Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review protocol.

Abstract

This systematic review will aim to summarize and evaluate the literature describing the evidence regarding adverse events from the administration of nitrates during right ventricular myocardial infarction. Withholding nitrates in the setting of right ventricular myocardial infarction is currently recommended by the American Heart Association, European Society of Cardiology, and in the Australian Journal of General Practice, due to the risk that decreasing preload in the setting of already compromised right ventricular ejection fraction may reduce cardiac output and precipitate hypotension or exacerbate cardiogenic shock. The original evidence from 1989 underpinning these recommendations displays methodological weaknesses including low sample size and confounding interventions. More recent and comprehensive research from 2014, 2016, 2018, and 2019 conflicts with the conclusions from the 1989 study, suggesting instead that nitrate administration during right ventricular myocardial infarction results in no significant difference in the rate of adverse events. The combination of recommended practice based on 30-year-old evidence and the emergence of recent challenging evidence suggest that this topic merits systematic review. The study will include both experimental and observational (descriptive and analytical) study designs that discuss the occurrence of adverse events from the administration of nitrates during a known right ventricular myocardial infarction. Six databases will be systematically searched: the Cochrane CENTRAL Register, PubMed, Embase, MEDLINE Complete, CINAHL, and Google Scholar. Identified studies will be independently assessed for inclusion by two investigators using JBI critical appraisal tools. Data will be extracted for narrative and tabular synthesis. PROSPERO CRD42020172839.