOI: 10.1097/00045391-200211000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- John C Somberg
- Rush-Presbyterian-St. Luke's Medical Center, Rush University, Chicago, Illinois, USA
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21
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Yoshiga Y, Shimizu A, Yamagata T, Hayano T, Ueyama T, Ohmura M, Itagaki K, Kimura M, Matsuzaki M. Beta-blocker decreases the increase in QT dispersion and transmural dispersion of repolarization induced by bepridil. Circ J 2002; 66:1024-8. [PMID: 12419934 DOI: 10.1253/circj.66.1024] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Bepridil is effective for intractable cardiac arrhythmia, but in rare cases will induce torsades de pointes (TdP) associated with QT interval prolongation. Beta-blockers will effectively prevent TdP in some clinical settings, so the effect of beta-blocker on the change in QT interval, QT dispersion and transmural dispersion of repolarization (TDR) induced by bepridil was investigated in 10 patients (7 male, 3 female; 62+/-6 years old) with intractable paroxysmal atrial fibrillation. The QTc interval, QTc dispersion and TDR were measured before and after 1 month of administration of bepridil, and then a beta-blocker was added and the QTc interval, QTc dispersion and TDR re-measured 1 month later. Bepridil significantly prolonged the QTc interval (0.42+/-0.05 to 0.50+/-0.08; p<0.01), and increased both the QT dispersion (0.07+/-0.05 to 0.14+/-0.08; p<0.01) and TDR (0.10+/-0.04 to 0.16+/-0.05; p<0.01). The addition of a beta-blocker decreased the QTc interval (0.50+/-0.08 to 0.47+/-0.04; p=0.09) and significantly decreased both the QTc dispersion (0.14 +/-0.08 to 0.06+/-0.02; p<0.01) and TDR (0.16+/-0.05 to 0.11+/-0.04; p<0.001). Compared with the control, the combination therapy significantly prolonged the QTc interval, but did not increase either QTc dispersion or TDR, and so was effective in all patients with intractable AF. The findings suggest that beta-blocker reduces the increase in QT dispersion and TDR induced by bepridil, and combined therapy with bepridil and beta-blocker might thus be useful for intractable atrial fibrillation.
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Affiliation(s)
- Yasuhiro Yoshiga
- Division of Cardiovascular Medicine, Department of Medical Bioregulation, Yamaguchi University School of Medicine, Ube, Japan
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22
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Hilleman DE, Bauman AL. Role of Antiarrhythmic Therapy in Patients at Risk for Sudden Cardiac Death: An Evidence-Based Review. Pharmacotherapy 2001; 21:556-75. [PMID: 11349745 DOI: 10.1592/phco.21.6.556.34550] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sudden cardiac death (SCD) accounts for more than half of all cardiac deaths occurring each year in the United States. Although it has several causes, patients at greatest risk are those with coronary artery disease and impaired left ventricular function, heart failure secondary to ischemia or idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy, documented sustained ventricular tachycardia or ventricular fibrillation, and survivors of cardiac arrest. The presence of asymptomatic ventricular arrhythmias, positive signal-averaged electrocardiogram (ECG), low heart rate variability index, or inducible ventricular tachycardia or ventricular fibrillation increases the risk. In primary prevention trials in patients with ischemic heart disease, beta-blockers reduced both total mortality and SCD, whereas class I antiarrhythmic drugs, especially class IC, increased mortality. Among class III agents, d,l-sotalol and dofetilide have a neutral effect on mortality, whereas d-sotalol increases mortality. Amiodarone has a neutral effect on total and cardiac mortality but does reduce the risk of arrhythmic death and cardiac arrest. Three primary prevention trials in patients with ischemic heart disease were conducted with implantable cardioverter-defibrillators (ICDs). Patients with low ejection fractions (EFs), asymptomatic ventricular arrhythmias, and inducible ventricular tachycardia or ventricular fibrillation had significant reductions in total, cardiac, and arrhythmic death with ICDs compared with either no drug therapy or conventional antiarrhythmic agents. The ICDs did not reduce mortality in patients with low EFs and a positive signal-averaged ECG undergoing coronary bypass graft. In those with heart failure, beta-blockers reduced total and SCD mortality, but dofetilide and amiodarone had a neutral effect on mortality. In the secondary prevention of SCD, antiarrhythmic drugs alone generally are not thought to improve survival. In three trials in patients with documented sustained ventricular tachycardia or ventricular fibrillation, or survivors of SCD, ICDs reduced cardiac and arrhythmic mortality. Total mortality, however, was significantly reduced in only one of these trials. The role of antiarrhythmic drugs in secondary prevention of SCD is limited to patients in whom ICD is inappropriate or in combination with ICD. Antiarrhythmics can be given selectively with ICDs to decrease episodes of ventricular tachycardia or fibrillation to reduce ICD discharges, to suppress episodes of nonsustained ventricular tachycardia that trigger ICD discharges, to slow the rate of ventricular tachycardia to increase hemodynamic stability, to allow effective antitachycardia pacing, or to suppress supraventricular arrhythmias.
