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Velliou M, Sanidas E, Diakantonis A, Ventoulis I, Parissis J, Polyzogopoulou E. The Optimal Management of Patients with Atrial Fibrillation and Acute Heart Failure in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2113. [PMID: 38138216 PMCID: PMC10744575 DOI: 10.3390/medicina59122113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation (AF) and acute heart failure (AHF) are two closely interrelated conditions that frequently coexist in a manifold manner, with AF serving either as the causative factor or as the consequence or even as an innocent bystander. The interplay between these two clinical conditions is complex, given that they share common pathophysiological pathways and they can reciprocally exacerbate each other, thus triggering a vicious cycle that worsens the prognosis and increases the thromboembolic risk. The optimal management of AF in the context of AHF in the emergency department remains a challenge depending on the time onset, as well as the nature and the severity of the associated symptoms. Acute rate control, along with early rhythm control, when indicated, and anticoagulation represent the main pillars of the therapeutic intervention. The purpose of this review is to elucidate the pathophysiological link between AF and AHF and accordingly present a stepwise algorithmic approach for the management of AF in AHF patients in the emergency setting.
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Affiliation(s)
- Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Elias Sanidas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece;
| | - Antonis Diakantonis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece;
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [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: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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Abstract
Rate and rhythm control are still considered equivalent strategies for symptom control using the Atrial Fibrillation Better Care algorithm recommended by the recent atrial fibrillation guideline. In acute situations or critically ill patients, a personalized approach should be used for rapid rhythm or rate control. Even though electrical cardioversion is generally indicated in haemodynamically unstable patients or for rapid effective rhythm control in critically ill patients, this is not always possible due to the high percentage of failure or relapses in such patients. Rate control remains the background therapy for all these patients, and often rapid rate control is mandatory. Short and rapid-onset-acting beta-blockers are the most suitable drugs for acute rate control. Esmolol was the classical example; however, landiolol a newer very selective beta-blocker, recently included in the European atrial fibrillation guideline, has a more favourable pharmacokinetic and pharmacodynamic profile with less haemodynamic interference and is better appropriate for critically ill patients.
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Abstract
Atrial tachyarrhythmias and worsening heart failure frequently coexist and potentially progress to a life threatening condition. Therapeutic approach requires simultaneous management of rapid ventricular response and heart failure symptom relief in order to improve haemodynamic stability and cardiac function. Landiolol is an ultra-short-acting b-adrenergic receptor blocker with high b1 selectivity incorporated in 2020 European Society of Cardiology guidelines for the management of atrial fibrillation. We provide a report of two cases with atrial fibrillation treated with landiolol in the acute setting of pulmonary oedema and cardiogenic shock, respectively. Additionally, we searched the international database PUBMED (MEDLINE, PubMed Central) to retrieve scientific evidence regarding its implementation in the treatment of atrial tachyarrhythmias in patients with cardiac dysfunction. Recent studies support the use of landiolol in patients with acute heart failure and atrial tachyarrhythmias. Compared to digoxin, landiolol proved to be more effective in controlling heart rate, with minimal adverse effects. Moreover, landiolol may be helpful in the conversion of atrial tachyarrhythmia to sinus rhythm. A more potent effect has been reported in patients with heart failure with preserved or mildly reduced ejection fraction, small left ventricular volume and high blood pressure. Likewise, administration of low doses of landiolol in patients with cardiogenic shock and atrial tachyarrhythmias reduced heart rate and pulmonary capillary wedge pressure and improved cardiac contractility without reducing blood pressure. Landiolol seems to be an attractive alternative in the acute management of patients with atrial tachyarrhythmias and cardiac dysfunction, though further clinical trials are needed to establish its role.
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Affiliation(s)
| | | | - Eftihia Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Chaidari 12462, Athens, Greece
| | - Antonios Boultadakis
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari 12462, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Chaidari 12462, Athens, Greece
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Shinohara M, Wada R, Yano K, Akitsu K, Koike H, Kinoshita T, Suzuki T, Fujino T, Ikeda T. Comparison of Landiolol and Digoxin as an Intravenous Drug for Controlling the Heart Rate in Patients with Atrial Fibrillation and Severely Depressed Left Ventricular Function. Int Heart J 2020; 61:944-950. [PMID: 32921677 DOI: 10.1536/ihj.20-256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinical experience with landiolol use in patients with atrial fibrillation (AF) and a severely depressed left ventricular (LV) function is limited. We compared the efficacy and safety of landiolol with that of digoxin as an intravenous drug in controlling the heart rate (HR) during AF associated with a very low LV ejection fraction (LVEF).We retrospectively analyzed 53 patients treated with landiolol (n = 34) or digoxin (n = 19) for AF tachycardias with an LVEF ≤ 25. The landiolol dose was adjusted between 0.5 and 10 μg/kg/minute according to the patient's condition. The response to treatment was defined as a decrease in the HR of ≤ 110/minute, and that decreased by ≥ 20% from baseline.There were no significant differences between the two groups regarding the clinical characteristics. The responder rate to landiolol at 24 hours was significantly higher than that to digoxin (71.0% versus 41.2%; odds ratio: 4.65, 95% confidence interval: 1.47-31.0, P = 0.048). The percent decrease in the HR from baseline at 1, 2, 12, and 24 hours was greater in the landiolol group than in the digoxin group (P < 0.01, P = 0.071, P = 0.036, and P = 0.016, respectively). The systolic blood pressure (SBP) from baseline within 24 hours after administering landiolol was significantly reduced, whereas digoxin did not decrease the SBP over time. Hypotension (< 80 mmHg) occurred in two patients in the landiolol group and 0 in the digoxin group (P = 0.53).Landiolol could be more effective in controlling the AF HR than digoxin even in patients with severely depressed LV function. However, careful hemodynamic monitoring is necessary when administering landiolol.
