Intravenous Amiodarone Research Articles

3181 Intravenous Amiodarone: An Uncommon Culprit of Reversible Hyper-Acute Liver Injury

INTRODUCTION: Amiodarone is a commonly used anti-arrhythmic agent and it is important that physicians are familiar with the toxicity profile. We are reporting a case of intravenous (IV) amiodarone induced hyper-acute liver injury. CASE DESCRIPTION/METHODS: 62-year-old man with history of atrial fibrillation, non-ischemic cardiomyopathy and tobacco abuse, was admitted with atrial fibrillation and rapid ventricular response related to medication non-adherence. Patient was given IV amiodarone (total of 1050 mg) over 24-hour period, following which patient developed marked elevation of aspartate aminotransferase/AST (4021 U/L) and alanine aminotransferase/ALT (3000 U/L) with mild elevation of alkaline phosphatase/ALP (218 U/L) and total bilirubin (2.0 mg/dL). International Normalized Ratio (INR) - 5.3. Viral hepatitis panel, acetaminophen and drug toxicology screen - negative. Ceruloplasmin – normal. Ultrasound abdomen – normal liver and CBD diameter 4 mm. Portal venous duplex – no thrombosis. Patient denied use of over the counter medications or herbal supplements. No hypotensive episodes or evidence of cardiogenic shock. Due to the temporal relationship between the use of intravenous amiodarone and the development of liver injury, amiodarone-induced liver injury was suspected. Amiodarone was immediately discontinued and patient was given IV N-acetylcysteine (NAC). 24 hours later, AST fell by 50% to 2167 U/L. Liver enzymes continued to decrease and on day 4 (day of discharge), AST and ALT levels were 212 U/L and 929 U/L. After the liver enzymes normalized, our patient was started on oral amiodarone without recurrence of liver injury. DISCUSSION: IV amiodarone is typically used as a short-term therapy for various arrhythmias and is primarily eliminated by biliary excretion. Acute hepatitis due to parenteral therapy is extremely rare and can develop within 1 day of administration. Amiodarone should be immediately discontinued in those cases. The different mechanisms suspected to cause acute liver toxicity due to IV amiodarone are ischemic liver injury due to relative hypotension, hypersensitivity reaction, toxicity of the vehicle (polysorbate-80), and idiosyncratic toxicity. Limited evidence is available about the use of NAC in amiodarone induced liver injury.

P2655ST-elevation myocardial infarction in women: a more satisfactory outcome?

Abstract Background Despite all the advances registered in the last decade regarding acute myocardial infarction with ST-segment elevation (STEMI) treatment, this entity remains prevalent and highly lethal. Women constitute a lower proportion of STEMI patients, however, they show important differences when compared to men. Thanks to the lower representation of women in STEMI trials, less is know about this patient subpopulation. Purpose To determine and understand gender differences in patients admitted with STEMI in a coronary care unit (CCU). Methods Observational retrospective study of patients admitted with STEMI in a CCU, between 2006 and 2017. Patients were split between groups according to gender and were assessed in terms of risk factors, diagnosis, treatment, complications and mortality. Results A total of 2516 patients were included in the study. 1833 were men (72.9%) and 682 were women (27.1%). Mean age was superior in women (73.3±13.2 vs. 64.1±12.8 years, p<0.001), and displayed a greater cardiovascular comorbidity burden such as hypertension (79.6% vs. 66.2%, p<0.001) and diabetes (55.8% vs. 45.3%, p<0.001). At admission time women registered a higher mean TIMI (2.79 vs. 2.62, p=0.009) and GRACE score (166.3 vs. 146.3, p<0.001) which did not reflect in a higher hospital stay (mean 4.75 vs. 5.29 days, p=0.043). Before admission women were less treated with aspirin (26.4% vs. 33.2%, p=0.014) and statins (36.8% vs. 46.5%, p=0.001). There were no differences regarding access to revascularization (98% vs. 96.5%, p=0.105) but women presented more normal coronary angiographies (10.2% vs. 3.6%, p<0.001). During hospital stay, women evolved more to Killip-Kimball (KK) class III (4.5% vs. 1.9%, p<0.001) and KK class IV (15.9% vs. 11.2%, p<0.001). Intra-hospital (13.9% vs. 8.2%, p<0.001), 1-month (18.4% vs. 13.2%, p<0.001), 6-month (22.2% vs. 16.1%, p<0.001) and 1-year mortality (25.7% vs. 17.8%, p<0.01) was superior in women. After multivariate analysis heart failure on admission (OR 9.2, CI 95% 6.7–12.8), intravenous amiodarone use (OR 3.5, CI 95% 2.5–4.8), diabetes (OR 2.3, CI 95% 1.8–2.8), female gender (OR 1.6, CI 95% 1.3–2.0) and peak serum creatinine during hospital stay (OR 1.7, CI 95% 1.6–1.9) were independent predictors of 1-year mortality. After adjustment for age, diabetes, hypertension, previous acute myocardial infarction and initial KK, female gender maintained its potency as a significant 1-year mortality predictor. Conclusions Women presenting with STEMI register poorer outcomes compared to men. In our study, female gender was considered a good independent predictor of short-term and long-term mortality.

