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Robinson K, Katzenellenbogen JM, Kleinig TJ, Kim J, Budgeon CA, Thrift AG, Nedkoff L. Large Burden of Stroke Incidence in People with Cardiac Disease: A Linked Data Cohort Study. Clin Epidemiol 2023; 15:203-211. [PMID: 36846512 PMCID: PMC9945299 DOI: 10.2147/clep.s390146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/28/2023] [Indexed: 02/19/2023] Open
Abstract
Purpose People with cardiac disease have 2-4 times greater risk of stroke than the general population. We measured stroke incidence in people with coronary heart disease (CHD), atrial fibrillation (AF) or valvular heart disease (VHD). Methods We used a person-linked hospitalization/mortality dataset to identify all people hospitalized with CHD, AF or VHD (1985-2017), and stratified them as pre-existing (hospitalized 1985-2012 and alive at October 31, 2012) or new (first-ever cardiac hospitalization in the five-year study period, 2012-2017). We identified first-ever strokes occurring from 2012 to 2017 in patients aged 20-94 years and calculated age-specific and age-standardized rates (ASR) for each cardiac cohort. Results Of the 175,560 people in the cohort, most had CHD (69.9%); 16.3% had multiple cardiac conditions. From 2012-17, 5871 first-ever strokes occurred. ASRs were greater in females than males in single and multiple condition cardiac groups, largely driven by rates in females aged ≥75 years, with stroke incidence in this age group being at least 20% greater in females than males in each cardiac subgroup. In females aged 20-54 years, stroke incidence was 4.9-fold greater in those with multiple versus single cardiac conditions. This differential declined with increasing age. Non-fatal stroke incidence was greater than fatal stroke in all age groups except in the 85-94 age group. Incidence rate ratios were up to 2-fold larger in new versus pre-existing cardiac disease. Conclusion Stroke incidence in people with cardiac disease is substantial, with older females, and younger patients with multiple cardiac conditions, at elevated risk. These patients should be specifically targeted for evidence-based management to minimize the burden of stroke.
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Affiliation(s)
- Keira Robinson
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia,Correspondence: Keira Robinson, School of Population and Global Health, The University of Western Australia, M431, 35 Stirling Hwy, Crawley, WA, 6009, Australia, Email
| | - Judith M Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joosup Kim
- Department of Medicine, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Victoria, Australia,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Charley A Budgeon
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
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Zaki HA, Bashir K, Iftikhar H, Salem W, Mohamed EH, Elhag HM, Hendy M, Kassem AAO, Salem EED, Elmoheen A. An Integrative Comparative Study Between Digoxin and Amiodarone as an Emergency Treatment for Patients With Atrial Fibrillation With Evidence of Heart Failure: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e26800. [PMID: 35971374 PMCID: PMC9372377 DOI: 10.7759/cureus.26800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 11/06/2022] Open
Abstract
The emergency treatment of atrial fibrillation (AF) involves utilizing two strategies. The first strategy normally involves permitting the atrial fibrillation to persevere as the ventricular rate is controlled. The other method involves utilizing anti-arrhythmic drugs in cardioversion and attempting to maintain sinus rhythm. Different pharmacological treatments, including digoxin and amiodarone, have been used to manage AF. A literature review on amiodarone and digoxin in the treatment of AF among patients with heart failure (HF) has shown that both drugs have potential risks. Therefore, we are conducting this systematic review and meta-analysis to compare the effectiveness of amiodarone and digoxin in the treatment of AF among patients with evidence of HF. A literature search of relevant articles was conducted on six electronic databases (PubMed, Web of Science, Medline, ScienceDirect, Cochrane Library, and Google Scholar) from 2000 to 2022. The search yielded seven studies that had met the inclusion criteria. Our meta-analysis of four studies showed that there was no significant difference in the reduction of heart rate after treatment with either amiodarone or digoxin (mean difference (MD): -5.44; 95% confidence interval (CI): -9.53 to -1.34; I2 = 25%; p = 0.26). On the other hand, the statistical analysis showed that amiodarone had a better effect on the conversion to sinus rhythm than digoxin (63% versus 35%, respectively). Based on evidence from our meta-analysis, the clinical effect of amiodarone and digoxin in the emergency treatment of AF on heart rate control was unclear. However, amiodarone has a significant impact on the restoration of sinus rhythm compared with digoxin and can be considered the first-line drug regimen in conversion to sinus rhythm for AF patients with evidence of heart failure. However, the use of amiodarone and digoxin is complicated by adverse events and all-cause mortality.
