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Meerman M, Buijser M, van den Berg L, van den Heuvel AM, Hoohenkerk G, van Driel V, Munsterman L, de Vroege R, Bailey M, Bellomo R, Ludikhuize J. Magnesium sulphate to prevent perioperative atrial fibrillation in cardiac surgery: a randomized clinical trial : A protocol description of the PeriOperative Magnesium Infusion to Prevent Atrial fibrillation Evaluated (POMPAE) trial. Trials 2024; 25:540. [PMID: 39148128 PMCID: PMC11328354 DOI: 10.1186/s13063-024-08368-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 08/02/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common and potentially serious complication post cardiac surgery. Hypomagnesaemia is common after cardiac surgery and recent evidence indicates that supplementation of magnesium may prevent POAF. We aim to investigate the effectiveness of continuous intravenous magnesium sulphate administration in the perioperative period to prevent POAF as compared to placebo. METHODS The (POMPAE) trial is a phase 2, single-center, double-blinded randomized superiority clinical study. It aims to assess the impact of perioperative continuous intravenous magnesium administration on the occurrence of cardiac surgery-related POAF. A total of 530 patients will be included. Eligible patients will be randomized in 1:1 ratio to the intervention or placebo group with stratification based on the presence of valvular surgery. The objective of the infusion is to maintain ionized magnesium levels between 1.5 and 2.0 mmol/L. DISCUSSION The primary outcome measure is the incidence of de novo POAF within the first 7 days following surgery, with censoring at hospital discharge. This trial may generate crucial evidence for the prevention of POAF and reduce clinical adverse events in patients following cardiac surgery. TRIAL REGISTRATION The POMPAE trial was registered at ClinicalTrials.gov under the following identifier NTC05669417, https://clinicaltrials.gov/ct2/show/NCT05669417 . Registered on December 30, 2022. PROTOCOL VERSION Version 3.3, dated 13-01-2023.
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Affiliation(s)
- Manon Meerman
- Department of Intensive Care, HagaZiekenhuis, The Hague, The Netherlands
| | - Marit Buijser
- Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands
| | | | | | - Gerard Hoohenkerk
- Department of Cardiothoracic Surgery, HagaZiekenhuis, The Hague, The Netherlands
| | - Vincent van Driel
- Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands
| | - Luuk Munsterman
- Department of Cardiac Anaesthesia, HagaZiekenhui, The Hague, The Netherlands
| | - Roel de Vroege
- Department of Perfusion, HagaZiekenhuis, The Hague, The Netherlands
| | - Michael Bailey
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Jeroen Ludikhuize
- Department of Intensive Care, HagaZiekenhuis, The Hague, The Netherlands.
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Klinkhammer B, Glotzer TV. Management of Arrhythmias in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:89-103. [PMID: 37973359 DOI: 10.1016/j.ccc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Arrhythmias in the cardiovascular intensive care unit (CVICU) can be difficult to manage because of the complex hemodynamic and respiratory states of critically ill patients. Treating physicians must be educated to prevent, diagnose, and treat a multitude of tachyarrhythmias and bradyarrhythmias. In this review article, the authors outline a pragmatic approach to patient assessment, arrhythmia diagnosis, and management of the most common arrhythmias seen in the CVICU.
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Affiliation(s)
- Brent Klinkhammer
- Division of Cardiac Electrophysiology, Hackensack University Medical Center, Hackensack, NJ 07601, USA; Hackensack Meridian School of Medicine, Hackensack, NJ 07601, USA
| | - Taya V Glotzer
- Division of Cardiac Electrophysiology, Hackensack University Medical Center, Hackensack, NJ 07601, USA; Hackensack Meridian School of Medicine, Hackensack, NJ 07601, USA.
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Bouillon-Minois JB, Khaled L, Vitte F, Miraillet L, Eschalier R, Jabaudon M, Sapin V, Derault L, Kahouadji S, Brailova M, Durif J, Schmidt J, Moustafa F, Pereira B, Futier E, Bouvier D. Ionized Magnesium: Interpretation and Interest in Atrial Fibrillation. Nutrients 2023; 15:236. [PMID: 36615893 PMCID: PMC9823795 DOI: 10.3390/nu15010236] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Magnesium (Mg) is often used to manage de novo atrial fibrillation (AF) in the emergency department (ED) and intensive care unit (ICU). Point of care measurement of ionized magnesium (iMg) allows a rapid identification of patients with impaired magnesium status, however, unlike ionized calcium, the interpretation of iMg is not entirely understood. Thus, we evaluated iMg reference values, correlation between iMg and plasmatic magnesium (pMg), and the impact of pH and albumin variations on iMg levels. Secondary objectives were to assess the incidence of hypomagnesemia in de novo AF. METHODS A total of 236 emergency department and intensive care unit patients with de novo AF, and 198 control patients were included. Reference values were determined in the control population. Correlation and concordance between iMg and pMg were studied using calcium (ionized and plasmatic) as a control in the whole study population. The impact of albumin and pH was assessed in the discordant iMg and pMg values. Lastly, we assessed the incidence of ionized hypomagnesemia (hypoMg) among de novo AF. RESULTS The reference range values established in our study for iMg were: 0.48-0.65 mmol/L (the manufacturers were: 0.45-0.60 mmol/L). A strong correlation was observed between pMg and iMg (r = 0.85), but, unlike for calcium values, there was no significant impact of pH and albumin in iMg/pMg interpretation. The incidence of hypoMg among de novo AF patients was 8.5% (12.7% using our ranges). When using our ranges, we found a significant link (p = 0.01) between hyopMg and hypokalemia. CONCLUSION We highlight the need for more accurate reference range values of iMg. Furthermore, our results suggest that blood Mg content is not identical to that of calcium. The incidence of ionized hypomagnesemia among de novo AF patients in our study is 8.5%.
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Affiliation(s)
- Jean-Baptiste Bouillon-Minois
- Emergency Department, Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Louisa Khaled
- Anesthesiology and Critical Care Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Florence Vitte
- Service des Urgences, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Ludovic Miraillet
- Service des Urgences, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Romain Eschalier
- Cardiology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Lucas Derault
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Samy Kahouadji
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Marina Brailova
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Julie Durif
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Jeannot Schmidt
- Emergency Department, Université Clermont Auvergne, CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Fares Moustafa
- Service des Urgences, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Damien Bouvier
- Department of Medical Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
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Bedford JP, Garside T, Darbyshire JL, Betts TR, Young JD, Watkinson PJ. Risk factors for new-onset atrial fibrillation during critical illness: A Delphi study. J Intensive Care Soc 2022; 23:414-424. [PMID: 36751347 PMCID: PMC9679893 DOI: 10.1177/17511437211022132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background New-onset atrial fibrillation (NOAF) is common during critical illness and is associated with poor outcomes. Many risk factors for NOAF during critical illness have been identified, overlapping with risk factors for atrial fibrillation in patients in community settings. To develop interventions to prevent NOAF during critical illness, modifiable risk factors must be identified. These have not been studied in detail and it is not clear which variables warrant further study. Methods We undertook an international three-round Delphi process using an expert panel to identify important predictors of NOAF risk during critical illness. Results Of 22 experts invited, 12 agreed to participate. Participants were located in Europe, North America and South America and shared 110 publications on the subject of atrial fibrillation. All 12 completed the three Delphi rounds. Potentially modifiable risk factors identified include 15 intervention-related variables. Conclusions We present the results of the first Delphi process to identify important predictors of NOAF risk during critical illness. These results support further research into modifiable risk factors including optimal plasma electrolyte concentrations, rates of change of these electrolytes, fluid balance, choice of vasoactive medications and the use of preventative medications in high-risk patients. We also hope our findings will aid the development of predictive models for NOAF.
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Affiliation(s)
- Jonathan P Bedford
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Tessa Garside
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Julie L Darbyshire
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Timothy R Betts
- Radcliffe Department of Medicine, University of Oxford, Oxford,
UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of
Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
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Chan JW, Yanase F, See E, McCue C, Yong ZT, Talbot LJ, Flanagan JP, Eastwood GM. A pilot study of the pharmacokinetics of continuous magnesium infusion in critically ill patients. CRIT CARE RESUSC 2022; 24:29-38. [PMID: 38046838 PMCID: PMC10692660 DOI: 10.51893/2022.1.oa4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The pharmacokinetics and haemodynamic effect of continuous magnesium infusion in non-cardiac intensive care unit (ICU) patients are poorly understood. We aimed to measure serum and urine magnesium levels during bolus and continuous infusion in critically ill adults, compare serum levels with those of a control population, and assess its haemodynamic effect. Design: Pharmacokinetic study Setting: A single tertiary adult ICU. Participants: Mechanically ventilated adults requiring vasopressor support. Intervention: A 10 mmol bolus of magnesium sulfate followed by 1.5-3 mmol/h infusion for 24 hours. Main outcome measures: The primary outcome was the change in total serum magnesium concentration. The main secondary outcome was mean arterial pressure (MAP)- adjusted vasopressor dose. Results: We matched 31 treated patients with 93 controls. Serum total magnesium concentration increased from a median 0.94 mmol/L (interquartile range [IQR], 0.83-1.10 mmol/L) to 1.38 mmol/L (IQR, 1.25-1.69 mmol/L; P < 0.001) and stabilised between a median 1.64 mmol/L (IQR, 1.38-1.88 mmol/L) at 7 hours and 1.77 mmol/L (IQR, 1.53-1.85 mmol/L) at 25 hours. This was significantly greater than in the control group (P < 0.001). The MAP-adjusted vasopressor dose decreased during magnesium infusion (P < 0.001). Conclusion: In critically ill patients, a magnesium sulfate bolus followed by continuous infusion achieved moderately elevated levels of total serum magnesium with a decrease in MAP-adjusted vasopressor dose. Trial registration number: ACTRN12619000925145.