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Affiliation(s)
- D E Hilleman
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Allied Health Professions, Omaha, Nebraska 68178, USA
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23
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Abstract
Congestive heart failure is increasing in prevalence and, despite recent advances in therapy, mortality remains high. Sudden cardiac death (SCD) represents a significant percentage of overall mortality, accounting for almost 1 in 2 deaths in patients with congestive heart failure. In patients with asymptomatic left ventricular dysfunction or mild degrees of functional impairement, overall annual mortality is low, although a significant portion of the deaths are sudden; on the other hand, in advanced heart failure annual mortality increases, but SCD contributes to it to a lesser degree. The mechanisms of SCD in heart failure are multiple, including ventricular tachycardia/ventricular fibrillation, bradyarrhythmias, electromechanical dissociation, acute coronary events, and thromboembolic events. Only a minority of patients with advanced heart failure or on the waiting list for heart transplant experience SCD as a consequence of ventricular tachycardia (VT) or ventricular fibrillation (VF). The availability of effective therapies to prevent sudden arrhythmic death, such as that provided by automatic implantable cardioverter defibrillators, may help to reduce the burden of SCD in congestive heart failure, but major efforts will be needed to identify the candidates who may benefit from this approach.
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Affiliation(s)
- E de Teresa
- Department of Cardiology, Hospital Clínico Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
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24
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O'Connor CM, Gattis WA, Ryan TJ. The role of clinical nonfatal end points in cardiovascular phase II/III clinical trials. Am Heart J 2000; 139:S143-54. [PMID: 10740121 DOI: 10.1016/s0002-8703(00)90062-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- C M O'Connor
- Duke University Medical Center, Durham, NC 27710, USA
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25
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García García J, Serrano Sánchez JA, del Castillo Arrojo S, Cantalapiedra Alsedo JL, Villacastín J, Almendral J, Arenal A, González S, Delcán Domínguez JL. [Predictors of sudden death in coronary artery disease]. Rev Esp Cardiol 2000; 53:440-62. [PMID: 10712973 DOI: 10.1016/s0300-8932(00)75108-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although advances in the management of acute myocardial infarction have resulted in a decline in long-term risk of sudden death, it continues to be high in certain subsets of patients. Thus, it is important to identify and treat these patients. Left ventricular ejection fraction less than 0.40, frequent premature ventricular ectopy on Holter monitoring, late potentials on signal-averaged electrocardiogram, impaired heart rate variability, abnormal baroreflex sensitivity and inducible sustained monomorphic ventricular tachycardia during electrophysiological study are predictors of sudden death and arrhythmic events. Although the negative predictive value of each factor is high, the positive predictive accuracy is low. Several tests can be combined to obtain higher positive predictive values. In fact, in some studies combined noninvasive tests have been used to select patients for ventricular stimulation study. Some preventive treatment can be applied in these patients. Available data do not justify prophylactic therapy with amiodarone in high-risk survivors of acute myocardial infarction. Sudden death and total mortality have been significantly reduced in postinfarction patients by long-term beta blockade. Hence, beta blockers should be given to all patients with acute myocardial infarction who do not have contraindications to their use. The MADIT study has shown the beneficial effect of implantable cardioverter defibrillator in reducing mortality in patients with prior myocardial infarction, an ejection fraction less than 0.36, asymptomatic nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia, unsuppressable by procainamide. Besides, several studies are under way to evaluate the prophylactic use of implantable defibrillator for improving survival in high-risk patients.
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Affiliation(s)
- J García García
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid
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26
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Abstract
Amiodarone is an antiarrhythmic agent commonly used in the treatment of supraventricular and ventricular tachyarrhythmias. This article reviews the results and clinical implications of primary and secondary prevention trials in which amiodarone was used in one of the treatment arms. Key post-myocardial infarction primary prevention trials include the European Myocardial Infarct Amiodarone Trial (EMIAT) and the Canadian Amiodarone Myocardial Infarction Trial (CAMIAT), both of which demonstrated that amiodarone reduced arrhythmic but not overall mortality. In congestive heart failure patients, amiodarone was studied as a primary prevention strategy in two pivotal trials: Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiac en Argentina (GESICA) and Amiodarone in Patients With Congestive Heart Failure and Asymptomatic Ventricular Arrhythmia (CHF-STAT). Amiodarone was associated with a neutral overall survival and a trend toward improved survival in nonischemic cardiomyopathy patients in CHF/STAT and improved survival in GESICA. In post-myocardial infarction patients with nonsustained ventricular tachycardia and a depressed ejection fraction, the Multicenter Automatic Defibrillator Implantation Trial (MADIT) demonstrated that implantable cardioverter-defibrillators (ICD) statistically improved survival compared to the antiarrhythmic drug arm, most of whose patients were taking amiodarone. In patients with histories of sustained ventricular tachycardia or ventricular fibrillation, the Cardiac Arrest Study in Seattle: Conventional Versus Amiodarone Drug Evaluation (CASCADE) trial demonstrated that empiric amiodarone lowered arrhythmic recurrence rates compared to other drugs guided by serial Holter or electrophysiologic studies. However, arrhythmic death rates were high in both treatment arms of the study. Several secondary prevention trials, including the Antiarrhythmics Versus Implantable Defibrillators Study (AVID), the Canadian Implantable Defibrillator Study (CIDS), and the Cardiac Arrest Study Hamburg (CASH), have demonstrated the superiority of ICD therapy compared to empiric amiodarone in improving overall survival. Based on the above findings, amiodarone is safe to use in post-myocardial infarction and congestive heart failure patients that need antiarrhythmic therapy. Although amiodarone is effective in treating malignant arrhythmias, high-risk patients should be considered for an ICD as frontline therapy.