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Affiliation(s)
- Masaya Shinohara
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Ryou Wada
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Kensuke Yano
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Katsuya Akitsu
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Hideki Koike
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Toshio Kinoshita
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takeya Suzuki
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
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Imamura T, Kinugawa K. Novel rate control strategy with landiolol in patients with cardiac dysfunction and atrial fibrillation. ESC Heart Fail 2020; 7:2208-2213. [PMID: 32666693 PMCID: PMC7524084 DOI: 10.1002/ehf2.12879] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 01/15/2023] Open
Abstract
While patients with acute heart failure often have tachycardia with atrial fibrillation, there have been no established medical tools that control tachycardia safely and definitely. Digoxin has been recommended as a first choice in the former guidelines, but it takes time to affect and has a risk of adverse events particularly for those with chronic kidney disease. Landiolol is a recently innovated ultra‐short‐acting beta‐blocker with 251‐fold β1/β2 selectivity, which was originally indicated only to control peri‐operative supra‐ventricular tachyarrhythmia by 2013 in Japan. We aimed to review how to use landiolol in patients with cardiac dysfunction and tachycardia due to atrial fibrillation. We reviewed recently conducted randomized control trials using landiolol, recently updated guidelines, as well as current practical use of landiolol. Japan landiolol vs. Digoxin (J‐Land) study demonstrated that landiolol was more effective to control tachycardia than digoxin in atrial fibrillation patients with left ventricular dysfunction in 2013. Given the result, the revised Japanese heart failure guideline recommends landiolol for rate control during atrial fibrillation in acute heart failure patients as Class IIa with evidence level B. Currently in Japan, landiolol is used for rate control, even in patients with advanced heart failure receiving continuous infusion of inotropes. The clinical use of landiolol in patients with cardiac dysfunction and tachycardia due to atrial fibrillation is increasing. Further studies are warranted to investigate the implication of faster and safer rate control using landiolol.
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Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, Toyama University, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, Toyama University, Toyama, Japan
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Nitta D, Imamura T. What Determines the Response to Landiolol? Circ J 2019; 83:1617. [DOI: 10.1253/circj.cj-19-0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Daisuke Nitta
- Division of Cardiology, Department of Medicine, The University of Chicago Medicine
| | - Teruhiko Imamura
- Division of Cardiology, Department of Medicine, The University of Chicago Medicine
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Rehberg S, Joannidis M, Whitehouse T, Morelli A. Landiolol for managing atrial fibrillation in intensive care. Eur Heart J Suppl 2018; 20:A15-A18. [PMID: 30188960 PMCID: PMC5909768 DOI: 10.1093/eurheartj/sux039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Landiolol is an injectable ultrashort acting beta-blocker with high beta1 selectivity indicated for heart rate control of atrial fibrillation in the emergency and critical care setting. Accordingly, landiolol is associated with a significantly reduced risk of arterial hypotension and negative inotropic effects. Based on this particular profile along with the clinical experience in Japan for more than a decade landiolol represents a promising agent for the management of elevated heart rate and atrial fibrillation in intensive care patients even with catecholamine requirements. This article provides a review and perspective of landiolol for heart rate control in intensive care patients based on the current literature.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anaesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, University Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care Medicine, University of Rome "La Sapienza", Italy Policlinico Umberto I° Hospital, Viale del Policlinico 155, Rome, Italy
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von Haehling S, Bělohlávek J, Er F, Gassanov N, Guarracino F, Bouvet O. Landiolol for rate control management of atrial fibrillation in patients with cardiac dysfunction. Eur Heart J Suppl 2018; 20:A19-A24. [PMID: 30188957 PMCID: PMC5909772 DOI: 10.1093/eurheartj/sux035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Atrial fibrillation (AFib) is frequently associated with heart failure. Guidelines for AFib management have been recently updated and include an algorithm for acute heart rate control based on left ventricular ejection fraction and haemodynamics. Landiolol is an injectable ultra-short beta-blocker with very high beta-1 selectivity, listed in Japanese Guidelines for AFib management as potential option for rate control of patient with heart failure. Landiolol is now available in Europe with indication of controlling heart rate in AFib and supraventricular tachycardia. This review discusses existing clinical data in Japan and perspectives of landiolol use for acute rate control of AFib patients with cardiac dysfunction.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, Göttingen, Germany
| | - Jan Bělohlávek
- Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Faculty of Medicine, Charles University, U Nemocnice 2, Praha 2, Prague, Czech Republic
| | - Fikret Er
- Department of Cardiology, Rhythmology and Intensive Care Medicine, Klinikum Gütersloh, Germany
| | - Natig Gassanov
- Department of Cardiology, Rhythmology and Intensive Care Medicine, Klinikum Gütersloh, Germany
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Cardiothoracic and Vascular Anaesthesia, Azienda Ospedaliero Universitaria Pisana, Via Roma n. 67, Pisa, Italy
| | - Olivier Bouvet
- Department of Clinical Research and Pharmaceutical Development, Amomed Pharma GmbH Vienna, Austria
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