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Lan Q, Wu F, Han B, Ma L, Han J, Yao Y. Intravenous diltiazem versus metoprolol for atrial fibrillation with rapid ventricular rate: A meta-analysis. Am J Emerg Med 2021; 51:248-256. [PMID: 34781150 DOI: 10.1016/j.ajem.2021.08.082] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/10/2021] [Accepted: 08/10/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Intravenous diltiazem and metoprolol are both commonly used to treat atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED), but the advantages and disadvantages of these drugs cannot be verified. This meta-analysis aimed to assess the efficacy and safety of intravenous diltiazem versus metoprolol for AF with RVR. METHOD We systematically searched PubMed, Web of Science, Embase, Cochrane library, the China National Knowledge Infrastructure (CNKI), Wanfang, China Biology Medicine disc (CBM) and the WeiPu (VIP). Meta-analysis was performed using weighted mean difference (WMD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1. RESULTS Seventeen studies involving 1214 patients in nine randomized controlled trials (RCTs) and eight cohort studies were included in meta-analysis, including 643 patients in the intravenous diltiazem group and 571 patients group in the intravenous metoprolol. The results of the meta-analysis showed that compared with intravenous metoprolol, intravenous diltiazem was found higher efficacy (RR =1.11; 95% CI = 1.06 to 1.16, p < 0.00001), shorter average onset time (RR = -1.13; 95% CI = -1.97 to -0.28, p = 0.009), lower ventricular rate (RR = -9.48; 95% CI = -12.13 to -6.82, p<0.00001), less impact on systolic blood pressure (WMD = 3.76; 95% CI: 0.20 to 7.33, P = 0.04), and no significant difference in adverse events (RR = 0.80, 95% CI = 0.55 to 1.14, P = 0.22) and diastolic blood pressure (WMD = -1.20; 95% CI: -3.43 to 1.04, P = 0.29) was found between intravenous diltiazem and metoprolol. CONCLUSION Intravenous diltiazem has higher efficacy, shorter average onset time, lower ventricular rate, less impact on blood pressure, and with no increase in adverse events compared to intravenous metoprolol.
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Affiliation(s)
- Qingsu Lan
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China; Key Laboratory of Cardiovascular Diseases of Gansu Province, Lanzhou, China
| | - Fengchao Wu
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Bing Han
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China; Key Laboratory of Cardiovascular Diseases of Gansu Province, Lanzhou, China
| | - Lanhu Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Junxian Han
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yali Yao
- Department of Heart Center, The First Hospital of Lanzhou University, Lanzhou, China; Key Laboratory of Cardiovascular Diseases of Gansu Province, Lanzhou, China.
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4
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Mendoza PA, McIntyre WF, Belley-Côté EP, Wang J, Parkash R, Atzema CL, Benz AP, Oldgren J, Whitlock RP, Healey JS. Oral anticoagulation for patients with atrial fibrillation in the ED: RE-LY AF registry analysis. J Thromb Thrombolysis 2021; 53:74-82. [PMID: 34338944 DOI: 10.1007/s11239-021-02530-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/27/2022]
Abstract
Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF). We sought to determine predictors of OAC initiation in AF patients presenting to the emergency department (ED). Secondary analysis of the RE-LY AF registry which enrolled individuals from 47 countries between 2007 and 2011 who presented to an ED with AF and followed them for 1 year. A total of 4149 patients with AF as their primary diagnosis who were not already taking OAC and had a CHA2DS2-VASc ≥ 1 for men or ≥ 2 for women were included in this analysis. Of these individuals, 26.8% were started on OAC (99.2% vitamin K antagonists) in the ED and 29.8% were using OAC one year later. Factors associated with initiating OAC in the ED included: specialist consultation (relative risk [RR] 1.84, 95%CI 1.44-2.36), rheumatic heart disease (RR 1.60, 95%CI 1.29-1.99), persistence of AF at ED discharge (RR 1.33, 95%CI 1.18-1.50), diabetes mellitus (RR 1.32, 95%CI 1.19-1.47), and hospital admission (RR 1.30, 95%CI 1.14-1.47). Heart failure (RR 0.83, 95%CI 0.74-0.94), antiplatelet agents (RR 0.77, 95%CI 0.69-0.84), and dementia (RR 0.61, 95%CI 0.40-0.94) were inversely associated with OAC initiation. Patients taking OAC when they left the ED were more likely using OAC at 1-year (RR 2.81, 95%CI 2.55-3.09) and had lower rates of death (RR 0.55, 95%CI 0.38-0.79) and stroke (RR 0.59, 95%CI 0.37-0.96). In patients with AF presenting to the ED, prompt initiation of OAC and specialist involvement are associated with a greater use of OAC 1 year later and may result in improved clinical outcomes.