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Affiliation(s)
- G V Naccarelli
- Section of Cardiology and the Cardiovascular Center, Penn State University College of Medicine, Milton S. Hershey Medical Center 17033, USA
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27
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28
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Affiliation(s)
- S J Connolly
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada.
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29
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Abstract
During the past 15 years, the efficacy of antiarrhythmic drugs has been investigated for reducing premature death in patients at high risk of arrhythmia. Whereas the benefits of beta-blocker therapy are well established, a reduction in mortality with other antiarrhythmic drugs remains unproved and in some cases, there is evidence of increased mortality with class I and some class III agents. A limitation of individual clinical trials is inadequate sample size to detect significant differences between interventions. Meta-analysis, by combining results from multiple clinical trials, provides a technique to overcome sample size limitations and assess the benefits and limitations of an intervention. Thirteen randomized clinical trials evaluated the role of prophylactic amiodarone in patients at risk of death from cardiac arrhythmias. Whereas 3 of these studies reported a reduction in mortality, several others revealed no benefits of amiodarone. Because neither trial was designed to detect reductions in total mortality, it remained unclear whether the beneficial effect of amiodarone on arrhythmic death and resuscitated ventricular fibrillation translated into a beneficial effect on total mortality. To address this, a meta-analysis was performed from the 13 trials of amiodarone in patients after an acute myocardial infarction or with congestive heart failure. The results showed a significant reduction in mortality and in arrhythmic death with amiodarone.
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Affiliation(s)
- S J Connolly
- Faculty of Health Sciences, McMaster University, Ontario, Canada
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30
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Abstract
Beta-adrenergic blockers reduce mortality and sudden death in patients convalescing from myocardial infarction, and probably in patients with heart failure. However, the notion that class I antiarrhythmic drugs might save lives by suppressing the triggers of life-threatening ventricular arrhythmias was proved incorrect when the Cardiac Arrhythmia Suppression Trial (CAST) demonstrated that patients, whose ventricular ectopics were successfully suppressed by a number of class I antiarrhythmic drugs, died more readily than similar patients when treated with drugs rather than the placebo. Attention was diverted to class III antiarrhythmic drugs for patients with a poor ejection fraction who survived myocardial infarction and those with heart failure. A preliminary metaanalysis of 3 trials (Basel Antiarrhythmic Study of Infarct Survival [BASIS], Polish Amiodarone Trial [PAT], and the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial [CAMIAT]) suggested that amiodarone might reduce arrhythmic and all-cause mortality in high-risk post-myocardial-infarction (MI) patients. BASIS suggested that this was only true for patients with preserved ventricular function. Nevertheless, 2 major trials were instituted: the European Myocardial Infarct Amiodarone Trial (EMIAT) and the CAMIAT. Both reported similar results except that patients recruited because of high-density ventricular ectopy seemed to benefit a little more from amiodarone than did patients with poor ventricular function. Detailed analysis of these trials revealed important insights into the value of amiodarone.
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Affiliation(s)
- Y G Yap
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom
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31
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Abstract
SCD continues to be an important cause of death and morbidity. Despite expanding insight into the mechanisms causing SCD, the population at high risk is not being effectively identified. Although there is still much to do in the management phase of SCD (predicting the efficacy of various therapies), recent clinical trials have helped define the relative risks and benefits of therapies in preventing SCD. Trials are underway to determine whether treating other patient populations, including asymptomatic patients after MI, will improve survival rate. The approach to reducing mortality rate will always be multifaceted; primary prevention of coronary artery disease and prompt salvage of jeopardized myocardium are 2 important aspects of this approach. In addition to interventions for MI, such as myocardial revascularization when indicated, simple and easily administered therapies that are likely to remain the most effective prophylactic interventions are aspirin, ACE inhibitors, beta-blockers, and cholesterol-lowering agents. However, the MADIT and AVID data clearly demonstrate a role for ICD therapy in a subgroup of patients who have VT/VF and are at risk of cardiac arrest. Even though the absolute magnitude of benefit associated with ICDs is still to be determined, the AVID study and other recent reports provide convincing evidence that patients who have VT/VF fare better with ICDs than with antiarrhythmic drug therapy. For the high-risk population described in this article, in addition to aggressive anti-ischemic and heart failure therapy, ICDs are now a mainstay of life-saving treatment. Still to be surmounted is the challenge of identifying patients who have nonischemic substrates and of providing them with the appropriate therapy. Guided by genetic studies and new insight into the mechanisms of such problems as congenital long QT syndrome, life-saving and life-enhancing therapies may soon be available for the management of SCD.