2383 Amiodarone-Induced Acute Liver Injury

INTRODUCTION: Amiodarone is a lipophilic structure with a half-life of 25-100 days. Long term oral amiodarone is associated with photosensitivity, thyroid dysfunction, pulmonary, and hepatic toxicity. Hepatic toxicity varies from an asymptomatic and transient rise of serum aminotransferases that resolves after dose reduction or withdrawal, to severe liver disease. Acute hepatotoxicity is a rare but lethal complication of amiodarone use. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of hypertension and atrial fibrillation admitted for shortness of breath. He was taking Lopressor 25 mg twice a day and apixaban 5 mg twice a day at home. On exam, blood pressure was 130/70 mmHg, saturation 92% on room air, respiratory rate 13, and heart rate 145, which was irregular. ECG showed atrial fibrillation with a rapid ventricular rate. He was treated with diltiazem bolus and infusion but became hypotensive, so diltiazem infusion was discontinued. Amiodarone 150 mg bolus was given, followed by continuous amiodarone infusion of 900 mg over 24 hours. Blood work performed 24 hours later showed a sudden rise in aminotransferases (aspartate aminotransferase 3254 U/L, alanine aminotransferase 1643 U/L), and direct bilirubin (5.12 mg/dL). International normalized ratio, Gamma-GT, and alkaline phosphatase were normal. Extensive workup like abdominal ultrasonography, viral hepatitis serologies (hepatitis B and C, cytomegalovirus, Epstein-Barr, HIV and herpes zoster viruses) and autoimmune markers (antinuclear antibody, anti-smooth muscle antibody, anti-liver/kidney microsomal antibody type 1) were unremarkable. Amiodarone was discontinued about 50 hours after its beginning and his liver enzymes improved with normalization in 7 days. He was started on oral Lopressor and diltiazem, and his heart rate was well controlled. DISCUSSION: Acute intravenous amiodarone-induced hepatotoxicity is a rare but potentially lethal side effect so physicians should be aware of it and check for its occurrence by performing serial liver tests. The exact mechanism for intravenous amiodarone-induced acute liver failure is not well defined, but the hypotensive effect attributable to polysorbate 80 present in intravenous amiodarone is a compelling hypothesis. Treatment is mainly supportive. A recent study favored the use of N-acetylcysteine in acute liver injury beyond acetaminophen intoxication. Liver injury does not recur upon reintroduction of amiodarone by the oral route.