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Affiliation(s)
- Jian Wen Chan
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emily See
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Claire McCue
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Zhen-Ti Yong
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Lachlan J. Talbot
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | | | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
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6
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Bhatti H, Mohmand B, Ojha N, P Carvounis C, L Carhart R. The Role of Magnesium in the Management of Atrial Fibrillation with Rapid Ventricular Rate. J Atr Fibrillation 2021; 13:2389. [PMID: 34950320 DOI: 10.4022/jafib.2389] [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: 05/20/2020] [Revised: 05/26/2020] [Accepted: 07/01/2020] [Indexed: 11/10/2022]
Abstract
Background Atrial fibrillation is currently managed with a variety of rate controlling and antiarrhythmic agents. Often, magnesium is used as adjunctive therapy, however, the benefit it provides in managing Afib with RVR has been debated. This study aimed to determine if IV MgSO4 administration in conjunction with standard therapy provides any synergistic effect in acute and prolonged control of Afib with RVR. Methods This was a retrospective study involving ninety patients with episodes of Afib with RVR during their hospitalization. The treatment group included those that had received magnesium (n=32) along with standard management and the control group (n=58) received only standard management. Heart rates at different time intervals were collected. Dose dependent effects of IV MgSO4 on heart rates were also evaluated. Results Patients that received magnesium had a lower mean heart rate (85 BPM versus 96 BPM, P<0.05) 24 hours after onset of the episode. Also, in the last 16 hours of observation, it appeared that administration of higher levels of magnesium resulted in statistically lower heart rates. In the group of patients that received 2 grams of magnesium, the mean heart rate at 8 hours was 103.4 beats/min and 84.8 beats/min at 24 hours (p<0.01). This same trend was not seen in patients that received 1 gram of magnesium or in the control group. Conclusions Overall, the use of IV MgSO4 as an adjunctive treatment permitted normalization of the heart rate progressively that continued to at least 24 hours.
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7
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Johnston BW, Chean CS, Duarte R, Hill R, Blackwood B, McAuley DF, Welters ID. Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis. Br J Anaesth 2021; 128:759-771. [PMID: 34916053 DOI: 10.1016/j.bja.2021.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND New onset atrial fibrillation (NOAF) is the most common arrhythmia affecting critically unwell patients. NOAF can lead to worsening haemodynamic compromise, heart failure, thromboembolic events, and increased mortality. The aim of this systematic review and narrative synthesis is to evaluate the non-pharmacological and pharmacological management strategies for NOAF in critically unwell patients. METHODS Of 1782 studies, 30 were eligible for inclusion, including 4 RCTs and 26 observational studies. Efficacy of direct current cardioversion, amiodarone, β-antagonists, calcium channel blockers, digoxin, magnesium, and less commonly used agents such as ibutilide are reported. RESULTS Cardioversion rates of 48% were reported for direct current cardioversion; however, re-initiation of NOAF was as high as 23.4%. Amiodarone was the most commonly reported intervention with cardioversion rates ranging from 18% to 95.8% followed by β-antagonists with cardioversion rates from 40% to 92.3%. Amiodarone was more effective than diltiazem (odds ratio [OR]=1.91, P=0.32) at cardioversion. Short-acting β-antagonists esmolol and landiolol were more effective compared with diltiazem at cardioversion (OR=3.55, P=0.04) and HR control (OR=3.2, P<0.001). CONCLUSION There was significant variation between studies with regard to the definition of successful cardioversion and heart rate control, making comparisons between studies and interventions difficult. Future RCTs comparing individual anti-arrhythmic agents, in particular magnesium, amiodarone, and β-antagonists, and the role of anticoagulation in critically unwell patients are required. There is also an urgent need for a core outcome dataset for studies of new onset atrial fibrillation to allow comparisons between different anti-arrhythmic strategies. CLINICAL TRIAL REGISTRATION PROSPERO CRD42019121739.
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Affiliation(s)
- Brian W Johnston
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Chung S Chean
- Northampton General Hospital NHS Trust, Northampton, UK
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ingeborg D Welters
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Bedford J, Drikite L, Corbett M, Doidge J, Ferrando-Vivas P, Johnson A, Rajappan K, Mouncey P, Harrison D, Young D, Rowan K, Watkinson P. Pharmacological and non-pharmacological treatments and outcomes for new-onset atrial fibrillation in ICU patients: the CAFE scoping review and database analyses. Health Technol Assess 2021; 25:1-174. [PMID: 34847987 DOI: 10.3310/hta25710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND New-onset atrial fibrillation occurs in around 10% of adults treated in an intensive care unit. New-onset atrial fibrillation may lead to cardiovascular instability and thromboembolism, and has been independently associated with increased length of hospital stay and mortality. The long-term consequences are unclear. Current practice guidance is based on patients outside the intensive care unit; however, new-onset atrial fibrillation that develops while in an intensive care unit differs in its causes and the risks and clinical effectiveness of treatments. The lack of evidence on new-onset atrial fibrillation treatment or long-term outcomes in intensive care units means that practice varies. Identifying optimal treatment strategies and defining long-term outcomes are critical to improving care. OBJECTIVES In patients treated in an intensive care unit, the objectives were to (1) evaluate existing evidence for the clinical effectiveness and safety of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, (2) compare the use and clinical effectiveness of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, and (3) determine outcomes associated with new-onset atrial fibrillation. METHODS We undertook a scoping review that included studies of interventions for treatment or prevention of new-onset atrial fibrillation involving adults in general intensive care units. To investigate the long-term outcomes associated with new-onset atrial fibrillation, we carried out a retrospective cohort study using English national intensive care audit data linked to national hospital episode and outcome data. To analyse the clinical effectiveness of different new-onset atrial fibrillation treatments, we undertook a retrospective cohort study of two large intensive care unit databases in the USA and the UK. RESULTS Existing evidence was generally of low quality, with limited data suggesting that beta-blockers might be more effective than amiodarone for converting new-onset atrial fibrillation to sinus rhythm and for reducing mortality. Using linked audit data, we showed that patients developing new-onset atrial fibrillation have more comorbidities than those who do not. After controlling for these differences, patients with new-onset atrial fibrillation had substantially higher mortality in hospital and during the first 90 days after discharge (adjusted odds ratio 2.32, 95% confidence interval 2.16 to 2.48; adjusted hazard ratio 1.46, 95% confidence interval 1.26 to 1.70, respectively), and higher rates of subsequent hospitalisation with atrial fibrillation, stroke and heart failure (adjusted cause-specific hazard ratio 5.86, 95% confidence interval 5.33 to 6.44; adjusted cause-specific hazard ratio 1.47, 95% confidence interval 1.12 to 1.93; and adjusted cause-specific hazard ratio 1.28, 95% confidence interval 1.14 to 1.44, respectively), than patients who did not have new-onset atrial fibrillation. From intensive care unit data, we found that new-onset atrial fibrillation occurred in 952 out of 8367 (11.4%) UK and 1065 out of 18,559 (5.7%) US intensive care unit patients in our study. The median time to onset of new-onset atrial fibrillation in patients who received treatment was 40 hours, with a median duration of 14.4 hours. The clinical characteristics of patients developing new-onset atrial fibrillation were similar in both databases. New-onset atrial fibrillation was associated with significant average reductions in systolic blood pressure of 5 mmHg, despite significant increases in vasoactive medication (vasoactive-inotropic score increase of 2.3; p < 0.001). After adjustment, intravenous beta-blockers were not more effective than amiodarone in achieving rate control (adjusted hazard ratio 1.14, 95% confidence interval 0.91 to 1.44) or rhythm control (adjusted hazard ratio 0.86, 95% confidence interval 0.67 to 1.11). Digoxin therapy was associated with a lower probability of achieving rate control (adjusted hazard ratio 0.52, 95% confidence interval 0.32 to 0.86) and calcium channel blocker therapy was associated with a lower probability of achieving rhythm control (adjusted hazard ratio 0.56, 95% confidence interval 0.39 to 0.79) than amiodarone. Findings were consistent across both the combined and the individual database analyses. CONCLUSIONS Existing evidence for new-onset atrial fibrillation management in intensive care unit patients is limited. New-onset atrial fibrillation in these patients is common and is associated with significant short- and long-term complications. Beta-blockers and amiodarone appear to be similarly effective in achieving cardiovascular control, but digoxin and calcium channel blockers appear to be inferior. FUTURE WORK Our findings suggest that a randomised controlled trial of amiodarone and beta-blockers for management of new-onset atrial fibrillation in critically ill patients should be undertaken. Studies should also be undertaken to provide evidence for or against anticoagulation for patients who develop new-onset atrial fibrillation in intensive care units. Finally, given that readmission with heart failure and thromboembolism increases following an episode of new-onset atrial fibrillation while in an intensive care unit, a prospective cohort study to demonstrate the incidence of atrial fibrillation and/or left ventricular dysfunction at hospital discharge and at 3 months following the development of new-onset atrial fibrillation should be undertaken. TRIAL REGISTRATION Current Controlled Trials ISRCTN13252515. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan Bedford