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Affiliation(s)
- J Sra
- University of Wisconsin Medical School, St Luke's Medical Center, Milwaukee, USA
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32
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Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J. Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials. Am J Cardiol 1999; 83:55D-63D. [PMID: 10089841 DOI: 10.1016/s0002-9149(98)01027-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Several trials have evaluated the role of amiodarone in decreasing mortality in patients at high risk of developing sudden death. Current evidence does not support the prophylactic use of amiodarone in myocardial infarction (MI) survivors with a depressed left ventricular function and/or frequent or complex ventricular ectopy. Some postinfarction trials (e.g., the Spanish Study of Sudden Death [SSSD]) found mortality rates in controls much lower than the expected figures. Other postinfarction trials--the European Amiodarone Myocardial Infarction Arrhythmia Trial (EMIAT) and the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial (CAMIAT)--despite observing a 2-year mortality rate of about 15% as expected, could not demonstrate a significant reduction in mortality. Amiodarone decreases the risk of sudden death in postinfarction patients by about 35%. In patients with a history of heart failure and left ventricular dysfunction, evidence is not sufficiently strong to use amiodarone for prevention of sudden death. The 2 major trials on such patients, Group for the Study of Survival in Heart Failure in Argentina (Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina or GESICA) and the Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure (STAT-CHF), arrived at conflicting results. Meta-analyses have been performed to overcome the small sample size of these trials, with the aim of assessing the benefit of amiodarone on total mortality. Differences among the recruited populations make it difficult to extract clinically applicable conclusions from these overviews. Even accepting that amiodarone might decrease total mortality by 10%, it is difficult to identify the patients for whom such a beneficial effect applies. A practical consequence of amiodarone trials is that this drug can be used rather safely in patients with left ventricular dysfunction of any etiology as, in contrast to some class I agents, it does not increase mortality. Therefore, amiodarone is the drug of choice when antiarrhythmic drug treatment is indicated in patients with left ventricular dysfunction.
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MESH Headings
- Aged
- Amiodarone/administration & dosage
- Amiodarone/adverse effects
- Anti-Arrhythmia Agents/administration & dosage
- Anti-Arrhythmia Agents/adverse effects
- Clinical Trials as Topic
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Female
- Humans
- Male
- Middle Aged
- Myocardial Infarction/complications
- Myocardial Infarction/drug therapy
- Myocardial Infarction/mortality
- Survival Rate
- Tachycardia, Ventricular/drug therapy
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/mortality
- Treatment Outcome
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/mortality
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Affiliation(s)
- J Farré
- Department of Cardiology, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Spain
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33
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Gonzalez ER, Kannewurf BS, Ornato JP. Intravenous amiodarone for ventricular arrhythmias: overview and clinical use. Resuscitation 1998; 39:33-42. [PMID: 9918445 DOI: 10.1016/s0300-9572(98)00111-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Numerous pharmacological agents with varying cellular electrophysiological effects are available to treat cardiac arrhythmias. Amiodarone is predominantly a Vaughan Williams Class III agent, but also possesses electrophysiological characteristics of the other three Vaughan Williams classes (Class I and IV and minor Class II effects). Amiodarone's primary mechanism is to prolong the cardiac action potential and repolarization time leading to an increased refractory period and reduced membrane excitability. The efficacy and tolerability of intravenous (IV) amiodarone for acute treatment of recurrent and refractory ventricular tachycardia and ventricular fibrillation has been demonstrated in clinical trials. The ARREST trial, a randomized trial comparing IV amiodarone to placebo, found a significant improvement in the proportion of patients surviving to the emergency department following out-of-hospital cardiac arrest in amiodarone-treated patients. Intravenous amiodarone is an effective anti-arrhythmic agent for the acute treatment of life-threatening ventricular arrhythmias and represents an important treatment option for emergency anti-arrhythmic therapy for patients suffering from cardiac arrest.
