β-Blocker premedication does not increase the frequency of allergic reactions from coronary CT angiography: Results from the Advanced Cardiovascular Imaging Consortium

Risk for Anaphylactic Reaction from Cardiac Catheterization in Patients Receiving β-Adrenergic Blockers or Angiotensin-Converting Enzyme-Inhibitors

BACKGROUND

β-Adrenergic blockers (BBs) have been associated with increased risk for severe anaphylactic reaction (AR) from contrast media; however, this was shown with intravenous contrast media, before widespread use of low osmolar contrast media, angiotensin-converting enzyme-inhibitors (ACE-Is), and cardioselective BBs.

OBJECTIVE

To assess the risk for AR during cardiac catheterization (CC) associated with BB or ACE-I exposure.

METHODS

Patients who experienced adverse reactions during CC from January 2004 to December 2013 were identified; 1 to 2 matched controls were assigned for each case. We analyzed AR rates in association with demographic variables, medication exposures (BBs, ACE-Is, angiotensin-receptor blockers, aspirin), and comorbidities: cardiovascular disorders, asthma, and atopy.

RESULTS

We analyzed 71,782 CCs. Of these, severe 70 reactors were identified-46 (0.06%) fulfilled AR criteria. There were 35 cases of mild to moderate AR and 11 cases of severe AR (0.015%). There were no significant differences in age (61.3% vs 61.5%), sex (63% vs 64% males), cardiovascular disorder rate (78% vs 93%), and exposure to BBs (46% vs 51%; cardioselective: 77% vs 80%) and ACE-Is (37.0% vs 37.2%) in cases versus controls. Via multivariate logistic regression, BB exposure was not associated with greater AR frequency (P = .35) or severity (P = .40). Neither cardioselective BBs (P = 0.2) nor noncardioselective BBs (P = .5) influenced AR severity. ACE-Is had no effect on AR frequency (P = .35) or severity (P = .14). Lower AR frequency was associated with cardiovascular disorder (P = .01).

CONCLUSIONS

In this case-control study, severe AR was rarely observed. Exposure to BBs or ACE-Is did not significantly influence AR frequency or severity; however, most BBs were cardioselective. Our findings imply that cardioselective BB or ACE-I suspension is not warranted in association with CC.

Relationship Between Anaphylaxis and Use of Beta-Blockers and Angiotensin-Converting Enzyme Inhibitors: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Beta-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs) have been associated with an increased risk and severity of anaphylaxis. However, the evidence supporting these findings is contradictory.

OBJECTIVE

We carried out a systematic review and meta-analysis of studies that assess the influence of BBs and ACEIs on anaphylaxis.

METHODS

We searched PubMed/MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Web of Science for relevant observational studies. We searched for studies where the presence and severity of anaphylaxis were compared between patients taking BBs, ACEIs, both types of drug, or neither type of drug. We performed a meta-analysis using a random-effects model.

RESULTS

A total of 21 studies met the study criteria. Of these, 15 assessed the severity and 9 the incidence of anaphylaxis. The studies brought together 22,313 anaphylaxis episodes for the severity studies and 18,101 anaphylaxis episodes for the studies of new cases of anaphylaxis. BBs and ACEIs increased the severity of anaphylaxis (BBs, odds ratio [OR] 2.19, 95% confidence interval [CI] 1.25-3.84; ACEIs, OR 1.56, 95% CI 1.12-2.16), but not the presence of new cases of anaphylaxis (BBs, OR 1.40, 95% CI 0.91-2.14; ACEIs, OR 1.38, 95% CI 0.39-4.86). It was not possible to perform an analysis adjusted for cardiovascular diseases, because only 1 study each for BBs and ACEIs, respectively, had adjusted data.

CONCLUSIONS

The quality of evidence showing that the use of BBs and ACEI increases the severity of anaphylaxis is low owing to differences in the control of confounders arising from the concomitant presence of cardiovascular diseases.

Computed tomography coronary angiography with heart rate control premedication: a best practice implementation project

BACKGROUND

Computed tomography coronary angiography patient preparation with heart rate control premedication is employed in departments across Australia. However, the methods of administration vary widely between institutions and do not always follow best practice.

OBJECTIVES

This aim of the study was to identify and promote best practice in the administration of heart rate premedication in computed tomography coronary angiography at a regional hospital in Australia.

METHODS

The Joanna Briggs Institute have validated audit and feedback tools to assist with best practice implementation projects. This project used these tools, which involve three phases of activity - a pre-implementation audit, reflecting on results and implementing strategies to address non-compliance, and a post-implementation audit to assess the outcomes.

RESULTS

A baseline audit identified non-compliance in the majority of measured audit criteria. Following implementation of an institution-specific guideline and associated worksheet, improved compliance was shown across all audit criteria.

CONCLUSIONS

Following the development and implementation of institution-specific evidence-based resources relating to heart rate control in computed tomography coronary angiography, a high level of compliance consistent with best practice was achieved.

Are ACE Inhibitors and Beta-blockers Dangerous in Patients at Risk for Anaphylaxis?

The objective of this article is to review the available studies regarding angiotensin converting enzyme (ACE) inhibitors and beta-blockers and their effect on patients at risk for anaphylaxis. A literature search was conducted in PUBMED to identify peer-reviewed articles using the following keywords: anaphylaxis, ACE inhibitor, beta-blocker, food allergy, radiocontrast media, venom allergy, skin testing, and immunotherapy. Some studies show an increased risk of anaphylaxis in patients who are taking ACE inhibitors and beta-blockers, whereas others studies do not show an increased risk. For venom immunotherapy, there are more data supporting the concomitant use of beta-blockers and ACE inhibitors in the build-up and maintenance phases. Most of the medical literature is limited to case reports and retrospective data. Prospective controlled trials are needed on this important topic. For those patients at risk of anaphylaxis who lack cardiovascular disease, it is recommended to avoid beta-blockers and possibly ACE inhibitors. However, for those patients with cardiovascular disease, beta-blockers and ACE inhibitors have been shown to increase life expectancy. Consideration should be given for the concomitant use of these medications while patients are receiving venom immunotherapy.

Coronary Whole-heart MR Angiography: Feasibility of Breath-hold Chasing with Diaphragmatic Navigation

We propose a simple but novel data acquisition technique for whole-heart coronary magnetic resonance angiography (CMRA). In this technique, the breath-hold chasing MRA, data are collected during breath-hold intervals, with the navigation window manually adjusted to the diaphragmatic level. Compared with the conventional free breathing MRA, this method provided 33% reduction of acquisition time and improved visibility of right coronary artery in 18 normal subjects without any additional software or hardware requirements.