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Laura Drikite
- Intensive Care National Audit and Research Centre, London, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, London, UK
| | | | - Alistair Johnson
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kim Rajappan
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Duncan Young
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Peter Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yoshida T, Uchino S, Sasabuchi Y, Kyo M, Igarashi T, Inoue H. Rhythm-control therapy for new-onset atrial fibrillation in critically ill patients: A post hoc analysis from the prospective multicenter observational AFTER-ICU study. IJC HEART & VASCULATURE 2021; 33:100742. [PMID: 33732869 PMCID: PMC7937754 DOI: 10.1016/j.ijcha.2021.100742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sustained new-onset atrial fibrillation (AF) in the intensive care unit has been reported to be associated with poor outcomes. However, in critical illness, whether rhythm-control therapy can achieve sinus rhythm (SR) restoration is unknown. This study aimed to assess the impact of rhythm-control therapy on SR restoration for new-onset AF in critically ill patients. METHODS This post-hoc analysis of a prospective multicenter observational study involving 32 Japan intensive care units compared patients with and without rhythm-control therapy for new-onset atrial fibrillation (AF) and conducted a multivariable analysis using Cox proportional hazards regression analysis including rhythm-control therapy as a time-varying covariate for SR restoration. RESULTS Of 423 new-onset AF patients, 178 patients (42%) underwent rhythm-control therapy. Among those patients, 131 (31%) underwent rhythm-control therapy within 6 h after AF onset. Magnesium sulphate was the most frequently used rhythm-control drug. The Cox proportional hazards model for SR restoration showed that rhythm-control therapy had a significant positive association with SR restoration (adjusted hazard ratio: 1.46; 95% confidence interval: 1.16-1.85). However, the rhythm-control group had numerically higher hospital mortality than the non-rhythm-control group (31% vs. 23%, p = 0.09). CONCLUSIONS Rhythm-control therapy for new-onset AF in critically ill patients was associated with SR restoration. However, patients with rhythm-control therapy had poorer prognosis, possibly due to selection bias. These findings may provide important insight for the design and feasibility of interventional studies assessing rhythm-control therapy in new-onset AF.
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Affiliation(s)
- Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | | | - Michihito Kyo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takashi Igarashi
- Department of Trauma and Critical Care Medicine, School of Medicine, Kyorin University, Tokyo, Japan
| | - Haruka Inoue
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - on behalf of the AFTER-ICU Study Group
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
- Data Science Center, Jichi Medical University, Tochigi, Japan
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Trauma and Critical Care Medicine, School of Medicine, Kyorin University, Tokyo, Japan
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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O'Bryan LJ, Redfern OC, Bedford J, Petrinic T, Young JD, Watkinson PJ. Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review. BMJ Open 2020; 10:e034774. [PMID: 32209631 PMCID: PMC7202704 DOI: 10.1136/bmjopen-2019-034774] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/17/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness. PARTICIPANTS Critically ill adult patients who developed NOAF during admission. PRIMARY AND SECONDARY OUTCOMES Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events. METHODS We searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale. RESULTS Of 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies). CONCLUSION The reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.
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Affiliation(s)
- Liam Joseph O'Bryan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, Victoria, Australia
| | - Oliver C Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jonathan Bedford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tatjana Petrinic
- Cairns Library, University of Oxford Health Care Libraries, Oxford, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Heitz C, Morgenstern J, Bond C, Milne WK. Hot Off the Press: Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study. Acad Emerg Med 2019; 26:1093-1095. [PMID: 30815951 DOI: 10.1111/acem.13720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/28/2022]
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12
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New-onset atrial fibrillation in adult critically ill patients: a scoping review. Intensive Care Med 2019; 45:928-938. [DOI: 10.1007/s00134-019-05633-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022]
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13
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Bouida W, Beltaief K, Msolli MA, Azaiez N, Ben Soltane H, Sekma A, Trabelsi I, Boubaker H, Grissa MH, Methemem M, Boukef R, Dridi Z, Belguith A, Nouira S. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med 2019; 26:183-191. [PMID: 30025177 DOI: 10.1111/acem.13522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/12/2018] [Accepted: 07/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aim to determine the benefit of two different doses magnesium sulfate (MgSO4 ) compared to placebo in rate control of rapid atrial fibrillation (AF) managed in the emergency department (ED). METHODS We undertook a randomized, controlled, double-blind clinical trial in three university hospital EDs between August 2009 and December 2014. Patients > 18 years with rapid AF (>120 beats/min) were enrolled and randomized to 9 g of intravenous MgSO4 (high-dose group, n = 153), 4.5 g of intravenous MgSO4 (low-dose group, n = 148), or serum saline infusion (placebo group, n = 149), given in addition to atrioventricular (AV) nodal blocking agents. The primary outcome was the reduction of baseline ventricular rate (VR) to 90 beats/min or less or reduction of VR by 20% or greater from baseline (therapeutic response). Secondary outcome included resolution time (defined as the elapsed time from start of treatment to therapeutic response), sinus rhythm conversion rate, and adverse events within the first 24 hours. RESULTS At 4 hours, therapeutic response rate was higher in low- and high-MgSO4 groups compared to placebo group; the absolute differences were, respectively, 20.5% (risk ratio [RR] = 2.31, 95% confidence interval [CI] = 1.45-3.69) and +15.8% (RR = 1.89, 95% CI = 1.20-2.99). At 24 hours, compared to placebo group, therapeutic response difference was +14.1% (RR = 9.74, 95% CI = 2.87-17.05) with low-dose MgSO4 and +10.3% (RR = 3.22, 95% CI = 1.45-7.17) with high-dose MgSO4 . The lowest resolution time was observed in the low-dose MgSO4 group (5.2 ± 2 hours) compared to 6.1 ± 1.9 hours in the high-dose MgSO4 group and 8.4 ± 2.5 hours in the placebo group. Rhythm control rate at 24 hours was significantly higher in the low-dose MgSO4 group (22.9%) compared to the high-dose MgSO4 group (13.0%, p = 0.03) and the placebo group (10.7%). Adverse effects were minor and significantly more frequent with high-dose MgSO4 . CONCLUSIONS Intravenous MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control. Similar efficacy was observed with 4.5 and 9 g of MgSO4 but a dose of 9 g was associated with more side effects.
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Affiliation(s)
- Wahid Bouida
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Kaouthar Beltaief
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mohamed Amine Msolli
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | | | - Houda Ben Soltane
- Research Laboratory LR12SP18 University of Monastir Monastir
- Emergency Department Farhat Hached University Hospital Sousse Tunisia
| | - Adel Sekma
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Imen Trabelsi
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Hamdi Boubaker
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mohamed Habib Grissa
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Mehdi Methemem
- Emergency Department Farhat Hached University Hospital Sousse Tunisia
| | - Riadh Boukef
- Emergency Department Sahloul University Hospital Sousse
- Research Laboratory LR12SP18 University of Monastir Monastir
| | - Zohra Dridi
- Cardiology Department Fattouma Bourguiba University Hospital Monastir
| | - Asma Belguith
- Department of Preventive Medicine Fattouma Bourguiba University Hospital Monastir
| | - Semir Nouira
- Emergency Department Fattouma Bourguiba University Hospital Monastir
- Research Laboratory LR12SP18 University of Monastir Monastir
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Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
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15
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Al Alawi AM, Majoni SW, Falhammar H. Magnesium and Human Health: Perspectives and Research Directions. Int J Endocrinol 2018; 2018:9041694. [PMID: 29849626 PMCID: PMC5926493 DOI: 10.1155/2018/9041694] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/22/2018] [Accepted: 03/05/2018] [Indexed: 12/13/2022] Open
Abstract
Magnesium is the fourth most abundant cation in the body. It has several functions in the human body including its role as a cofactor for more than 300 enzymatic reactions. Several studies have shown that hypomagnesemia is a common electrolyte derangement in clinical setting especially in patients admitted to intensive care unit where it has been found to be associated with increase mortality and hospital stay. Hypomagnesemia can be caused by a wide range of inherited and acquired diseases. It can also be a side effect of several medications. Many studies have reported that reduced levels of magnesium are associated with a wide range of chronic diseases. Magnesium can play important therapeutic and preventive role in several conditions such as diabetes, osteoporosis, bronchial asthma, preeclampsia, migraine, and cardiovascular diseases. This review is aimed at comprehensively collating the current available published evidence and clinical correlates of magnesium disorders.