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Affiliation(s)
- E R Gonzalez
- Department of Pharmacy and Pharmaceutics, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond 23298, USA
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34
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Yamada S, Yamaguchi I. Effect of relatively low dose amiodarone therapy on left ventricular function in patients with ventricular tachyarrhythmias. JAPANESE CIRCULATION JOURNAL 1998; 62:707-9. [PMID: 9766713 DOI: 10.1253/jcj.62.707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The effect of oral amiodarone (AMD) therapy on left ventricular (LV) function was evaluated retrospectively in Japanese patients with ventricular tachyarrhythmias and congestive heart failure. Seventeen patients were treated with oral AMD (maintenance dose 191+/-52mg/day) for more than 12 months. Fractional shortening (FS) on echocardiography revealed a trend towards an increase in the short-term (3 months) (p=0.06), but was not significant in the long-term follow-up period (more than 12 months) after AMD therapy. In 8 patients with 1 episode of myocardial infarction, FS revealed a trend towards an increase (p=0.09). In all of the 4 patients with dilated cardiomyopathy whose LV end-diastolic diameter was increased, FS was decreased in the long-term follow-up. Neither hospitalization frequency nor New York Heart Association classification were reduced by AMD therapy. In conclusion,oral AMD therapy did not cause LV function to recover significantly and could not improve the clinical course in patients with ventricular tachyarrhythmias. However, if the underlying disease is not progressive, AMD therapy may improve LV function.
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Affiliation(s)
- S Yamada
- Department of Internal Medicine, University of Tsukuba, Ibaraki, Japan
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35
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Abstract
Sudden cardiac death (SCD) remains a significant medical problem in the United States. The incidence of SCD increases with advancing age because cardiovascular disease is more prevalent in the elderly. Management of ventricular arrhythmias in the elderly patient is especially challenging because of increased risk of interventional and pharmacologic therapies, altered pharmacokinetics of drugs, and sometimes unclear long-term benefits.
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Affiliation(s)
- D D Tresch
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, USA
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Naccarelli GV, Wolbrette DL, Dell'Orfano JT, Patel HM, Luck JC. A decade of clinical trial developments in postmyocardial infarction, congestive heart failure, and sustained ventricular tachyarrhythmia patients: from CAST to AVID and beyond. Cardiac Arrhythmic Suppression Trial. Antiarrhythmic Versus Implantable Defibrillators. J Cardiovasc Electrophysiol 1998; 9:864-91. [PMID: 9727666 DOI: 10.1111/j.1540-8167.1998.tb00127.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Multiple trials using antiarrhythmic drugs, pharmacologic therapy, and implantable cardioverter defibrillators have been performed in an attempt to improve survival in patients: (1) postmyocardial infarction; (2) with congestive heart failure, with and without nonsustained ventricular tachycardia; and (3) with sustained ventricular tachycardia and those who have survived an out-of-hospital cardiac arrest. This article reviews some of the key findings and limitations of completed and ongoing trials. We also make recommendations for the current treatment of such patients based on the results of these trials.
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Affiliation(s)
- G V Naccarelli
- Section of Cardiology and Cardiovascular Center, Penn State University College of Medicine, Hershey, USA
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Pedretti RF, Migliori GB, Mapelli V, Daniele G, Podrid PJ, Tramarin R. Cost-effectiveness analysis of invasive and noninvasive tests in high risk patients treated with amiodarone after acute myocardial infarction. J Am Coll Cardiol 1998; 31:1481-9. [PMID: 9626823 DOI: 10.1016/s0735-1097(98)00171-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate 1) the cost-effectiveness of amiodarone therapy in postinfarction patients; and 2) the influence of alternative diagnostic strategies (noninvasive only vs. noninvasive and electrophysiologic testing) on survival benefit and cost-effectiveness ratio of amiodarone therapy. BACKGROUND The cost-effectiveness of amiodarone therapy in postinfarction patients is still unknown, and no study has determined which diagnostic strategy should be used to maximize amiodarone survival benefit while improving its cost-effectiveness ratio. METHODS We designed a postinfarction scenario wherein heart rate variability analysis on 24-h Holter monitoring was used as a screening test for 2-year amiodarone therapy in a cohort of survivors (mean age 57 years) of a recent myocardial infarction. Three different therapeutic strategies were compared: 1) no amiodarone; 2) amiodarone in patients with depressed heart rate variability; 3) amiodarone in patients with depressed heart rate variability and a positive programmed ventricular stimulation. Total variable costs and quality-adjusted life expectancy during a 20-year period were predicted with use of a Markov simulation model. Costs and charges were calculated with reference to an Italian and American hospital. RESULTS Amiodarone therapy in patients with depressed heart rate variability and a positive programmed ventricular stimulation was dominated by a blend of the two alternatives. Compared with the no-treatment strategy, the incremental cost-effectiveness ratio of amiodarone therapy in patients with depressed heart rate variability was $10,633 and $39,422 per gained quality-adjusted life-year using Italian costs and American charges, respectively. CONCLUSIONS Compared with a noninterventional option, amiodarone prescription in all patients with depressed heart rate variability seems to be a more appropriate approach than the alternative based on the combined use of heart rate variability and electrophysiologic study.
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Affiliation(s)
- R F Pedretti
- Fondazione Salvatore Maugeri, Care and Research Institute, Administrative Department, Rehabilitation Institute, Tradate, Italy.