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Affiliation(s)
- Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, ON, Canada
| | - Ratika Parkash
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | | | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Bilaszewski Ł, Timler W, Budrewicz K, Marczak M, Kozłowski R, Wizowska J, Timler M, Jagielski D, Dudek M, Rasmus P, Zyśko D, Timler D. The Impact of COVID-19 on Admissions and Management of Patients with Atrial Fibrillation Episodes in the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116048. [PMID: 34199795 PMCID: PMC8200085 DOI: 10.3390/ijerph18116048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND During the COVID-19 pandemic, the number of admissions to the emergency department (ED) due to a primary diagnosis of atrial fibrillation (AF) has decreased when compared to pre-pandemic times. The principal aim of the study was to assess the frequency of SARS-CoV-2 infections and sinus rhythm restoration among patients who arrived at the ED with AF. Secondary aims included determining whether patients arriving at the ED principally due to AF delayed their presentations and whether the frequency of successful cardioversion for AF was decreased during the pandemic period. MATERIALS AND METHODS A retrospective analysis of medical records of patients admitted to two hospital EDs due to AF during July-December 2019 (pre-pandemic period) versus July-December 2020 (pandemic period) was performed. RESULTS During the study periods, 601 ED visits by 497 patients were made due to the primary diagnosis of AF. The patients were aged 71.2+/-13.5 years and 51.3% were male. The duration of an AF episode before the ED admission was 10 h (4.5-30 h) during the pandemic period vs. 5 h (3-24 h) during the non-pandemic period (p = 0.001). A shorter duration of the AF episode before ED admission was associated with the successful restoration of the sinus rhythm. During the pandemic period, among patients with short-lasting AF who were not treated with Phenazolinum, the restoration of the sinus rhythm was more frequent in the Copernicus Memorial Hospital than in the University Hospital (p = 0.026). A positive SARS-CoV-2 test was found in 5 (1%) patients, while 2 other patients (0.5%) had a prior diagnosis of COVID-19 disease noted in their medical history. CONCLUSIONS 1. The number of AF episodes treated in these two EDs was lower during the pandemic than non-pandemic period. 2. The patients with AF appeared at the ED later after AF onset in the pandemic period. 3. Successful cardioversion of atrial fibrillation was more frequent during the pre-pandemic period in one of the two hospitals. 4. A difference of approaches to the treatment of short-lasting AF episodes between EDs during the pandemic period may exist between these two EDs. 5. The patients with SARS-CoV-2 infection during the second wave of the COVID-19 pandemic constituted a small percentage of the patients admitted to EDs due to an AF episode.