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Affiliation(s)
- Abdullah M. Al Alawi
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sandawana William Majoni
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
- Northern Territory Medical Program, Flinders University School of Medicine, Darwin, NT, Australia
| | - Henrik Falhammar
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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16
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Hupp S, Ribes S, Seele J, Bischoff C, Förtsch C, Maier E, Benz R, Mitchell TJ, Nau R, Iliev AI. Magnesium therapy improves outcome in Streptococcus pneumoniae meningitis by altering pneumolysin pore formation. Br J Pharmacol 2017; 174:4295-4307. [PMID: 28888095 DOI: 10.1111/bph.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/26/2017] [Accepted: 08/29/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults and is characterized by high lethality and substantial cognitive disabilities in survivors. Here, we have studied the capacity of an established therapeutic agent, magnesium, to improve survival in pneumococcal meningitis by modulating the neurological effects of the major pneumococcal pathogenic factor, pneumolysin. EXPERIMENTAL APPROACH We used mixed primary glial and acute brain slice cultures, pneumolysin injection in infant rats, a mouse meningitis model and complementary approaches such as Western blot, a black lipid bilayer conductance assay and live imaging of primary glial cells. KEY RESULTS Treatment with therapeutic concentrations of magnesium chloride (500 mg·kg-1 in animals and 2 mM in cultures) prevented pneumolysin-induced brain swelling and tissue remodelling both in brain slices and in animal models. In contrast to other divalent ions, which diminish the membrane binding of pneumolysin in non-therapeutic concentrations, magnesium delayed toxin-driven pore formation without affecting its membrane binding or the conductance profile of its pores. Finally, magnesium prolonged the survival and improved clinical condition of mice with pneumococcal meningitis, in the absence of antibiotic treatment. CONCLUSIONS AND IMPLICATIONS Magnesium is a well-established and safe therapeutic agent that has demonstrated capacity for attenuating pneumolysin-triggered pathogenic effects on the brain. The improved animal survival and clinical condition in the meningitis model identifies magnesium as a promising candidate for adjunctive treatment of pneumococcal meningitis, together with antibiotic therapy.
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Affiliation(s)
- Sabrina Hupp
- Institute of Anatomy, University of Bern, Bern, Switzerland.,DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Sandra Ribes
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Jana Seele
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Carolin Bischoff
- DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Christina Förtsch
- DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Elke Maier
- Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Roland Benz
- Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
| | - Timothy J Mitchell
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Roland Nau
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Asparouh I Iliev
- Institute of Anatomy, University of Bern, Bern, Switzerland.,DFG Membrane/Cytoskeleton Interaction Group, Institute of Pharmacology and Toxicology & Rudolf Virchow Center for Experimental Medicine, University of Würzburg, Würzburg, Germany
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17
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Baker WL. Treating arrhythmias with adjunctive magnesium: identifying future research directions. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2016:pvw028. [DOI: 10.1093/ehjcvp/pvw028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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18
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Palin CA, Kailasam R, Hogue CW. Atrial Fibrillation After Cardiac Surgery: Pathophysiology and Treatment. Semin Cardiothorac Vasc Anesth 2016; 8:175-83. [PMID: 15375479 DOI: 10.1177/108925320400800302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) occurs in 25% to 60% of patients after cardiac surgery. It is most consistently associated with advanced age and valvular heart operations. Despite improving knowledge of the pathophysiology of chronic AF, postoperative AF remains an obstinate clinical problem. It is associated with an increased risk of stroke, longer hospital stay, and higher hospital expenditure. Consequently, there has been great interest in strategies to prevent and treat this arrhythmia. Treatment for postoperative AF may require immediate electrical cardioversion for hemodynamically unstable patients. Heart rate control is useful in most patients, with anticoagulation considered after 48 hours. Antiarrhythmic therapy is often effective in restoring sinus rhythm but its use needs to be balanced against the patient's risk of proarrhythmic side effects such as torsade de pointes.
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Affiliation(s)
- Christopher A Palin
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
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19
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Report of Societies. Scott Med J 2016. [DOI: 10.1177/003693300505000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Mitrić G, Udy A, Bandeshe H, Clement P, Boots R. Variable use of amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:90. [PMID: 27038791 PMCID: PMC4818931 DOI: 10.1186/s13054-016-1252-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 02/22/2016] [Indexed: 12/17/2022]
Abstract
Background Atrial fibrillation is a common rhythm disturbance in the general medical-surgical intensive care unit. Amiodarone is a popular drug in this setting but evidence to inform clinical practice remains scarce. We aimed to identify whether variation in the clinical use of amiodarone was associated with recurrent atrial fibrillation. Methods This was a retrospective audit of 177 critically ill patients who developed new-onset atrial fibrillation after admission to a tertiary level medical-surgical trauma intensive care unit. Patterns of amiodarone prescription (including dosage schedule and duration) were assessed in relation to recurrence of atrial fibrillation during the intensive care unit stay. Known recurrence risk factors, such as inotrope administration, cardiac disease indices, Charlson Comorbidity Index, magnesium concentrations, fluid balance, and potassium concentrations, were also included in adjusted analysis using forward stepwise logistic regression modelling. Results The cohort had a median (interquartile range) age of 69 years (60–75), Acute Physiology and Chronic Health Evalution II score of 22 (17–28) and Charlson Comorbidity Index of 2 (1–4). A bolus dose of amiodarone followed by infusion (P = 0.02), in addition to continuing amiodarone infusion through to discharge from the intensive care unit (P < 0.001), were associated with less recurrent dysrhythmia. Recurrence after successful treatment was associated with ceasing amiodarone while an inotrope infusion continued (P < 0.001), and was more common in patients with a prior history of congestive cardiac failure (P = 0.04), and a diagnosis of systemic inflammatory response syndrome (P = 0.02). Conclusions Amiodarone should be administered as a bolus dose followed immediately with an infusion when treating atrial fibrillation in the medical-surgical intensive care unit. Consideration should be given to continuing amiodarone infusions in patients on inotropes until they are ceased.
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Affiliation(s)
- Goran Mitrić
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Prahran, VIC, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, Prahran, Melbourne, VIC, Australia
| | - Hiran Bandeshe
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Herston, Brisbane, QLD, Australia
| | - Pierre Clement
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Herston, Brisbane, QLD, Australia
| | - Rob Boots
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Herston, Brisbane, QLD, Australia. .,Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, QLD, Australia.
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21
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Abstract
New-onset atrial fibrillation is a common problem in critically ill patients, with reported incidence ranging from 5% to 46%. It is associated with significant morbidity and mortality. The present review summarizes studies investigating new-onset atrial fibrillation conducted in the critical care setting, focusing on the etiology, management of the hemodynamically unstable patient, rate versus rhythm control, ischemic stroke risk and anticoagulation. Recommendations for an approach to management in the intensive care unit are drawn from the results of these studies.
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22
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Walkey AJ, Hogarth DK, Lip GYH. Optimizing atrial fibrillation management: from ICU and beyond. Chest 2016; 148:859-864. [PMID: 25951122 DOI: 10.1378/chest.15-0358] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) that newly occurs during critical illness presents challenges for both short- and long-term management. During critical illness, patients with new-onset AF are clinically evaluated for hemodynamic instability owing to the arrhythmia as well as for potentially reversible arrhythmia triggers. Hemodynamically significant AF that persists during critical illness may be treated with heart rate or rhythm control strategies. Recent evidence suggests that patients in whom AF develops during acute illness (eg, sepsis, postoperatively) have high long-term risks for AF recurrence and for AF-associated complications, such as stroke, heart failure, and death. Therefore, we suggest increased efforts to improve communication of AF events between inpatient and outpatient providers and to reassess patients who had experienced new-onset AF during critical illness after they transition to the post-ICU setting. We describe various strategies for the assessment and long-term management of patients with new-onset AF during critical illness.
