Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study

Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock

PURPOSE

The echocardiography parameters may predict the maintenance of sinus rhythm after cardioversion of a supraventricular arrhythmia (SVA).

MATERIALS AND METHODS

Patients in septic shock with onset of an SVA, normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of <1.0 μg/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1 h and 4 h post cardioversion on an infusion of propafenone or amiodarone.

RESULTS

Cardioversion was achieved in 96% of the 209 patients within a median time of 6(1.8-15.6)h, 134(64.1%) patients experienced at least one SVA recurrence after cardioversion. At 4 h the left atrial emptying fraction (LA_EF, cut-off 38.4%, AUC 0.69,p˂0.001), and transmitral A wave velocity-time-integral (Avti, cut-off 6.8 cm, AUC 0.65,p = 0.001) showed as limited predictors of a single arrhythmia recurrence. The LA_EF 44(36,49)%, (p = 0.005) and the Avti 8.65(7.13,9.50)cm, (p < 0.001) were associated with sustained sinus rhythm and decreased proportionally to increasing numbers of arrhythmia recurrences (p < 0.001 and p = 0.007, respectively). The enlarged left atrial end-systolic diameter at the arrhythmia onset (p = 0.04) and elevated systolic pulmonary artery pressure at 4 h (p = 0.007) were weak predictors of multiple(˃3) recurrences.

CONCLUSION

The LA_EF and Avti are related to arrhythmia recurrences post-cardioversion suggesting potential guidance to the choice between rhythm and rate control strategies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03029169, registered on 24th of January 2017.

Cardiac index and heart rate as prognostic indicators for mortality in septic shock: A retrospective cohort study from the MIMIC-IV database

Background

Septic shock is a life-threatening condition that can lead to organ dysfunction and death. In the ICU, monitoring of cardiac index (CI) and heart rate (HR) is commonly used to guide management and predict outcomes in septic shock patients. However, there is a lack of research on the association between CI and HR and the risk of mortality in this patient population. Therefore, the aim of this study was to investigate the relationship between different levels of CI and HR and mortality in septic shock patients.

Methods

Data analysis was obtained from the MIMIC-IV version 2.0 database. Sepsis and septic shock were primarily defined by sepsis-3, the third international consensus on sepsis and septic shock. CI was computed using cardiac output (CO) and body surface area (BSA). To evaluate the incidence of CI with respect to each endpoint (7-, 14-, 21-, and 28-day mortality), a restricted cubic spline curve function (RCS) was used. The optimal cutoff value for predicted mortality was determined using the Youden index. Analyses of KM curves, cox regression, and logistic regression were conducted separately to determine the relationship between various CI and HR and 28-day mortality.

Results

This study included 1498 patients with septic shock. A U-shaped relationship between CI levels and risk of mortality in septic shock was found by RCS analysis (p < 0.001). CI levels within the intermediate range of 1.85-2.8 L/min/m2 were associated with a mortality hazard ratio (HR) < 1. In contrast, low CI (HR = 1.87 95% CI: 1.01-3.49) and high CI (HR = 1.93 95% CI: 1.26-2.97) had a significantly increased risk of mortality. The AUC for heart rate prediction of mortality by Youden index analysis was 0.70 95%CI:0.64-0.76 with a cut-off value of 93.63 bpm. According to the characteristics of HR and CI, patients were divided into six subgroups HR↓+CI intermediate group (n = 772), HR↓+CI↓ group (n = 126), HR↓+CI↑ group (n = 294), HR↑+CI intermediate group (n = 132), HR↑+CI↓ group (n = 24), and HR↑+CI↑ group (n = 150). The KM curves, COX regression, and logistic regression analysis showed that the survival rates the of HR↓+CI intermediate group, HR↓+CI↓ group, and HR↓+CI↑ were higher than the other groups. The risk factors of HR↑+CI intermediate group, HR↑+CI↓, and HR↑+CI↑ with ICU 28-day mortality were HR = 2.91 (95% CI: 1.39-5.97), HR = 3.67 (95% CI: 1.39-11.63), and HR = 5.77 (95% CI: 2.98-11.28), respectively.