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Affiliation(s)
- Łukasz Bilaszewski
- Department of Emergency Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (Ł.B.); (K.B.); (J.W.); (D.Z.)
| | - Wojciech Timler
- Department of Emergency Medicine and Disaster Medicine, Medical University of Lodz, 92-212 Lodz, Poland;
| | - Katarzyna Budrewicz
- Department of Emergency Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (Ł.B.); (K.B.); (J.W.); (D.Z.)
| | - Michał Marczak
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland; (M.M.); (M.T.)
| | - Remigiusz Kozłowski
- Center of Security Technologies in Logistics, Faculty of Management, University of Lodz, 90-237 Lodz, Poland;
| | - Joanna Wizowska
- Department of Emergency Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (Ł.B.); (K.B.); (J.W.); (D.Z.)
| | - Małgorzata Timler
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland; (M.M.); (M.T.)
| | - Dariusz Jagielski
- Centre for Heart Diseases, Department of Cardiology, 4th Military Hospital, 50-981 Wroclaw, Poland;
| | - Michał Dudek
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lodz, 90-153 Lodz, Poland;
| | - Paweł Rasmus
- Department of Medical Psychology, Medical University of Lodz, 90-131 Lodz, Poland;
| | - Dorota Zyśko
- Department of Emergency Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (Ł.B.); (K.B.); (J.W.); (D.Z.)
| | - Dariusz Timler
- Department of Emergency Medicine and Disaster Medicine, Medical University of Lodz, 92-212 Lodz, Poland;
- Correspondence: ; Tel.: +48-501306238
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Ghosh S, Chandra A, Sen S, Dutta S. Atrial fibrillation following low voltage electrical injury. BMJ Case Rep 2021; 14:14/1/e239306. [PMID: 33462048 PMCID: PMC7813334 DOI: 10.1136/bcr-2020-239306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Electrical injuries can have myriad presentations, including significant cardiac involvement. Arrhythmias are the most frequently experienced cardiac affliction, of which sinus tachycardia or bradycardia, ventricular fibrillation, atrial or ventricular premature beats and bundle branch block are most commonly reported. A 50-year-old man, with no prior history of cardiac disease, presented with palpitations following low voltage electrical injury. On examination, he was tachycardic with an irregularly irregular pulse. An ECG confirmed atrial fibrillation with rapid ventricular rate. Chemical cardioversion was attempted successfully, following which the patient reverted to sinus rhythm. Atrial fibrillation following electrical injury has been rarely described in the literature, and is rarer so without associated high voltage electrical exposure or pre-existing cardiac ailment.
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Affiliation(s)
- Shrestha Ghosh
- Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, India
| | - Atanu Chandra
- Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, India
| | - Sourav Sen
- Department of Internal Medicine, Midnapore Medical College and Hospital, Midnapore, India
| | - Sukanta Dutta
- Department of Internal Medicine, Midnapore Medical College and Hospital, Midnapore, India
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Magliari RT, Neto JNDA. How to Manage Atrial Fibrillation in the Emergency Department: a Critical Appraisal. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i1.3390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmia in emergency departments. There is growing evidence that certain patients with acute atrial fibrillation can be safely managed in the emergency room without the need for hospitalization, minimizing costs and reducing unnecessary exposures. This review addresses the emergency management of atrial fibrillation based on the latest updates on the subject with a focus on the assessment and prevention of thromboembolic phenomena, control of frequency x control of rhythm and strategies for cardioversion and restoration of sinus rhythm or for heart rate control.
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Safavi-Naeini P, Rasekh A. Thromboembolism in Atrial Fibrillation: Role of the Left Atrial Appendage. Card Electrophysiol Clin 2019; 12:13-20. [PMID: 32067643 DOI: 10.1016/j.ccep.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia. Patients with AF have a higher risk for thromboembolism than individuals without AF. The left atrial appendage (LAA) is the main source of thromboembolism because of its anatomic, mechanical, and electrophysiologic properties, and accounts for more than 90% of thrombus formation in patients with AF. Advancement in imaging expands knowledge about anatomic and physiologic characteristics of LAA. The risk of thromboembolism events in patients with AF depends on clinical comorbidities and structural and physiologic parameters of atria, especially LAA. This article discusses AF-related thromboembolic events and the role of the LAA.
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Affiliation(s)
- Payam Safavi-Naeini
- Electrophysiology Clinical Research and Innovation, Texas Heart Institute, Houston, TX, USA
| | - Abdi Rasekh
- Cardiology, Baylor College of Medicine, 6624 Fannin Street Suite 2480, Houston, TX 77030, USA; Cardiology, Texas Heart Institute, Houston, TX, USA.