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA.
| | - D Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, England; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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23
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Walkey AJ, Evans SR, Winter MR, Benjamin EJ. Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis: A Propensity-Matched Cohort Study. Chest 2016; 149:74-83. [PMID: 26270396 DOI: 10.1378/chest.15-0959] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) during sepsis is associated with increased morbidity and mortality, but practice patterns and outcomes associated with rate- and rhythm-targeted treatments for AF during sepsis are unclear. METHODS This was a retrospective cohort study using enhanced billing data from approximately 20% of United States hospitals. We identified factors associated with IV AF treatments (?-blockers [BBs], calcium channel blockers [CCBs], digoxin, or amiodarone) during sepsis. We used propensity score matching and instrumental variable approaches to compare mortality between AF treatments. RESULTS Among 39,693 patients with AF during sepsis, mean age was 77 ± 11 years, 49% were women, and 76% were white. CCBs were the most commonly selected initial AF treatment during sepsis (14,202 patients [36%]), followed by BBs (11,290 [28%]), digoxin (7,937 [20%]), and amiodarone (6,264 [16%]). Initial AF treatment selection differed according to geographic location, hospital teaching status, and physician specialty. In propensity-matched analyses, BBs were associated with lower hospital mortality when compared with CCBs (n = 18,720; relative risk [RR], 0.92; 95% CI, 0.86-0.97), digoxin (n = 13,994; RR, 0.79; 95% CI, 0.75-0.85), and amiodarone (n = 5,378; RR, 0.64; 95% CI, 0.61-0.69). Instrumental variable analysis showed similar results (adjusted RR fifth quintile vs first quintile of hospital BB use rate, 0.67; 95% CI, 0.58-0.79). Results were similar among subgroups with new-onset or preexisting AF, heart failure, vasopressor-dependent shock, or hypertension. CONCLUSIONS Although CCBs were the most frequently used IV medications for AF during sepsis, BBs were associated with superior clinical outcomes in all subgroups analyzed. Our findings provide rationale for clinical trials comparing the effectiveness of AF rate- and rhythm-targeted treatments during sepsis.
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA.
| | - Stephen R Evans
- Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA; Section of Preventive Medicine, Boston University School of Medicine, Boston, MA; Department of Epidemiology, Boston University School of Public Health, Boston, MA
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Fairley J, Glassford NJ, Zhang L, Bellomo R. Magnesium status and magnesium therapy in critically ill patients: A systematic review. J Crit Care 2015; 30:1349-58. [PMID: 26337558 DOI: 10.1016/j.jcrc.2015.07.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 07/23/2015] [Accepted: 07/27/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE Magnesium is frequently measured and administered in general intensive care unit patients. However, magnesium status, its association with outcomes, and therapeutic utility in such patients are unclear. We performed a systematic review of the relevant literature to define current knowledge in this field. MATERIALS AND METHODS We searched MEDLINE, CENTRAL, and EMBASE from 1975 to July 2014 for adult English language articles excluding obstetric, non-intensive care unit based, and specific population (poisoning, cardiothoracic, and neurosurgery) studies. We identified articles on magnesium measurement, associations, and therapy. We calculated pooled effect estimates from reported adjusted risk estimates. RESULTS We identified 34 relevant studies. Total serum total magnesium was the most commonly measure of magnesium status. Risk of mortality was significantly increased with hypomagnesemia (odds ratio, 1.85; 95% confidence interval, 1.31-2.60). No consistent associations existed between magnesemia or magnesium administration and any other outcomes. CONCLUSIONS Total serum magnesium levels are generally used to estimate magnesium status in critical illness. Hypomagnesemia appears associated with greater risk of mortality, but the efficacy of magnesium administration is open to challenge.
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Affiliation(s)
- Jessica Fairley
- Alfred Hospital, Prahran, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
| | - Neil John Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia
| | - Ling Zhang
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia.
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Arrigo M, Bettex D, Rudiger A. [Treatment of atrial fibrillation in intensive care units and emergency departments]. Med Klin Intensivmed Notfmed 2015; 110:614-20. [PMID: 25876744 DOI: 10.1007/s00063-015-0006-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/08/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia in patients hospitalized in intensive care units and emergency departments and is associated with an increased morbidity and mortality. In critically ill patients, atrial fibrillation can cause hemodynamic instability and cardiogenic shock. The mechanisms and the management of atrial fibrillation are significantly different in critically ill patients compared to outpatients. DIAGNOSIS AND TREATMENT The initial management includes the evaluation of the hemodynamic consequences of new-onset atrial fibrillation and the optimization of reversible causes. In patients with hemodynamic instability the rapid restoration of an adequate perfusion pressure is the initial goal. Often, a rapid conversion in sinus rhythm is required to achieve hemodynamic stabilization. Electrical cardioversion, if possible performed after pretreatment with an antiarrhythmic drug to increase the success rate, frequently plays a central role in the conversion to sinus rhythm of hemodynamically unstable patients. Stable patients are initially treated with a short-acting intravenous β-blocker to achieve heart rate control. A conversion to sinus rhythm may be achieved pharmacologically with vernakalant, an atrial-specific multichannel blocker. EVALUATION All patients with atrial fibrillation lasting more than 48 h should be evaluated for anticoagulation in order to reduce cardio-embolic complications. After recovering from the acute illness, atrial fibrillation persists only in a minority of patients.
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Affiliation(s)
- M Arrigo
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.,Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - D Bettex
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - A Rudiger
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.
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Management of atrial fibrillation in critically ill patients. Crit Care Res Pract 2014; 2014:840615. [PMID: 24527212 PMCID: PMC3914350 DOI: 10.1155/2014/840615] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 12/24/2013] [Accepted: 12/24/2013] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF) is common in ICU patients and is associated with a two- to fivefold increase in mortality. This paper provides a reappraisal of the management of AF with a special focus on critically ill patients with haemodynamic instability.
AF can cause hypotension and heart failure with subsequent organ dysfunction. The underlying mechanisms are the loss of atrial contraction and the high ventricular rate. In unstable patients, sinus rhythm must be rapidly restored by synchronised electrical cardioversion (ECV). If pharmacological treatment is indicated, clinicians can choose between the rate control and the rhythm control strategy. The optimal substance should be selected depending on its potential adverse effects. A beta-1 antagonist with a very short half-life (e.g., esmolol) is an advantage for ICU patients because the effect of beta-blockade on cardiovascular stability is unpredictable in those patients. Amiodarone is commonly used in the ICU setting but has potentially severe cardiac and noncardiac side effects. Digoxin controls the ventricular response at rest, but its benefit decreases in the presence of adrenergic stress. Vernakalant converts new-onset AF to sinus rhythm in approximately 50% of patients, but data on its efficacy and safety in critically ill patients are lacking.
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Sharma P, Chung C, Vizcaychipi M. Magnesium: The Neglected Electrolyte? A Clinical Review. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/pp.2014.57086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zochios VA, Wilkinson J. Correspondence Regarding: Atrial Fibrillation in the Intensive Care Setting. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Vasileios A Zochios
- Acute Care Common Stem (ACCS)-Anaesthesia CT, Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS, Leicester Royal Infirmary NHS Trust
| | - Jonathan Wilkinson
- Consultant Intensivist, Department of Anaesthesia and Critical Care, Northampton General Hospital NHS Trust
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Marqué S, Launey Y. Traitement de la fibrillation atriale en réanimation (hors anticoagulation). MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0454-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Westaby S. Atrail Fibrillation after Carfiac Surgery: Benign or Deserving of Prophylaxis. J Atr Fibrillation 2010; 3:337. [PMID: 28496681 DOI: 10.4022/jafib.337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 12/10/2010] [Accepted: 12/14/2010] [Indexed: 12/27/2022]
Abstract
New onset atrial fibrillation (AF) is the commonest complication after cardiac surgery affecting around 30% of coronary artery bypass graft (CABG) patients, up to 50% of valve surgery patients and as many as 60% of those undergoing combined valve and CABG operations. After cardiac transplantation where the native pulmonary veins are electrically separated from the donor heart atria the incidence is only 11%.
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Cook RC, Humphries KH, Gin K, Janusz MT, Slavik RS, Bernstein V, Tholin M, Lee MK. Prophylactic intravenous magnesium sulphate in addition to oral {beta}-blockade does not prevent atrial arrhythmias after coronary artery or valvular heart surgery: a randomized, controlled trial. Circulation 2009; 120:S163-9. [PMID: 19752363 DOI: 10.1161/circulationaha.108.841221] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial arrhythmias (AA) are an important cause of morbidity after cardiac surgery. Efforts at prevention of postoperative AA have been suboptimal. Perioperative beta-blocker administration is the standard of care at many centers. Although prophylactic administration of magnesium sulfate (MgSO(4)) has been recommended, review of all previously published trials of MgSO(4) reveals conflicting results. This study was designed to address methodological shortcomings from previous studies and is the largest randomized, placebo-controlled trial of intravenous (IV) MgSO(4) for the prevention of AA after coronary artery bypass grafting or cardiac valvular surgery. METHODS AND RESULTS A total of 927 nonemergent cardiac surgery patients were stratified into 2 groups: isolated coronary artery bypass grafting (n=694), or valve surgery with or without coronary artery bypass grafting (n=233), and randomized to receive either 5g IV MgSO(4) or placebo on removal of the cross-clamp, followed by daily 4-hour infusions, from postoperative day 1 until postoperative day 4. All patients were treated according to an established oral beta-blocker protocol. Postoperative serum Mg levels were checked and standard of care was to administer IV MgSO(4) for low serum levels. The primary end point was AA lasting > or =30 minutes or requiring treatment for hemodynamic compromise. There were no differences in the incidence of AA between patients who received IV MgSO(4) or placebo (26.4% versus 24.3%, respectively). The results were similar when broken down according to stratified groups. CONCLUSIONS In patients treated with a protocol for postoperative oral beta-blocker after nonemergent cardiac surgery, the addition of prophylactic IV MgSO(4) did not reduce the incidence of AA.