69 Treatment Variation of Stable Ventricular Tachycardia in the Emergency Department

Advanced cardiac life support (ACLS) guidelines allow various treatments for stable monomorphic ventricular tachycardia (VT). Research on this topic has been limited by the transient nature of this rhythm, hence most studies have small sample sizes and are difficult to reproduce. The purpose of this study is to compare the relative effectiveness and safety of initial therapies used to treat stable VT across 21 community emergency departments (EDs). This retrospective cohort study used structured chart review of all treated adults with ED presentations for prolonged (>2 min) monomorphic VT in 21 community EDs from 01/2010 through 12/2017. We defined monomorphic VT as a regular wide complex tachycardia (WCT) with QRS >120 ms and rate >120 beats/min. Supraventricular tachycardia with aberrancy was excluded based on Brugada criteria for VT and confirmed by the cardiology consult obtained during the patient encounter. We excluded unstable patients defined as those with an abnormal level of consciousness, dyspnea at rest, severe anginal symptoms, or physician documentation of instability. We used descriptive statistics and reported results at the patient encounter level. We described the incidence of initial treatments, successful termination (defined as VT termination within 20 minutes lasting >30 min), ED cardiac arrest following the initial intervention, and death. We compare outcomes using a two-tailed chi-square test. We analyzed 359 eligible ED presentations from 339 patients. Mean age was 70.0 years and 22.3% of cases were female: 125 (34.8%) had an automated implantable cardioverter-defibrillator (AICD), 185 (51.5%) had congestive heart failure, and 122 (34.0%) were taking chronic antiarrhythmic medications. WCT was evaluated with adenosine in 40 cases (11.1%). Initial VT treatments were intravenous amiodarone (n=196, 54.6%), external direct-current cardioversion [DCC] (n=88, 24.5%), lidocaine (n=30, 8.4%), AICD shock (n=14, 3.9%), procainamide (n=3, 0.8%), and other treatments (n=28, 7.8%). We report initial treatment success in the Table. DCC was significantly more effective than amiodarone (81.8% vs 37.2%; p<0.0001). Overall, 160 presentations (45.1%) required multiple treatments prior to ED disposition. Cardiac arrest was uncommon in this study (2.7%) and could not be associated with specific interventions due to small sample size. Five patients (1.5%) suffered cardiac arrest after the initial ED intervention, four others (1.2%) suffered cardiac arrest in the ED after subsequent interventions, one of whom died in the ED prior to disposition. Emergency physicians use a variety of treatments for stable monomorphic VT with differing rates of success. Amiodarone is the most common initial treatment, but it may be less effective than DCC. Because initial treatments are often ineffective, patients frequently require multiple interventions. Opportunities exist for improvements in care.

Evaluation of Amiodarone Use for New-Onset Atrial Fibrillation in Critically Ill Patients With Septic Shock.

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.

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Replace Finish It With Begin It.

Profound Hypotension in Supraventricular Tachycardia with Intermittent Wolff-Parkinson-White Syndrome Refractory to Cardioversion

We report a case of an 87-year-old man with unstable supraventricular tachycardia (SVT) with intermittent Wolff-Parkinson-White (WPW) syndrome refractory to biphasic synchronized electrical cardioversion terminated by adding intravenous amiodarone. We conclude that the unique properties of intravenous amiodarone might make it especially effective in emergency situations when urgent intervention is needed to terminate life-threatening wide-complex tachycardias (WCTs) with evidence of hemodynamic instability refractory to synchronized electrical cardioversion.

Quinidine-Responsive Polymorphic Ventricular Tachycardia in Patients With Coronary Heart Disease.

Polymorphic ventricular tachycardia (VT) without QT prolongation is well described in patients without structural heart disease (mainly idiopathic ventricular fibrillation and Brugada syndrome) and in patients with acute ST-elevation myocardial infarction. Retrospective study of patients with polymorphic VT related to coronary artery disease, but without evidence of acute myocardial ischemia. The authors identified 43 patients in whom polymorphic VT developed within days of an otherwise uncomplicated myocardial infarction or coronary revascularization procedure. The polymorphic VT events were invariably triggered by extrasystoles with short (364±36 ms) coupling interval. Arrhythmic storms (4-16 events of polymorphic VT deteriorating to ventricular fibrillation) occurred in 23 (53%) patients. These arrhythmic storms were always refractory to conventional antiarrhythmic therapy, including intravenous amiodarone, but invariably responded to quinidine therapy. In-hospital mortality was 17% for patients with arrhythmic storm. Patients treated with quinidine invariably survived to hospital discharge. During long-term follow-up (of 5.6±6 years; range, 1 month to 18 years), 3 (16%) of patients discharged without quinidine developed recurrent polymorphic VT. There were no recurrent arrhythmias during quinidine therapy Conclusions: Arrhythmic storm with recurrent polymorphic VT in patients with coronary disease responds to quinidine therapy when other antiarrhythmic drugs (including intravenous amiodarone) fail.

Application of nurse-patient co-management intervention in arrhythmia patients with intravenous amiodarone

Objective To explore the application effects of nurse-patient co-management intervention in arrhythmia patients with intravenous amiodarone. Methods From October 2015 to September 2017, we selected 126 arrhythmia patients with amiodarone of the First Affiliated Hospital of Xinjiang Medical University as subjects by convenience sampling. All of the subjects were randomly divided into intervention group and control group, 63 cases in each group. Control group adopted routine nursing, while intervention group carried out nurse-patient co-management intervention. We compared the differences in the incidence of phlebitis, blood pressure, heart rate, adverse reactions, hospital stay and satisfaction of patients both groups. Results The incidence of phlebitis and its cumulative occurrence time of intervention group were lower than those of control group (P<0.05) ; the level of blood pressure after using medication of patients in intervention group was higher than that in control group, and incidence of gastrointestinal adverse reaction and hospital stay of patients in intervention group were less than those in control group (P<0.05) . Satisfaction with nursing of intervention group was higher than that of control group (P<0.05) . Conclusions Nurse-patient co-management intervention can increase the safety of arrhythmia patients with amiodarone, reduce the incidence of adverse reactions and improve patient satisfaction which is worthy of being widely used in clinical application. Key words: Arrhythmias, cardiac; Amiodarone; Phlebitis; Nurse-patient co-management; Adverse reaction