Conclusion

Our retrospective study shows that monitoring cardiac index and heart rate in patients with septic shock may help predict the organismal response and hemodynamic consequences, as well as the prognosis. Thus, healthcare providers should carefully monitor changes in these parameters in septic shock patients transferred to the ICU for treatment.

Propafenone versus amiodarone for supraventricular arrhythmias in septic shock: a randomised controlled trial

PURPOSE

Acute onset supraventricular arrhythmias can contribute to haemodynamic compromise in septic shock. Both amiodarone and propafenone are available interventions, but their clinical effects have not yet been directly compared.

METHODS

In this two-centre, prospective controlled parallel group double blind trial we recruited 209 septic shock patients with new-onset arrhythmia and a left ventricular ejection fraction above 35%. The patients were randomised in a 1:1 ratio to receive either intravenous propafenone (70 mg bolus followed by 400-840 mg/24 h) or amiodarone (300 mg bolus followed by 600-1800 mg/24 h). The primary outcomes were the proportion of patients who had sinus rhythm 24 h after the start of the infusion, time to restoration of the first sinus rhythm and the proportion of patients with arrhythmia recurrence.

RESULTS

Out of 209 randomized patients, 200 (96%) received the study drug. After 24 h, 77 (72.8%) and 71 (67.3%) were in sinus rhythm (p = 0.4), restored after a median of 3.7 h (95% CI 2.3-6.8) and 7.3 h (95% CI 5-11), p = 0.02, with propafenone and amiodarone, respectively. The arrhythmia recurred in 54 (52%) patients treated with propafenone and in 80 (76%) with amiodarone, p  < 0.001. Patients with a dilated left atrium had better rhythm control with amiodarone (6.4 h (95% CI 3.5; 14.1) until cardioversion vs 18 h (95% CI 2.8; 24.7) in propafenone, p = 0.05).

CONCLUSION

Propafenone does not provide better rhythm control at 24 h yet offers faster cardioversion with fewer arrhythmia recurrences than with amiodarone, especially in patients with a non-dilated left atrium. No differences between propafenone and amiodarone on the prespecified short- and long-term outcomes were observed.

Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis

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.

Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction

PURPOSE

Left ventricular outflow tract obstruction (LVOTO) is a relatively uncommon but severe condition that may lead to hemodynamic impairment. It can be elicited by morphological (left ventricular hypertrophy, sigmoid septum, prominent papillary muscle, prolonged anterior mitral valve leaflet) and functional (hypovolemia, low afterload, hypercontractility, catecholamines) factors. We sought to determine the incidence of the most severe form of LVOTO in septic shock patients and describe the therapeutic effects of vasopressin.

METHODS

Over a period of 29 months, 527 patients in septic shock were screened for LVOTO. All were mechanically ventilated and treated according to sepsis bundles, including pre-load optimization and norepinephrine infusion. Vasopressin was added in addition to norepinephrine to reduce the adrenergic burden and decrease LVOTO.

RESULTS

Ten patients were diagnosed with the most severe form of LVOTO, including systolic anterior mitral valve motion (SAM) and severe mitral regurgitation (MR) with pulmonary oedema. The median norepinephrine dosage to obtain a mean arterial pressure of ≥70 mmHg was 0.58 mcg/Kg/min (IQR 0.40-0.78). All patients had a hyper-contractile left ventricle, septal hypertrophy, significant LVOTO (peak gradient 78 [56-123] mmHg) associated with SAM and severe MR with pulmonary oedema. Vasopressin (median 4 IU/h) allowed a significant reduction of norepinephrine (0.18 [0.14-0.30] mcg/kg/min; p = 0.01), LVOT gradient (35 [24-60] mmHg; p = 0.01) and MR with a significant paO₂/FiO₂ increase (174 [125-213] mmHg; p = 0.01).

CONCLUSION

Vasopressin allowed a reduction of norepinephrine with subsequent LVOTO reduction and hemodynamic improvement of the most severe form of LVOTO, which represented 1.9% of all septic shock patients.