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Perrett M, Gohil N, Tica O, Bunting KV, Kotecha D. Efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter is dependent on beta-1 selectivity: a systematic review and meta-analysis of randomised trials. Clin Res Cardiol 2024; 113:831-841. [PMID: 37658166 PMCID: PMC11108934 DOI: 10.1007/s00392-023-02295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/22/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Intravenous beta-blockers are commonly used to manage patients with acute atrial fibrillation (AF) and atrial flutter (AFl), but the choice of specific agent is often not evidence-based. METHODS A prospectively-registered systematic review and meta-analysis of randomised trials (PROSPERO: CRD42020204772) to compare the safety and efficacy of intravenous beta-blockers against alternative pharmacological agents. RESULTS Twelve trials comparing beta-blockers with diltiazem, digoxin, verapamil, anti-arrhythmic drugs and placebo were included, with variable risk of bias and 1152 participants. With high heterogeneity (I2 = 87%; p < 0.001), there was no difference in the primary outcomes of heart rate reduction (standardised mean difference - 0.65 beats/minute compared to control, 95% CI - 1.63 to 0.32; p = 0.19) or the proportion that achieved target heart rate (risk ratio [RR] 0.85, 95% CI 0.36-1.97; p = 0.70). Conventional selective beta-1 blockers were inferior for target heart rate reduction versus control (RR 0.33, 0.17-0.64; p < 0.001), whereas super-selective beta-1 blockers were superior (RR 1.98, 1.54-2.54; p < 0.001). There was no significant difference between beta-blockers and comparators for secondary outcomes of conversion to sinus rhythm (RR 1.15, 0.90-1.46; p = 0.28), hypotension (RR 1.85, 0.87-3.93; p = 0.11), bradycardia (RR 1.29, 0.25-6.82; p = 0.76) or adverse events leading to drug discontinuation (RR 1.03, 0.49-2.17; p = 0.93). The incidence of hypotension and bradycardia were greater with non-selective beta-blockers (p = 0.031 and p < 0.001). CONCLUSIONS Across all intravenous beta-blockers, there was no difference with other medications for acute heart rate control in atrial fibrillation and flutter. Efficacy and safety may be improved by choosing beta-blockers with higher beta-1 selectivity.
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Affiliation(s)
- Madeleine Perrett
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
| | - Nisha Gohil
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
| | - Otilia Tica
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
- Cardiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK.
- Cardiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Alrabadi N, Al-Nusair M, El-Zubi FK, Tashtoush M, Alzoubi O, Khamis S, Masadeh MM, Alzoubi KH, Al-Hiari M, Hammoudeh A. Evaluation of Clinical, Echocardiographic, and Therapeutic Characteristics, and Prognostic Outcomes of Coexisting Heart Failure among Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study. Curr Vasc Pharmacol 2024; 22:58-66. [PMID: 38038004 DOI: 10.2174/0115701611260211231115094716] [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: 04/30/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia in clinical practice. Heart failure (HF) can occur concurrently with AF. AIM We compared different demographic, clinical, and echocardiographic characteristics between patients with AF+HF and patients with AF only. Furthermore, we explored whether concurrent HF independently predicts several outcomes (all-cause mortality, cardiovascular mortality, ischemic stroke/systemic embolism (IS/SE), major bleeding, and clinically relevant non-major bleeding (CRNMB)). MATERIALS AND METHODS Comparisons between the AF+HF and the AF-only group were carried out. Multivariable Cox proportional hazard models were constructed for each outcome to assess whether HF was predictive of any of them while controlling for possible confounding factors. RESULTS A total of 2020 patients were included in this study: 481 had AF+HF; 1539 had AF only. AF+HF patients were older, more commonly males, and had a higher prevalence of diabetes mellitus, dyslipidemia, coronary artery disease, and chronic kidney disease (p≤0.05). Furthermore, AF+HF patients more commonly had pulmonary hypertension and low ejection fraction (p≤0.001). Finally, HF was independently predictive of all-cause mortality (adjusted HR 2.17, 95% CI (1.66-2.85) and cardiovascular mortality (adjusted HR 2.37, 95% CI (1.68-3.36). CONCLUSION Coexisting AF+HF was associated with a more labile and higher-risk population among Jordanian patients. Furthermore, coexisting HF independently predicted higher all-cause mortality and cardiovascular mortality. Efforts should be made to efficiently identify such cases early and treat them aggressively.
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Affiliation(s)
- Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Mohammed Al-Nusair
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Farah K El-Zubi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mais Tashtoush
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Osama Alzoubi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sa'ed Khamis
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Majd M Masadeh
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Karem H Alzoubi
- Department of Pharmacy Practice and Pharmacotherapeutics, University of Sharjah, Sharjah, United Arab Emirates
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammed Al-Hiari
- Department of Internal Medicine, School of Medicine, Marshall University, Huntington, West Virginia, USA
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Wang X, Mobley AR, Tica O, Okoth K, Ghosh RE, Myles P, Williams T, Haynes S, Nirantharakumar K, Shukla D, Kotecha D, Mehta S, Breeze S, Lancaster K, Fordyce S, Allen N, Calvert M, Denniston A, Gkoutos G, Jayawardana S, Ball S, Baigent C, Brocklehurst P, Lester W, McManus R, Seri S, Valentine J, Camm AJ, Haynes S, Moore DJ, Rogers A, Stanbury M, Flather M, Walker S, Wang D. Systematic approach to outcome assessment from coded electronic healthcare records in the DaRe2THINK NHS-embedded randomized trial . EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:426-436. [PMID: 36712153 PMCID: PMC9708037 DOI: 10.1093/ehjdh/ztac046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/15/2022] [Indexed: 02/01/2023]
Abstract
Aims Improving the efficiency of clinical trials is key to their continued importance in directing evidence-based patient care. Digital innovations, in particular the use of electronic healthcare records (EHRs), allow for large-scale screening and follow up of participants. However, it is critical these developments are accompanied by robust and transparent methods that can support high-quality and high clinical value research. Methods and results The DaRe2THINK trial includes a series of novel processes, including nationwide pseudonymized pre screening of the primary-care EHR across England, digital enrolment, remote e-consent, and 'no-visit' follow up by linking all primary- and secondary-care health data with patient-reported outcomes. DaRe2THINK is a pragmatic, healthcare-embedded randomized trial testing whether earlier use of direct oral anticoagulants in patients with prior or current atrial fibrillation can prevent thromboembolic events and cognitive decline (www.birmingham.ac.uk/dare2think). This study outlines the systematic approach and methodology employed to define patient information and outcome events. This includes transparency on all medical code lists and phenotypes used in the trial across a variety of national data sources, including Clinical Practice Research Datalink Aurum (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics (mortality). Conclusion Co-designed by a patient and public involvement team, DaRe2THINK presents an opportunity to transform the approach to randomized trials in the setting of routine healthcare, providing high-quality evidence generation in populations representative of the community at risk.
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Affiliation(s)
- Xiaoxia Wang
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alastair R Mobley
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Otilia Tica
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Rebecca E Ghosh
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Puja Myles
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Tim Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | | | - David Shukla
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK,Primary Care Clinical Research, NIHR Clinical Research Network West Midlands, Birmingham, UK
| | - Dipak Kotecha
- Corresponding author. Heritage Building, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK. Tel: +44 121 3718122,
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