Resistant Ventricular Tachycardia due to Idiopathic Left Ventricular Aneurysm: Successful Treatment with Surgery

Left ventricular aneurysms (LVAs) are characterized by a wide connection to the left ventricle and paradoxical systolic motions. Although patients with LVAs are usually asymptomatic, some may present with arrhythmias, heart failure, and even cardiac arrest. In this case report, we describe a 62-year-old male patient who presented to our emergency service with complaints of palpitation and shortness of breath of 2 hours' duration. His blood pressure was 84/56 mm Hg, and he was in a confused state. An electrocardiogram revealed ventricular tachycardia (VT) with right bundle branch block and a ventricular rate of 188 bpm. The patient's hemodynamic instability necessitated a direct current cardioversion, which restored the sinus rhythm. During the in-hospital course, he had numerous recurrent VT episodes despite treatment with intravenous amiodarone and magnesium sulfate as well as radiofrequency ablation. Upon consensus with a cardiovascular surgeon's team, urgent surgery was performed due to the resistant VT episodes. The patient's clinical course was uneventful, and he was discharged on the 11th postoperative day. We have been following up the patient for almost 1 year, during which he has not experienced palpitations or associated symptoms. Our case indicates that surgery may be a preferable treatment option for patients with heart failure and resistant VT related to LVAs.

Cardiovascular Collapse with Intravenous Amiodarone in Children: A Multi-Center Retrospective Cohort Study.

To determine the incidence of cardiovascular collapse in children receiving intravenous (IV) amiodarone and to identify the population at risk. A multicenter study of patients ≤18years of age who received intravenous amiodarone between January 2005 and December 2015. A retrospective analysis was performed to identify patients who developed cardiovascular collapse (bradycardia and/or hypotension). Of 456 patients who received amiodarone, cardiovascular collapse occurred in 47 patients (10%). Patient risk factors for collapse in a univariate analysis were as follows: age < 3 months (p = 0.04), depressed cardiac function (p < 0.001), blood pressure below 3rd percentile (p < 0.001), high lactate at baseline (p < 0.001). Administration risk factors included bolus administration (p = 0.04), and bolus administration over ≤ 20min (p = 0.04). In multivariate analysis, age, baseline blood pressure less than 3rd percentile, and rapid bolus delivery were independent risk factors for cardiovascular collapse in the study group. The mortality rate was significantly higher in the collapse group (28% versus 8%). We found an association between IV amiodarone administration and the risk of developing cardiovascular collapse in a significant subset of children. Extreme caution and careful hemodynamic monitoring is recommended when using IV amiodarone in this population, especially in young infants, hemodynamically compromised patients, and in patients receiving rapid amiodarone bolus administration.

Amiodarone for prevention of atrial fibrillation following esophagectomy

ObjectivesAtrial fibrillation (AF) is a common complication after esophagectomy and is associated with symptoms, hemodynamic instability, prolonged hospital stay, and an increased incidence of mortality. Our objective was to determine the efficacy and safety of intravenous amiodarone for prophylaxis of postesophagectomy AF. MethodsIn this retrospective cohort study, 309 patients who underwent esophagectomy formed the initial cohort. Following propensity score-matching, 110 patients who received prophylactic amiodarone 43.75 mg/hour via continuous intravenous infusion over 96 hours (total dose, 4200 mg) were matched to a control group of patients who did not undergo amiodarone prophylaxis (n = 110). The propensity score was obtained using a multivariate logistic regression model with amiodarone as the variable and the following covariates: age, sex, surgical approach, history of neoadjuvant chemotherapy and/or radiation, chronic obstructive pulmonary disease, heart failure, cardiovascular disease, alcohol use (>7 drinks/week), preadmission β-blockers discontinued during hospitalization, preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, preoperative use of corticosteroids, postoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, postoperative use of corticosteroids, postoperative use of statins, and preoperative Charlson comorbidity index. ResultsThe incidence of AF requiring treatment due to rapid ventricular rate and symptoms was lower in the amiodarone group (17 out of 110 [15.5%] vs 32 out of 110 [29.1%]; odds ratio, 0.45; 95% confidence interval, 0.23-0.86; P = .015). There were no significant differences between the groups in median postoperative length of hospital stay, incidence of pulmonary complications, or mortality. The incidences of hypotension requiring treatment (42.7% vs 21.8%; P = .001), bradycardia (8.2% vs 0.0%; P = .002), and corrected QT interval prolongation (10.9% vs 0.0%; P ≤ .0001) were significantly higher in the amiodarone group. ConclusionsProphylactic intravenous amiodarone is associated with a reduction in the incidence of AF following esophagectomy, but is not associated with shorter postoperative length of hospital stay. Intravenous amiodarone for prophylaxis of postesophagectomy AF is associated with hypotension, bradycardia, and corrected QT interval prolongation.