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Coleman CI, Sood N, Chawla D, Talati R, Ghatak A, Kluger J. Intravenous magnesium sulfate enhances the ability of dofetilide to successfully cardiovert atrial fibrillation or flutter: results of the Dofetilide and Intravenous Magnesium Evaluation. Europace 2009; 11:892-5. [DOI: 10.1093/europace/eup084] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chu K, Evans R, Emerson G, Greenslade J, Brown A. Magnesium sulfate versus placebo for paroxysmal atrial fibrillation: a randomized clinical trial. Acad Emerg Med 2009; 16:295-300. [PMID: 19207134 DOI: 10.1111/j.1553-2712.2009.00360.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to investigate the efficacy of magnesium sulfate (MgSO4) in decreasing the ventricular rate in emergency department (ED) patients presenting with new-onset, rapid atrial fibrillation (AF). METHODS A double-blinded, placebo-controlled randomized clinical trial was conducted in an adult university hospital. Patients aged > or =18 years with AF onset of less than 48 hours and a sustained ventricular rate of >100 beats/min were randomized to either intravenous (IV) MgSO4 10 mmol or normal saline (NSal). Rhythm and instantaneous heart rate as measured by the monitor were recorded at baseline and every 15 minutes for 2 hours after starting the trial drug. Heart rate and rhythm were compared at 2 hours. A multilevel modeling analysis was performed to adjust for differences in baseline heart rate and any additional treatment and to examine changes in heart rate over time. RESULTS Twenty-four patients were randomized to MgSO4 and 24 to NSal. Baseline heart rate was lower in the MgSO4 group (mean +/- standard deviation [+/-SD] = 125 +/- 24 vs. 140 +/- 21 beats/min]. One and 3 patients in the MgSO4 and NSal groups, respectively, were given another antiarrhythmic or were electrically cardioverted within 2 hours after starting the trial drug. Heart rate (mean +/- SD) at 2 hours in both MgSO4 (116 +/- 30 beats/min) and NSal groups (114 +/- 31 beats/min) decreased below their respective baseline levels. However, the rate of heart rate decrease across time did not differ between groups (p = 0.124). The proportion of patients who converted to sinus rhythm 2 hours post-trial drug did not differ (MgSO4 8.7% vs. NSal 25.0%, p = 0.25). CONCLUSIONS This study was unable to demonstrate a difference between IV MgSO4 10 mmol and saline placebo for reducing heart rate or conversion to sinus rhythm at 2 hours posttreatment in ED patients with AF of less than 48 hours duration.
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Affiliation(s)
- Kevin Chu
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Tiryakioglu O, Demirtas S, Ari H, Tiryakioglu SK, Huysal K, Selimoglu O, Ozyazicioglu A. Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations. J Cardiothorac Surg 2009; 4:8. [PMID: 19232084 PMCID: PMC2649924 DOI: 10.1186/1749-8090-4-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 02/20/2009] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to investigate the use of prophylactic magnesium sulphate and amiodarone in treating arrhythmias that may occur following coronary bypass grafting operations. Methods The study population consisted of 192 consecutive patients who were undergoing coronary artery bypass grafting (CABG). Sixty-four patients were given 3 g of magnesium sulphate (MgSO4) [20 ml = 24.32 mEq/L Mg+2] in 100 cc of isotonic 0.9% solution over 2 hours intravenously at the following times: 12 hours prior to the operation, immediately following the operation, and on postoperative days 1, 2, and 3 (Group 1). Another group of 64 patients was given a preoperative infusion of amiodarone (1200 mg) on first post-operative day (Group 2). After the operation amiodarone was administered orally at a dose of 600 mg/day. Sixty-four patients in group 3 (control group) had 100 cc. isotonic 0.9% as placebo, during the same time periods. Results In the postoperative period, the magnesium values were significantly higher in Group 1 than in Group 2 for all measurements. The use of amiodarone for total arrhythmia was significantly more effective than prophylactic treatment with magnesium sulphate (p = 0.015). There was no difference between the two drugs in preventing supraventricular arrhythmia, although amiodarone significantly delayed the revealing time of atrial fibrillation (p = 0.026). Ventricular arrhythmia, in the form of ventricular extra systole, was more common in the magnesium prophylaxis group. The two groups showed no significant differences in other operative or postoperative measurements. No side effects of the drugs were observed. Conclusion Prophylactic use of magnesium sulphate and amiodarone are both effective at preventing arrhythmia that may occur following coronary by-pass operations. Magnesium sulphate should be used in prophylactic treatment since it may decrease arrhythmia at low doses. If arrhythmia should occur despite this treatment, intervention with amiodarone may be preferable.
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Affiliation(s)
- Osman Tiryakioglu
- Bursa Yuksek Ihtisas Education and Research Hospital, Department of Cardiovascular Surgery, Bursa, Turkey.
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Treatment of new-onset atrial fibrillation in noncardiac intensive care unit patients: a systematic review of randomized controlled trials. Crit Care Med 2008; 36:1620-4. [PMID: 18434899 DOI: 10.1097/ccm.0b013e3181709e43] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Atrial fibrillation is a common problem associated with morbidity and mortality in critically ill patients; however, evidence-based treatment recommendations are lacking. The objective of this systematic review was to evaluate the efficacy of pharmacologic rhythm control of new-onset atrial fibrillation in noncardiac, critically ill adults. DATA SOURCE Citations identified from an electronic search of Medline, the Cochrane register of controlled trials, and Embase databases (1966 to August 2006) were independently reviewed by two investigators. STUDY SELECTION All prospective randomized controlled trials evaluating pharmacologic rhythm conversion regimens for new-onset atrial fibrillation in (noncardiac surgery) critically ill adult patients were included. The primary end point was atrial fibrillation resolution. DATA EXTRACTION Using a standardized data extraction form, data related to study design, population characteristics, pharmacologic intervention, and outcome measures were collected. DATA SYNTHESIS Four trials met inclusion criteria from 1995 citations screened. Of the 143 evaluable patients in these trials 89 (76%) had atrial fibrillation while the remaining ones had other atrial tachyarrhythmias. Drugs evaluated for rhythm conversion included amiodarone (n = 26), procainamide (n = 14), magnesium (n = 18), flecainide (n = 15), esmolol (n = 28), verapamil (n = 15), and diltiazem (n = 27). The definition of treatment success ranged from conversion within 1 hr to conversion within 24 hrs. No study evaluated maintenance of conversion, and one study included hemodynamically unstable patients. Lack of methodologic homogeneity prevented any pooled analysis. CONCLUSIONS Using the current published literature, we cannot recommend a standard treatment for atrial fibrillation in noncardiac critically ill adult patients. Clinical trials evaluating rhythm conversion in critically ill populations outside of cardiac surgery are lacking. Further trials that address goals of care in hemodynamically stable and unstable patients and utilize standardized definitions of successful cardioversion are required.
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Peter JV, Moran JL, Pichamuthu K, Chacko B. Adjuncts and Alternatives to Oxime Therapy in Organophosphate Poisoning—is There Evidence of Benefit in Human Poisoning? A Review. Anaesth Intensive Care 2008; 36:339-50. [DOI: 10.1177/0310057x0803600305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Organophosphate poisoning is common in developing countries. The morbidity and mortality with organophosphate poisoning is relatively high despite the use of atropine as specific antidotal therapy and oximes to reactivate acetylcholinesterase. Several adjunct and alternative therapies have been explored in animal and human studies. We reviewed the literature to ascertain if there was evidence of benefit of such therapies. Adjunct and alternative therapies included treatments to reduce poison absorption by topical application of creams, enhance toxin elimination by haemoperfusion or bioremediation and neutralise the poison by scavenging free organophosphate with cholinesterase-rich human plasma. In addition, magnesium, clonidine, diazepam, N-acetyl cysteine and adenosine receptor agonists have also been used to counteract poison effects. Detailed assessment was limited by the paucity of trials on adjunct/alternative therapies. The limited evidence from the review process suggested potential benefit from the use of human plasma infusion, early initiation of haemoperfusion and intravenous magnesium, in addition to standard therapy with atropine and pralidoxime. There appeared to be no additional benefit with alkalinisation or use of glycopyrrolate instead of atropine in human trials. Diazepam administration has been advocated by military authorities if symptoms developed following exposure to organophosphate. Bioremediation, clonidine, N-acetyl cysteine and adenosine receptor agonists have been evaluated only in animal models. The impact of adjunct and alternate therapies on outcomes in human poisoning needs to be further explored before implementation as standard treatment.