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Uretsky BF, Sheahan RG. Primary prevention of sudden cardiac death in heart failure: will the solution be shocking? J Am Coll Cardiol 1997; 30:1589-97. [PMID: 9385881 DOI: 10.1016/s0735-1097(97)00361-6] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sudden cardiac death (SCD) may occur in as many as 40% of all patients who suffer from heart failure. This review describes the scope of the problem, risk factors for SCD, the effect of medications used in heart failure on SCD and the potential effect of the implantable cardioverter-defibrillator in primary prevention.
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Affiliation(s)
- B F Uretsky
- Division of Cardiology, University of Texas Medical Branch at Galveston, 77555-0553, USA.
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39
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Sim I, McDonald KM, Lavori PW, Norbutas CM, Hlatky MA. Quantitative overview of randomized trials of amiodarone to prevent sudden cardiac death. Circulation 1997; 96:2823-9. [PMID: 9386144 DOI: 10.1161/01.cir.96.9.2823] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Some randomized clinical trials of amiodarone therapy to prevent sudden cardiac death have had positive results and others have had negative results, but all were relatively small. This meta-analysis aimed to pool all trials to assess the effect of amiodarone on mortality and the impact of differences in patient population and study design on trial outcomes. METHODS AND RESULTS Fifteen randomized trials were identified, and outcome measures were combined by use of a random effects model. The effect of patient population and study design on total mortality was assessed by use of a hierarchical Bayes model. Amiodarone reduced total mortality by 19% (confidence limits, 6% to 31%; P<.01), with somewhat greater reductions in cardiac mortality (23%, P<.001) and sudden death (30%, P<.001). Mortality reductions were similar in trials enrolling patients after myocardial infarction (21%), with left ventricular dysfunction (22%), and after cardiac arrest (25%). There was a trend toward greater risk reduction in trials requiring evidence of ventricular ectopy (25%) than in the remaining trials (10%). The trials using placebo controls had considerably less risk reduction (10%) than trials with active controls (27%) or usual care controls (42%, posterior odds <0.02). CONCLUSIONS Amiodarone reduced total mortality by 10% to 19% in patients at risk of sudden cardiac death. Amiodarone reduced risk similarly in patients after myocardial infarction, with heart failure, or with clinically evident arrhythmia. The apparent inconsistencies among results of randomized trials appear to be due to small sample sizes and the type of control group used, not the type of patient enrolled.
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Affiliation(s)
- I Sim
- Department of Health Research and Policy, Stanford University School of Medicine, Calif 94305-5092, USA
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Sicouri S, Moro S, Litovsky S, Elizari MV, Antzelevitch C. Chronic amiodarone reduces transmural dispersion of repolarization in the canine heart. J Cardiovasc Electrophysiol 1997; 8:1269-79. [PMID: 9395170 DOI: 10.1111/j.1540-8167.1997.tb01018.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Amiodarone is a potent antiarrhythmic agent used in the management of both atrial and ventricular arrhythmias. In addition to its beta-blocking properties, amiodarone is known to block the sodium, potassium, and calcium channels in the heart. Its complex electropharmacology notwithstanding, the reasons for the high efficacy of the drug remain unclear. Also not well understood is the basis for the low incidence of proarrhythmia seen with amiodarone relative to other agents with Class III actions. The present study was designed to examine the effects of chronic amiodarone in epicardial, endocardial, and M cells of the canine left ventricle. METHODS AND RESULTS We used standard microelectrode techniques to record transmembrane activity from endocardial, epicardial, mid-myocardial, and transmural strips isolated from the canine left ventricle. Tissues were obtained from mongrel dogs receiving amiodarone orally (30 to 40 mg/kg per day) for 30 to 45 days or from untreated controls. Chronic amiodarone produced a greater prolongation of action potential duration in epicardium and endocardium, but less of an increase, or even a decrease at slow rates, in the M region, thereby reducing transmural dispersion of repolarization. In addition, chronic amiodarone therapy suppressed the ability of the IKr blocker, d-sotalol, to induce a marked dispersion of repolarization or early afterdepolarization activity. CONCLUSION Our data demonstrate for the first time a direct effect of chronic amiodarone treatment to differentially alter the cellular electrophysiology of ventricular myocardium so as to produce an important decrease in transmural dispersion of repolarization, especially under conditions in which dispersion is exaggerated. These results may contribute to our understanding of the effectiveness of amiodarone in the treatment of life-threatening arrhythmias as well as to our understanding of the low incidence of proarrhythmia attending therapy with chronic amiodarone in comparison with other Class III agents.