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Bonora A, Turcato G, Franchi E, Taioli G, Dilda A, Zerman G, Maccagnani A, Pistorelli C, Olivieri O. Efficacy and safety in pharmacological cardioversion of recent-onset atrial fibrillation: a propensity score matching to compare amiodarone vs class IC antiarrhythmic drugs. Intern Emerg Med 2017; 12:853-859. [PMID: 27384766 DOI: 10.1007/s11739-016-1497-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Abstract
The acute management of recent-onset (<48 h) atrial fibrillation (AF) is still debated. Aim of our study was to compare efficacy and safety of intravenously administered class IC antidysrhythmic agents vs amiodarone in a propensity score matched series of patients acutely treated for AF in the emergency department. During a 3-year period, we retrospectively evaluated all episodes of recent-onset (<48 h) AF pharmacologically treated for sinus rhythm restoration in the emergency department. By means of a propensity score matching considering the main statistically different covariates, we selected two accurately matched treatment groups. We analysed the differences between amiodarone and class IC group in terms of efficacy and safety that is conversion to sinus rhythm rates within 12 and 48 h after starting treatment, time to conversion, and adverse drug effects. An overall number of 817 episodes of recent-onset AF were collected (amiodarone group = 406, class IC group = 411). After matching, we obtained 358 episodes equally divided (amiodarone group = 179 and class IC group = 179). Conversion rates within 12 h were 139 (53.1 %) in amiodarone group and 95 (72.6 %) in class IC group (p < 0.05). Median time for cardioversion was 420 min (331.6-508.3 CI 95 %) in amiodarone and 55 min (44.9-65.1 CI 95 %) in class IC group (p < 0.05). The incidence of adverse events in both groups was very low and equally distributed (p = ns). Intravenously administration of class IC agents, when compared with amiodarone, proved to be more rapid and effective, and equally safe in the acute management of recent-onset AF.
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Affiliation(s)
- Antonio Bonora
- Emergency and Intensive Care Department, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy.
| | - Gianni Turcato
- Postgraduate School of Emergency Medicine, University of Verona, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Elena Franchi
- Department of Cardiology, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Gabriele Taioli
- Postgraduate School of Emergency Medicine, University of Verona, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Alice Dilda
- Emergency and Intensive Care Department, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Germana Zerman
- Emergency and Intensive Care Department, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Antonio Maccagnani
- Emergency and Intensive Care Department, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Claudio Pistorelli
- Emergency and Intensive Care Department, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
| | - Oliviero Olivieri
- Department of Internal Medicine, Azienda Ospedaliera Universitaria Integrata, Piazzale L.A. Scuro, 10, Verona, 37134, Italy
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10
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Vogiatzis I, Papavasiliou E, Dapcevitch I, Pittas S, Koulouris E. Vernakalant versus ibutilide for immediate conversion of recent-onset atrial fibrillation. Hippokratia 2017; 21:67-73. [PMID: 30455558 PMCID: PMC6239091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The pharmacological cardioversion of recent-onset atrial fibrillation (AF) is a challenge for the clinician. The aim of the study was to compare the efficacy, the safety, and the overall cost of intravenous (iv) administration of vernakalant, which is a relatively new atrial-selective antiarrhythmic agent, versus ibutilide, in cardioversion of recent-onset AF. METHODS We enrolled in this study 78 patients (56 men, 22 women; mean age 63.72 ± 6.67 years) who presented with recent-onset AF. Cardioversion was attempted in 36 patients (group A: 24 men, 12 women; mean age 62.44 ± 7.24 years) by iv administration of vernakalant (3 mg/kg over 10 min and if needed after 15 min, a second dose 2 mg/kg over 10 min) while in 42 patients (group B: 32 men, 10 women; mean age 64.81 ± 6 years) iv ibutilide was administered (1 mg over 10 min and if needed after 10 min, a second dose 1 mg over 10 min). RESULTS AF was successfully converted in 52.78 % of (n =19) patients of group A vs 52.38 % of (n =22) patients of group B (p =0.58), with an average time of conversion 11.8 ± 4.3 min for group A patients vs 33.9 ± 20.25 min for group B patients (p <0.0001). The average length of hospital stay for patients of group A was 17.64 ± 15.96 hours vs 41.09 ± 17.6 hours for patients of Group B (p <0.0001). In one patient of group A, the administration of vernakalant was discontinued due to hypotension while two other patients reported dysgeusia during their hospitalization. In three patients of group B, the administration of ibutilide was discontinued due to development of nonsustained ventricular tachycardia, which resolved with discontinuation of the drug. The cost of administered drugs was estimated at 488.22 ± 170.34 € for patients of group A vs 142.43 ± 54.45 € for patients of group B (p <0.0001), however, hospitalization costs were significantly lower in patients of group A (258.5 8± 124.73 € over 414.43 ± 100.32; p =0.002). CONCLUSION There was no significant difference in the efficiency of converting recent-onset AF between vernakalant and ibutilide. Although vernakalant is an expensive drug, we recorded fewer side effects and more rapid restoration, which reduced the overall cost of hospitalization of these patients. HIPPOKRATIA 2017, 21(2): 67-73.