Phlebitis in Intravenous Amiodarone Administration: Incidence and Contributing Factors.

Intravenous amiodarone is the gold-standard treatment for arrhythmias, but phlebitis is a common adverse effect. To determine the incidence and contributing factors of amiodarone-induced phlebitis and examine phlebitis severity. A systematic review was conducted of articles published before February 2016 in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, MEDLINE, Embase, Web of Science, and gray databases (Bielefeld, Lenus, EUGrey, RIAN, and DART). All studies in which amiodarone-induced phlebitis was a primary or secondary outcome were included. Meta-analysis was not appropriate because of study heterogeneity. Studies of the same contributing factors were analyzed together. In the 20 included studies, phlebitis incidence ranged from 0% to 85%. Increasing the infusion concentration from 1.2 mg/mL to 1.8 mg/mL increased the phlebitis rate (P < .001). Total amiodarone doses greater than 1 g resulted in higher phlebitis rates than did doses less than 0.45 mg (P < .001). Most infusion durations and rates were not correlated with phlebitis incidence. However, phlebitis incidence was lower with bolus administration than with longer infusions (P = .002). The use of in-line filters and nursing guidelines significantly reduced phlebitis rates (P < .001) and phlebitis severity. The most common phlebitis severity grades, in descending order, were 0, 1, 2, 3, and 4. Understanding factors that increase the risk of amiodarone-induced phlebitis can guide better practice. In-line filters and nursing guidelines should always be implemented when administering intravenous amiodarone. Increased surveillance is required when higher dosages and concentrations are used.

Review of Intravenous Amiodarone Administration to Reduce the Occurrence of Phlebitis

Background: Intravenous (IV) amiodarone is regularly administered at the current clinic unit for atrial fibrillation, including cardiology and post-cardiac surgery patients. The unit noted an increase in chemical phlebitis from the submission of reportable events. From this increase, a systematic review of administration was performed. Method: A literature review was performed of global administration guidelines – from the National Health Service, Australia, Canada and United States of America – and compared with current administration. The concentrations were similar but it was noted that IV giving sets were not filtered at the current centre. In partnership with IV therapy, correct filter IV giving sets were replaced. A retrospective review was then performed of patients, from the previous 3 months, who had received amiodarone via old IV giving sets and 3-month review was performed of new IV giving sets; chemical phlebitis rates were compared. Results: Aligning administration with international standards saw a reduction in phlebitis by 30%. There were no effects on cardioversion numbers due to increased filtration of drugs and no increased cost to the District Health Board for change of giving sets. Conclusion: Aligning administration guidelines with international standards enabled a significant reduction in rates of phlebitis. This reduced pain and infection risks for patients and reduced length of stay; thus, reducing the cost of treatment.

Efficacy of Wenxin Keli Plus Amiodarone versus Amiodarone Monotherapy in Treating Recent-Onset Atrial Fibrillation.

Background Use of amiodarone (AMIO) in atrial fibrillation (AF) has significant side effects over prolonged periods. Wenxin Keli (WXKL), a Chinese herb extract, has been shown to be effective in atrial-selective inhibiting peak INa and hence beneficial in treating atrial arrhythmias, including atrial fibrillation. The aim of this randomized controlled trial was to evaluate potential effects of AMIO plus WXKL on conversion rate and time in patients with recent-onset AF. Methods A total of 41 patients (71 ± 12 years, 44% male) with recent-onset (<48 h) AF eligible for conversion were randomized to receive either intravenous amiodarone (loading dose 5 mg/kg in 1 hour followed by 50 mg/h; n=21) or amiodarone with same dosage plus oral WXKL 18 g thrice daily (n=20) for 24 hours. Results Conversion rate at 24 hours was of no difference between the two groups (75.0% vs. 81.0%, P=0.72); however, conversion time was markedly shorter in the AMIO + WXKL group compared to the AMIO group (291 ± 235 minutes vs. 725 ± 475 minutes, P=0.003). There were no serious adverse events during the study. Conclusion Administration of amiodarone plus WXKL for recent-onset AF conversion was safe and effective, with faster sinus rhythm restoration compared with amiodarone alone.