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Affiliation(s)
- S Sicouri
- Division Cardiologia, Hospital Ramos Mejia, Buenos Aires, Argentina
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Abstract
Death due to ventricular tachyarrhythmia (VT) remains an important public health problem; patients with prior myocardial infarction (MI) constitute the largest identifiable population for prophylactic interventions. Targeting of progressively higher-risk subgroups of post-MI survivors carries inevitable tradeoffs with respect to the global impact of interventions on overall mortality. Therapy with aspirin, beta blockers, and angiotensin-converting enzyme (ACE) inhibitors comprise the benchmark against which all additional interventions, including implantable defibrillators, must be measured. Initial enthusiasm for empiric amiodarone therapy has been tempered by the limited benefit demonstrated in recent randomized trials. Trials of other class III antiarrhythmic drugs, including both d,l-sotalol and d-sotalol, have also failed to demonstrate survival benefit. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) demonstrated significantly improved survival associated with defibrillators in a small subgroup of post-MI survivors with a high short-term risk of death. The ultimate number and optimal criteria for selection of patients who may benefit from prophylactic defibrillator therapy after MI will undergo continued evolution as new data from current and ongoing trials become available.
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Affiliation(s)
- D J Wilber
- Section of Cardiology, University of Chicago Hospitals, Illinois 60637, USA
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42
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Underwood RD, Sra J, Akhtar M. Evaluation and treatment strategies in patients at high risk of sudden death post myocardial infarction. Clin Cardiol 1997; 20:753-8. [PMID: 9294665 PMCID: PMC6655294 DOI: 10.1002/clc.4960200908] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/1995] [Accepted: 05/05/1997] [Indexed: 02/05/2023] Open
Abstract
Over 50 percent of deaths in patients who survive an acute myocardial infarction are due to fatal ventricular tachyarrhythmias. Patients who survive an episode of sustained ventricular arrhythmia are at highest risk of recurrent cardiac arrest. Electrophysiologic studies have been found to be useful in guiding therapy and reducing mortality in these patients and in patients with syncope due to arrhythmic etiology. Evaluation and treatment of nonsustained ventricular tachycardia post infarction remains somewhat controversial. A recently published trial (MADIT), however, showed improved survival with an implanted defibrillator in patients with coronary disease and asymptomatic nonsustained ventricular tachycardia. Asymptomatic patients post infarction at high risk include those who have significant left ventricular dysfunction, late potentials, high-grade ventricular ectopy, and abnormal heart rate variability. These tests individually, however, have a low positive predictive accuracy. This, combined with the fact that antiarrhythmic drugs are frequently not effective and can be proarrhythmic, leaves the best treatment for these patients uncertain. It is known, however, that beta-adrenoreceptor blocking agents do reduce mortality after an acute myocardial infarction. Early studies have shown mixed results relating to sudden death and total mortality with amiodarone. To date, no other antiarrhythmic drug has shown benefit, while several have been shown to be harmful. Recent studies have also shown some beneficial effects of angiotensin-converting enzyme inhibitors, carvedilol, a third-generation beta-blocking agent with vasodilator properties, and the angiotensin II receptor antagonist losartan. However, their precise role in reducing sudden death needs to be defined further.
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Affiliation(s)
- R D Underwood
- Electrophysiology Laboratory, Milwaukee Heart Institute of Sinai Samaritan Medical Center, Wisconsin, USA
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Abstract
OBJECTIVES We sought to assess the odds of experiencing adverse effects with low dose amiodarone therapy compared with placebo. BACKGROUND An estimate of the likelihood of experiencing amiodarone-related adverse effects with exposure to low daily doses of the drug is lacking in the published reports, and little information is available on adverse effect event rates in control groups not receiving the drug. METHODS Data from four published trials involving 1,465 patients were included in a meta-analysis design. The criteria for inclusion were 1) double-blind, placebo-controlled design; 2) absence of a crossover design between patient groups; 3) mean follow-up of at least 12 months; 4) maintenance amiodarone dose < or = 400 mg/day; and 5) presence of an explicit description of adverse effects. Data were pooled after testing for homogeneity of treatment effects across trials, and summary odds ratios were calculated by the Peto-modified Mantel-Haenszel method for each adverse effect. RESULTS The mean amiodarone dose per day ranged from 152 to 330 mg; 738 patients were randomized to receive amiodarone and 727 placebo. Exposure to amiodarone in this dose range, for a minimal duration of 12 months, resulted in odds similar to those of placebo for hepatic and gastrointestinal adverse effects, but in significantly higher odds than those of placebo (p < 0.05) for experiencing thyroid (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.0 to 8.7), neurologic (OR 2.0, 95% CI 1.1 to 3.7), skin (OR 2.5, 95% CI 1.1 to 6.2), ocular (OR 3.4, 95% CI 1.2 to 9.6) and bradycardic (OR 2.2, 95% CI 1.1 to 4.3) adverse effects. A trend toward increased odds of pulmonary toxicity was noted (OR 2.0, 95% CI 0.9 to 5.3), but this did not reach statistical significance (p = 0.07). The unadjusted total incidence of drug discontinuation was 22.9% in the amiodarone group and 15.4% in the placebo group. The odds of discontinuing the drug in the amiodarone group was approximately 1.5 times that of the placebo group (OR 1.52, 95% CI 1.2 to 1.9) (p = 0.003). CONCLUSIONS Compared with placebo, there is a higher likelihood of experiencing several amiodarone-related adverse effects with exposure to low daily doses of the drug. Thus, although low dose amiodarone may be well tolerated, it is not free of adverse effects.