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Affiliation(s)
- J. V. Peter
- Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India and Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Medical Intensive Care, Christian Medical College and Hospital
| | - J. L. Moran
- Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India and Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital
| | - K. Pichamuthu
- Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India and Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Medical Intensive Care, Christian Medical College and Hospital
| | - B. Chacko
- Department of Medical Intensive Care, Christian Medical College and Hospital, Vellore, India and Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Medical Intensive Care, Christian Medical College and Hospital
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Sleeswijk ME, Tulleken JE, Van Noord T, Meertens JHJM, Ligtenberg JJM, Zijlstra JG. Efficacy of magnesium-amiodarone step-up scheme in critically ill patients with new-onset atrial fibrillation: a prospective observational study. J Intensive Care Med 2008; 23:61-6. [PMID: 18320707 DOI: 10.1177/0885066607310181] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Amiodarone is considered a first-choice antiarrhythmic drug in critically ill patients with new-onset atrial fibrillation (AF). However, evidence supporting the use of this potentially toxic drug in critically ill patients is scarce. Magnesium sulphate (MgSO4) has shown to be effective for both rate and rhythm control, to act synergistically with antiarrhythmic drugs, and to prevent proarrhythmia. Treatment with MgSO4 may reduce the need for antiarrhythmic drugs such as amiodarone in critically ill patients with new-onset atrial fibrillation. The efficacy of a new institutional protocol was evaluated. Patients were treated with a new institutional protocol for new-onset atrial fibrillation in critically ill patients. An MgSO4 bolus (0.037 g/kg body weight in 15 minutes) was followed by continuous infusion (0.025 g/kg body weight/h). Intravenous amiodarone (loading dose 300 mg, followed by continuous infusion of 1200 mg/24 h) was given to those not responding to MgSO4 within 1 hour. Clinical response was defined as conversion to sinus rhythm or decrease in heart rate <110 beats/min. Sixteen of the 29 patients responded to MgSO4 monotherapy, whereas the addition of amiodarone was needed in 13 patients. Median (range) time until conversion to sinus rhythm after MgSO4 was 2 (1-45) hours. Median (range) conversion time in patients requiring amiodarone was 4 (2-78) hours, and median (range) conversion time in all patients was 3 (1-78) hours. The 24-hour conversion rate was 90%. Relapse atrial fibrillation was seen in 7 patients. The magnesium-amiodarone step-up scheme reduces the need for amiodarone, effectively converts new-onset atrial fibrillation into a sinus rhythm within 24 hours, and seems to be safe in critically ill patients.
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Affiliation(s)
- Mengalvio E Sleeswijk
- Intensive & Respiratory Care Unit, Department of Internal Medicine, University of Groningen, Groningen, The Netherlands.
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Sleeswijk ME, Van Noord T, Tulleken JE, Ligtenberg JJM, Girbes ARJ, Zijlstra JG. Clinical review: treatment of new-onset atrial fibrillation in medical intensive care patients--a clinical framework. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:233. [PMID: 18036267 PMCID: PMC2246197 DOI: 10.1186/cc6136] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation occurs frequently in medical intensive care unit patients. Most intensivists tend to treat this rhythm disorder because they believe it is detrimental. Whether atrial fibrillation contributes to morbidity and/or mortality and whether atrial fibrillation is an epiphenomenon of severe disease, however, are not clear. As a consequence, it is unknown whether treatment of the arrhythmia affects the outcome. Furthermore, if treatment is deemed necessary, it is not known what the best treatment is. We developed a treatment protocol by searching for the best evidence. Because studies in medical intensive care unit patients are scarce, the evidence comes mainly from extrapolation of data derived from other patient groups. We propose a treatment strategy with magnesium infusion followed by amiodarone in case of failure. Although this strategy seems to be effective in both rhythm control and rate control, the mortality remained high. A randomised controlled trial in medical intensive care unit patients with placebo treatment in the control arm is therefore still defendable.
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TERCIUS ALIXJ, KLUGER JEFFREY, COLEMAN CRAIGI, MICHAEL WHITE C. Intravenous Magnesium Sulfate Enhances the Ability of Intravenous Ibutilide to Successfully Convert Atrial Fibrillation or Flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1331-5. [DOI: 10.1111/j.1540-8159.2007.00866.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Onalan O, Crystal E, Daoulah A, Lau C, Crystal A, Lashevsky I. Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation. Am J Cardiol 2007; 99:1726-32. [PMID: 17560883 DOI: 10.1016/j.amjcard.2007.01.057] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 12/12/2022]
Abstract
The profile of electrophysiologic effects of magnesium on the heart suggests that magnesium might be effective in the treatment of atrial fibrillation (AF) in terms of rhythm and rate control. We aimed to investigate the efficacy of magnesium administration in the acute treatment of rapid AF. Randomized controlled trials comparing intravenous magnesium versus placebo or antiarrhythmic agents for the acute management of rapid AF were included. Nine electronic databases were searched for relevant trials from the earliest possible dates through June 2005, as were abstract books from 8 cardiovascular meetings held in the past 10 years. We analyzed all outcomes using a fixed-effect model because of the low number of trials in each comparison. The results were expressed as relative risks (RRs) or odds ratios (ORs) for dichotomous outcomes and weighted mean differences for continuous outcomes, along with their 95% confidence intervals (CIs). Data were pooled for 4 trials (n=303) and 8 trials (n=476), respectively, for rate control (<100 beats/min) and rhythm control. Magnesium was effective in achieving rate control (OR 1.96, 95% CI 1.24 to 3.08) or rhythm control (OR, 1.60, 95% CI 1.07 to 2.39). An overall response was achieved in 86% and 56% of patients in the magnesium and control groups, respectively (OR 4.61 95% CI 2.67 to 7.96). Time to response (in hours) was significantly shorter in the magnesium group (weighted mean difference, -6.98; 95% CI -9.27 to -4.68). The risk of having a major adverse effect in the magnesium group was similar to that in the placebo group (RR 0.85, 95% CI 0.44 to 1.61). In conclusion, the present meta-analysis of published data suggests that intravenous magnesium administration is an effective and safe strategy for the acute management of rapid AF.
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Affiliation(s)
- Orhan Onalan
- Arrhythmia Services, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
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Abstract
The development of many electrolyte disturbances in the ICU can be prevented by attention to the use of intravenous fluids and nutrition. Hyponatremia is a relative contraindication to the use of hypotonic intravenous fluids and hypernatremia calls for the administration of water. Formulae have been devised to guide the therapy of severe hyponatremia and hypernatremia. All formulae regard the patient as a closed system, and none takes into account ongoing fluid losses that are highly variable between patients. Thus, therapy of severe hyponatremia and hypernatremia must be closely monitored with serial electrolyte measurements. The significance of hypocalcemia in the critically ill is controversial. Hypokalemia, hypophosphatemia, and hypomagnesemia should be corrected.
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Affiliation(s)
- Martin Sedlacek
- Section of Nephrology and Hypertension, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
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Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart 2007; 93:1433-40. [PMID: 17449500 PMCID: PMC2016911 DOI: 10.1136/hrt.2006.111492] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To assess the effects of intravenous magnesium on converting acute onset atrial fibrillation to sinus rhythm, reducing ventricular response and risk of bradycardia. DESIGN AND DATA SOURCES Randomised controlled trials evaluating intravenous magnesium to treat acute onset atrial fibrillation from MEDLINE (1966 to 2006), EMBASE (1990 to 2006) and Cochrane Controlled Trials Register without language restrictions. REVIEW METHODS Two researchers independently performed the literature search and data extraction. RESULTS 10 randomised controlled trials, including a total of 515 patients with acute onset atrial fibrillation, were considered. Intravenous magnesium was not effective in converting acute onset atrial fibrillation to sinus rhythm when compared to placebo or an alternative antiarrhythmic drug. When compared to placebo, adding intravenous magnesium to digoxin increased the proportion of patients with a ventricular response <100 beats/min (58.8% vs 32.6%; OR 3.2, 95% CI 1.93 to 5.42; p<0.001). When compared to calcium antagonists or amiodarone, intravenous magnesium was less effective in reducing the ventricular response (21.4% vs 58.5%; OR 0.19, 95% CI 0.09 to 0.44; p<0.001) but also less likely to induce significant bradycardia or atrioventricular block (0% vs 9.2%; OR 0.13, 95% CI 0.02 to 0.76; p = 0.02). The use of intravenous magnesium was associated with transient minor symptoms of flushing, tingling and dizziness in about 17% of the patients (OR 14.5, 95% CI 3.7 to 56.7; p<0.001). CONCLUSIONS Adding intravenous magnesium to digoxin reduces fast ventricular response in acute onset atrial fibrillation. The effect of intravenous magnesium on the ventricular rate and its cardiovascular side effects are less significant than other calcium antagonists or amiodarone. Intravenous magnesium can be considered as a safe adjunct to digoxin in controlling the ventricular response in atrial fibrillation.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia.