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Affiliation(s)
- I Vogiatzis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - E Papavasiliou
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - I Dapcevitch
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - S Pittas
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - E Koulouris
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
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Rosa GM, Dorighi U, Ferrero S, Brunacci M, Bertero G, Brunelli C. Ranolazine for the treatment of atrial fibrillation. Expert Opin Investig Drugs 2015; 24:825-36. [DOI: 10.1517/13543784.2015.1036984] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Koskinas KC, Fragakis N, Katritsis D, Skeberis V, Vassilikos V. Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation. Europace 2014; 16:973-9. [DOI: 10.1093/europace/eut407] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Conde D, Costabel JP, Alves de Lima A. Recent-Onset Atrial Fibrillation in Patients With Left Ventricular Dysfunction: Amiodarone or Vernakalant? Can J Cardiol 2013; 29:1330.e11-1330.e12. [DOI: 10.1016/j.cjca.2013.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 02/25/2013] [Accepted: 02/25/2013] [Indexed: 10/26/2022] Open
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Torp-Pedersen C, Camm AJ, Butterfield NN, Dickinson G, Beatch GN. Vernakalant: Conversion of atrial fibrillation in patients with ischemic heart disease. Int J Cardiol 2013; 166:147-51. [PMID: 22108512 DOI: 10.1016/j.ijcard.2011.10.108] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 08/30/2011] [Accepted: 10/18/2011] [Indexed: 11/26/2022]
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15
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Mao Z, Wheeler JJ, Townsend R, Gao Y, Kshirsagar S, Keirns JJ. Population pharmacokinetic-pharmacodynamic analysis of vernakalant hydrochloride injection (RSD1235) in atrial fibrillation or atrial flutter. J Pharmacokinet Pharmacodyn 2011; 38:541-62. [PMID: 21786177 DOI: 10.1007/s10928-011-9207-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 06/18/2011] [Indexed: 01/19/2023]
Abstract
Vernakalant hydrochloride is a novel, relatively atrial-selective antiarrhythmic agent that rapidly converts atrial fibrillation (AF) to sinus rhythm (SR). This analysis integrates pharmacokinetic (PK) and safety data from 5 clinical trials of patients with AF or atrial flutter (AFL). Patients were initially given a 10-min intravenous (IV) infusion of vernakalant 3 mg/kg or placebo. If SR was not evident after a 15-min observation, then a second 10-min IV infusion of vernakalant 2 mg/kg or placebo was given. Population pharmacokinetic/pharmacodynamic (PK/PD) models were constructed for QT interval prolongation corrected for heart rate by Fridericia's formula (QTcF) and for changes in systolic blood pressure (SBP). The exposure-response relationships for QTcF and SBP were best described by sigmoidal maximum-effect (E (max)) models. For QTcF, the model was characterized by a typical E (max) of 20.3 ms, and by a vernakalant median effective concentration dependent (EC₅₀) on conversion status (4,222 ng/ml for patients converting to SR and 2,276 ng/ml for those remaining in AF/AFL). For SBP, the model was characterized by E (max) of 3.05 mmHg and EC₅₀ of 1,141 ng/ml. Risk of hypotension (SBP <90 mmHg) was primarily associated with low baseline SBP and to a smaller extent with a history of congestive heart failure (CHF); plasma vernakalant concentrations showed a small contribution to the risk of hypotension (relative risk = 1.4 at 4,000 ng/ml), which may be significant with a baseline SBP of <105 mmHg. These results show that vernakalant had a smaller effect on QTcF in patients who demonstrated conversion to SR than those remaining in AF or AFL, and it had a relatively small effect on SBP.