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Affiliation(s)
- V R Vorperian
- Department of Medicine, University of Wisconsin School of Medicine, Madison, USA.
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Singh SN, Fisher SG, Deedwania PC, Rohatgi P, Singh BN, Fletcher RD. Pulmonary effect of amiodarone in patients with heart failure. The Congestive Heart Failure-Survival Trial of Antiarrhythmic Therapy (CHF-STAT) Investigators (Veterans Affairs Cooperative Study No. 320). J Am Coll Cardiol 1997; 30:514-7. [PMID: 9247526 DOI: 10.1016/s0735-1097(97)00157-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the pulmonary effects of amiodarone in patients with heart failure, in those with chronic obstructive pulmonary disease (COPD) and in those undergoing a surgical procedure. BACKGROUND Amiodarone has been known to cause pulmonary complications; especially in those with COPD and in those undergoing a surgical procedure. METHODS Patients receiving vasodilator therapy for congestive heart failure were prospectively randomized to placebo or amiodarone at 800 mg/day for 14 days, 400 mg/day for 50 weeks and then 300 mg/day thereafter. Chest X-ray film and pulmonary function tests with diffuse capacity of carbon monoxide (DLCO) were obtained at baseline and annually. The power to detect a 20% difference in DLCO at 1 year exceeded 90% in all patients and in those with COPD (two-sided alpha = 0.05). The sample allowed a 75% power to detect pulmonary complications (1% vs. 5%) between the two treatment groups. RESULTS There was no difference in baseline characteristics between patients randomized to amiodarone (n = 269) or placebo (n = 250). The DLCO measurements at randomization were 18.3 +/- 6.9 and 17.7 +/- 7.6 ml/min per mm Hg for the amiodarone and placebo groups, respectively (p = 0.3). At 1 and 2 years, DLCO measurements were 17.7 +/- 7.0 and 18.3 +/- 7.7 ml/min per mm Hg for the amiodarone group and 17.9 +/- 7.2 and 18.2 +/- 7.2 for the placebo group, respectively. There were no significant differences between the groups, with corresponding p values of 0.73 ad 0.96 at years 1 and 2, respectively. Among patients with COPD, DLCO measurements at randomization were 17.9 +/- 6.7 and 15.8 +/- 6.8 ml/min per mm Hg for the amiodarone and placebo groups, respectively. At years 1 and 2, DLCO measurements were 16.6 +/- 7.8 and 17.8 +/- 9.5 ml/min per mm Hg for the amiodarone group and 16.5 +/- 6.6 and 16.3 +/- 7.0 ml/min per mm Hg for the placebo group, with corresponding p values of 0.95 and 0.48, respectively. There was no difference in survival free of noncardiac or perioperative deaths between patients assigned to amiodarone or placebo. Pulmonary fibrosis was diagnosed in four patients (1.1%) treated with amiodarone and in three patients (0.8%) receiving placebo. CONCLUSIONS Our study shows that amiodarone can be safely used, with an acceptable pulmonary toxicity, in patients with heart failure.
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Affiliation(s)
- S N Singh
- Veterans Affairs Medical Center, Washington, D.C. 20422, USA
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Domanski MJ, Zipes DP, Schron E. Treatment of sudden cardiac death. Current understandings from randomized trials and future research directions. Circulation 1997; 95:2694-9. [PMID: 9193439 DOI: 10.1161/01.cir.95.12.2694] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M J Domanski
- Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Md 20892, USA
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46
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Affiliation(s)
- J Sanderson
- Department of Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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47
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Fogoros RN. Major clinical trials assessing the prophylactic use of amiodarone in patients with ventricular tachyarrhythmias. CONTROLLED CLINICAL TRIALS 1996; 17:37S-46S. [PMID: 8877266 DOI: 10.1016/s0197-2456(96)00017-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to summarize and critique recently completed and ongoing clinical trials assessing the prophylactic use of amiodarone in patients with potentially life-threatening ventricular arrhythmias. Three of the trials compare amiodarone with an implantable cardioverter defibrillator.
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Affiliation(s)
- R N Fogoros
- Department of Medicine, Medical College of Pennsylvania, Allegheny General Hospital, Pittsburgh 15212, USA
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McMurray J, Rankin A. Cardiology--II: Treatment of heart failure and atrial fibrillation and arrhythmias. BMJ (CLINICAL RESEARCH ED.) 1994; 309:1631-5. [PMID: 7819948 PMCID: PMC2542004 DOI: 10.1136/bmj.309.6969.1631] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- J McMurray
- Department of Cardiology, Western General Hospital, Edinburgh
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