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Dunning J, Treasure T, Versteegh M, Nashef SAM. Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg 2006; 30:852-72. [PMID: 17070065 DOI: 10.1016/j.ejcts.2006.09.003] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 07/28/2006] [Accepted: 09/04/2006] [Indexed: 11/29/2022] Open
Affiliation(s)
- Joel Dunning
- James Cook University Hospital, Middlesbrough, UK
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Abstract
Magnesium (Mg) deficiency commonly occurs in critical illness and correlates with a higher mortality and worse clinical outcome in the intensive care unit (ICU). Magnesium has been directly implicated in hypokalemia, hypocalcemia, tetany, and dysrhythmia. Moreover, Mg may play a role in acute coronary syndromes, acute cerebral ischemia, and asthma. Magnesium regulates hundreds of enzyme systems. By regulating enzymes controlling intracellular calcium, Mg affects smooth muscle vasoconstriction, important to the underlying pathophysiology of several critical illnesses. The principle causes of Mg deficiency are gastrointestinal and renal losses; however, the diagnosis is difficult to make because of the limitations of serum Mg levels, the most common assessment of Mg status. Magnesium tolerance testing and ionized Mg2+ are alternative laboratory assessments; however, each has its own difficulties in the ICU setting. The use of Mg therapy is supported by clinical trials in the treatment of symptomatic hypomagnesemia and preeclampsia and is recommended for torsade de pointes. Magnesium therapy is not supported in the treatment of acute myocardial infarction and is presently undergoing evaluation for the treatment of severe asthma exacerbation, for the prevention of post-coronary bypass grafting dysrhythmias, and as a neuroprotective agent in acute cerebral ischemia.
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Affiliation(s)
- Garrison M Tong
- University of Southern California, School of Medicine, Los Angeles, CA 90089-9317, USA
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Davey MJ, Teubner D. A Randomized Controlled Trial of Magnesium Sulfate, in Addition to Usual Care, for Rate Control in Atrial Fibrillation. Ann Emerg Med 2005; 45:347-53. [PMID: 15795711 DOI: 10.1016/j.annemergmed.2004.09.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES We examine the safety and efficacy of magnesium sulfate infusion, in addition to usual care, for acute rate reduction in patients with atrial fibrillation and a rapid ventricular response rate. METHODS This was a prospective, randomized, double-blind, placebo-controlled trial of intravenous magnesium sulfate in adult emergency department patients with rapid atrial fibrillation. Study solutions were given in addition to any therapy the treating physician would normally consider appropriate, including the use of standard rate-reduction agents. Patients received either 20 mEq (2.5 g, 10 mmol) magnesium sulfate over a 20-minute period, followed by 20 mEq (2.5 g, 10 mmol) over a 2-hour period intravenously, or placebo. RESULTS One hundred ninety-nine patients were randomized, 102 to receive magnesium sulfate and 97 to receive placebo. The antiarrhythmic drug most commonly used by treating physicians was digoxin. Magnesium sulfate was more likely than placebo to achieve a pulse rate of less than 100 beats/min (63 [65%] of 97 versus 32 [34%] of 93, relative risk [RR] 1.89; 95% confidence interval [CI] 1.38 to 2.59; P <.0001) and more likely to convert to sinus rhythm (25 [27%] of 94 patients versus 11 [12%] of 91 patients; RR 2.20; 95% CI 1.15 to 4.21; P =.01). Comparative mean pulse rate reductions in the magnesium sulfate group did not reach predetermined clinical significance levels (> or =15 beats/min reduction) at any of the measured time points. Magnesium sulfate was more likely to be associated with an adverse event (14 [15%] of 95 patients versus 5 [5%] of 92 patients; RR 2.71; 95% CI 1.02 to 7.23; P =.04). CONCLUSION Magnesium sulfate, when used to supplement other standard rate-reduction therapies, enhances rate reduction and conversion to sinus rhythm in patients with rapid atrial fibrillation.
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Affiliation(s)
- Michael John Davey
- Department of Emergency Medicine, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
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Abstract
Atrial tachyarrhythmias, including atrial fibrillation and flutter, occur frequently. Magnesium has been studied in the early conversion and prevention of atrial tachyarrhythmias, as well as in prevention of atrial tachyarrhythmias after coronary artery bypass graft surgery. Early conversion of atrial tachyarrhythmias and control of heart rate may be greater with magnesium than with common antiarrhythmic agents. Magnesium appears to be less useful for preventing recurrent atrial tachyarrhythmias; however, discrepancies in study methodologies make interpretation of results difficult. The use of magnesium for prevention of postoperative atrial arrhythmias has produced conflicting results, likely due to differences in study design. From the limited data available, magnesium appears to have some inherent antiarrhythmic properties. Certain patient populations may derive benefit from magnesium for the treatment of atrial tachyarrhythmias. However, further study is necessary to define the role of magnesium clearly for the treatment or prevention of atrial tachyarrhythmias.
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Affiliation(s)
- Alexandria A Piotrowski
- Division of Pharmacotherapy, University of Texas Health Science Center, San Antonio, Texas, USA
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Fawcett WJ, Stone JP. Recurarization in the recovery room following the use of magnesium sulphate. Br J Anaesth 2003; 91:435-8. [PMID: 12925489 DOI: 10.1093/bja/aeg179] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 67-yr-old man weighing 104 kg, with a history of hypertension, underwent laparoscopic cholecystectomy. His preoperative serum potassium was 3.4 mmol litre(-1). The patient received cisatracurium 14 mg, which was antagonized with neostigmine 2.5 mg and glycoprolate 0.5 mg at the end of the procedure. A repeat dose of neostigmine 2.5 mg and glycoprolate 0.5 mg was required 5 min later, as the neuromuscular block was incompletely antagonized. He was transferred to the recovery room about 10 min after the end of surgery, having had recovery of neuromuscular function demonstrated with no fade on peripheral nerve stimulation at 50 Hz for 5 s. Five minutes later he developed rapid atrial fibrillation, which was treated over 5 min with magnesium sulphate 2 G i.v. Within the next 3 min, the patient developed marked neuromuscular weakness of a non-depolarizing pattern leading to respiratory arrest. This necessitated re-intubation of the trachea and artificial ventilation for 20 min, until there was spontaneous recovery of neuromuscular function demonstrated by peripheral nerve stimulation. Administration of magnesium appears to have caused recurarization in this patient. The dose of magnesium alone would not be expected to cause muscle weakness. Potentiation of neuromuscular blocking drugs by magnesium is well recognized, and we recommend its use is avoided for at least 30 min after reversal of neuromuscular block.
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Affiliation(s)
- W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK.
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Dubé L, Granry JC. The therapeutic use of magnesium in anesthesiology, intensive care and emergency medicine: a review. Can J Anaesth 2003; 50:732-46. [PMID: 12944451 DOI: 10.1007/bf03018719] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To review current knowledge concerning the use of magnesium in anesthesiology, intensive care and emergency medicine. METHODS References were obtained from Medline(R) (1995 to 2002). All categories of articles (clinical trials, reviews, or meta-analyses) on this topic were selected. The key words used were magnesium, anesthesia, analgesia, emergency medicine, intensive care, surgery, physiology, pharmacology, eclampsia, pheochromocytoma, asthma, and acute myocardial infarction. PRINCIPLE FINDINGS Hypomagnesemia is frequent postoperatively and in the intensive care and needs to be detected and corrected to prevent increased morbidity and mortality. Magnesium reduces catecholamine release and thus allows better control of adrenergic response during intubation or pheochromocytoma surgery. It also decreases the frequency of postoperative rhythm disorders in cardiac surgery as well as convulsive seizures in preeclampsia and their recurrence in eclampsia. The use of adjuvant magnesium during perioperative analgesia may be beneficial for its antagonist effects on N-methyl-D-aspartate receptors. The precise role of magnesium in the treatment of asthmatic attacks and myocardial infarction in emergency conditions needs to be determined. CONCLUSIONS Magnesium has many known indications in anesthesiology and intensive care, and others have been suggested by recent publications. Because of its interactions with drugs used in anesthesia, anesthesiologists and intensive care specialists need to have a clear understanding of the role of this important cation.
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Affiliation(s)
- Laurent Dubé
- Department of Anesthesiology, University Hospital, Angers, France.
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