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Affiliation(s)
- Zhongping Mao
- Astellas Pharma Global Development US, Inc., 3 Parkway North, Deerfield, IL 60015, USA
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16
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Camm AJ, Capucci A, Hohnloser SH, Torp-Pedersen C, Van Gelder IC, Mangal B, Beatch G. A randomized active-controlled study comparing the efficacy and safety of vernakalant to amiodarone in recent-onset atrial fibrillation. J Am Coll Cardiol 2011; 57:313-21. [PMID: 21232669 DOI: 10.1016/j.jacc.2010.07.046] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/22/2010] [Accepted: 07/19/2010] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This randomized double-blind study compared the efficacy and safety of intravenous vernakalant and amiodarone for the acute conversion of recent-onset atrial fibrillation (AF). BACKGROUND Intravenous vernakalant has effectively converted recent-onset AF and was well tolerated in placebo-controlled studies. METHODS A total of 254 adult patients with AF (3 to 48 h duration) eligible for cardioversion were enrolled in the study. Patients received either a 10-min infusion of vernakalant (3 mg/kg) followed by a 15-min observation period and a second 10-min infusion (2 mg/kg) if still in AF, plus a sham amiodarone infusion, or a 60-min infusion of amiodarone (5 mg/kg) followed by a maintenance infusion (50 mg) over an additional 60 min, plus a sham vernakalant infusion. RESULTS Conversion from AF to sinus rhythm within the first 90 min (primary end point) was achieved in 60 of 116 (51.7%) vernakalant patients compared with 6 of 116 (5.2%) amiodarone patients (p < 0.0001). Vernakalant resulted in rapid conversion (median time of 11 min in responders) and was associated with a higher rate of symptom relief compared with amiodarone (53.4% of vernakalant patients reported no AF symptoms at 90 min compared with 32.8% of amiodarone patients; p = 0.0012). Serious adverse events or events leading to discontinuation of study drug were uncommon. There were no cases of torsades de pointes, ventricular fibrillation, or polymorphic or sustained ventricular tachycardia. CONCLUSIONS Vernakalant demonstrated efficacy superior to amiodarone for acute conversion of recent-onset AF. Both vernakalant and amiodarone were safe and well tolerated in this study. (A Phase III Superiority Study of Vernakalant vs Amiodarone in Subjects With Recent Onset Atrial Fibrillation [AVRO]; NCT00668759).
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Affiliation(s)
- A John Camm
- St. George's University of London, United Kingdom.
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Stiell IG, Dickinson G, Butterfield NN, Clement CM, Perry JJ, Vaillancourt C, Calder LA. Vernakalant hydrochloride: A novel atrial-selective agent for the cardioversion of recent-onset atrial fibrillation in the emergency department. Acad Emerg Med 2010; 17:1175-82. [PMID: 21175515 DOI: 10.1111/j.1553-2712.2010.00915.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Vernakalant is a relatively atrial-selective antiarrhythmic agent that has been shown to successfully convert atrial fibrillation (AF) to normal sinus rhythm for some patients whose onset of dysrhythmia occurred less than 7 days previously. This study sought to evaluate the efficacy and safety of vernakalant for patients with recent-onset AF. METHODS This was a post hoc analysis of patients with recent-onset AF (> 3 to ≤ 48 hours) enrolled in the double-blind, placebo-controlled Atrial arrhythmia Conversion Trial (ACT) I and the open-label ACT IV trials. The studies enrolled adults presenting with AF to 78 emergency departments (ED) and cardiac clinics in six countries. Patients received a 10-minute intravenous infusion of vernakalant or placebo, followed by an additional infusion if necessary. Efficacy assessments included conversion to sinus rhythm within 90 minutes and median time to conversion. Safety evaluations included telemetry, Holter monitoring, and adverse events (AEs). RESULTS Of the 290 patients, 229 received vernakalant, 61 received placebo, and the overall mean age was 59 years. The vernakalant and placebo groups were similar. Of all patients given vernakalant, 136 (59.4%) converted to sinus rhythm within 90 minutes, compared with three (4.9%) placebo patients. The median time to conversion with vernakalant was 12 minutes (interquartile range = 7-24.5 minutes). Clinically significant bradycardia and hypotension were uncommon, and no cases of torsade de pointes or ventricular fibrillation occurred. CONCLUSIONS Vernakalant rapidly converted recent-onset AF to sinus rhythm in over half of patients, was well tolerated, and has the potential to offer an important therapeutic option for rhythm control of recent-onset AF in the ED.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Canada.
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Stead LG, Bellolio MF, Suravaram S, Brown RD, Bhagra A, Gilmore RM, Boie ET, Decker WW. Evaluation of transient ischemic attack in an emergency department observation unit. Neurocrit Care 2008; 10:204-8. [PMID: 18850077 DOI: 10.1007/s12028-008-9146-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 08/29/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the feasibility of a protocol for evaluation of transient ischemic attack (TIA) in an Emergency Department Observation Unit (EDOU), and assess the risk of early stroke after such an evaluation. METHODS All adult patients presenting to the Emergency Department (ED) with signs and symptoms consistent with TIA were prospectively enrolled in this observational study over a period of 3 years. Patients underwent a standardized TIA evaluation per protocol. Risk of subsequent stroke at 48 h, 1 week, 1 month, and 3 months was prospectively assessed. RESULTS In total, 418 patients were seen during the study period, and all were evaluated per the EDOU TIA protocol. The mean age was 73.1 (+/-13.3) years and 53.8% were males. Comorbidities included hypertension in 71.5%, diabetes mellitus in 20.1%, prior TIA in 19.6%, and prior ischemic stroke in 19.6% of the cohort. Brain CT, neurology consult, electrocardiogram, carotid ultrasound, and additional tests were performed, and education was given. A total of 30.4% of the patients were dismissed directly from the EDOU. The risk of stroke at 2 days was 0.96%, at 7 days 1.2%, at 30 days 1.9%, and 2.4% at 90 days. CONCLUSION An Emergency Department Observation Unit Protocol for TIA is a feasible option for expedited evaluation of these patients.
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Affiliation(s)
- Latha G Stead
- Department of Emergency Medicine, Division of Research, Mayo Clinic College of Medicine, Generose G-410, 200 First Street SW, Rochester, MN 55905, USA.
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Tsai SH, Chu SJ, Wu CP, Tsai TN, Cheng SM. Acute right ventricular dysfunction after cardioversion in an unrecognized thyrotoxicosis patient. Am J Emerg Med 2006; 24:631-3. [PMID: 16938611 DOI: 10.1016/j.ajem.2006.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Revised: 01/03/2006] [Accepted: 01/04/2006] [Indexed: 11/20/2022] Open
Affiliation(s)
- Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Korantzopoulos P, Kolettis TM, Goudevenos JA, Siogas K. Errors and pitfalls in the non-invasive management of atrial fibrillation. Int J Cardiol 2005; 104:125-30. [PMID: 16168803 DOI: 10.1016/j.ijcard.2004.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2004] [Revised: 10/16/2004] [Accepted: 11/06/2004] [Indexed: 11/21/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice while it has a significant impact on morbidity and mortality. The errors and pitfalls in the management of AF patients are not uncommon. These include errors in detection and management of the underlying conditions that promote and perpetuate the arrhythmia, in the selection and monitoring of antithrombotic treatment, in the selection of appropriate strategy for arrhythmia management (rate or rhythm control), in the cardioversion procedure, in the prevention of recurrence after cardioversion, in the acute or chronic control of heart rate, and in the monitoring of drug toxicities. The heterogeneity of the disease along with the diversity of current treatment options mainly account for these problems. Nevertheless, deep knowledge of the evidence-based therapeutic approaches, as well as the development of individualized therapeutic strategies, can substantially improve the effective management of such patients.
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