Rapidly Developing Acute Hepatotoxicity With Intravenous Amiodarone Infusion: A Case Report

Rapidly Developing Acute Hepatotoxicity With Intravenous Amiodarone Infusion: A Case Report

Interaction between warfarin and short-term intravenous amiodarone in intensive care unit patients after cardiac surgery

BackgroundAmiodarone and warfarin are sometimes administered immediately after cardiac surgery. Although the interaction between long-term oral amiodarone and warfarin has been reported, the interaction between warfarin and short-term intravenous amiodarone has not been reported. In this study, we investigated the effect of short-term intravenous amiodarone on the anticoagulant effect of warfarin in patients who underwent cardiac surgery.MethodsWe retrospectively reviewed the medical records of 11 patients who received oral warfarin before and after cardiac surgery, and loading doses of 125–150 mg or a 750 mg continuous infusion of amiodarone, or both in the intensive care unit (ICU) within 5 days after the surgery between July 2011 and January 2017. The prothrombin time-international normalized ratio (PT-INR)/daily warfarin dose (PT-INR/dose) was used as an indicator of anticoagulant effect. The values before surgery were considered as the baseline.ResultsThe PT-INR and PT-INR/dose values were elevated in 7 and 10 patients, respectively, after amiodarone administration. The mean PT-INR values were not significantly different before and after amiodarone administration (2.13 ± 0.58 vs 2.29 ± 0.50, respectively, p = 0.643). In contrast, the mean PT-INR/dose values were significantly elevated after the administration of amiodarone (0.93 ± 0.46 vs 1.54 ± 0.63, respectively, p = 0.002).ConclusionsShort-term intravenous amiodarone enhanced the anticoagulant effect of warfarin in patients admitted to the ICU after cardiac surgery. We suggest that the dose of warfarin should be carefully adjusted for a few days after cardiac surgery if intravenous amiodarone is coadministered.

Propranolol Versus Metoprolol for Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillator

BackgroundElectrical storm (ES), characterized by unrelenting recurrences of ventricular arrhythmias, is observed in approximately 30% of patients with implantable cardioverter-defibrillators (ICDs) and is associated with high mortality rates. ObjectivesSympathetic blockade with β-blockers, usually in combination with intravenous (IV) amiodarone, have proved highly effective in the suppression of ES. In this study, we compared the efficacy of a nonselective β-blocker (propranolol) versus a β1-selective blocker (metoprolol) in the management of ES. MethodsBetween 2011 and 2016, 60 ICD patients (45 men, mean age 65.0 ± 8.5 years) with ES developed within 24 h from admission were randomly assigned to therapy with either propranolol (160 mg/24 h, Group A) or metoprolol (200 mg/24 h, Group B), combined with IV amiodarone for 48 h. ResultsPatients under propranolol therapy in comparison with metoprolol-treated individuals presented a 2.67 times decreased incidence rate (incidence rate ratio: 0.375; 95% confidence interval: 0.207 to 0.678; p = 0.001) of ventricular arrhythmic events (tachycardia or fibrillation) and a 2.34 times decreased rate of ICD discharges (incidence rate ratio: 0.428; 95% CI: 0.227 to 0.892; p = 0.004) during the intensive care unit (ICU) stay, after adjusting for age, sex, ejection fraction, New York Heart Association functional class, heart failure type, arrhythmia type, and arrhythmic events before ICU admission. At the end of the first 24-h treatment period, 27 of 30 (90.0%) patients in group A, while only 16 of 30 (53.3%) patients in group B were free of arrhythmic events (p = 0.03). The termination of arrhythmic events was 77.5% less likely in Group B compared with Group A (hazard ratio: 0.225; 95% CI: 0.112 to 0.453; p < 0.001). Time to arrhythmia termination and length of hospital stay were significantly shorter in the propranolol group (p < 0.05 for both). ConclusionsThe combination of IV amiodarone and oral propranolol is safe, effective, and superior to the combination of IV amiodarone and oral metoprolol in the management of ES in ICD patients.

Pharmacological Cardioversion by Intravenous Amiodarone for Primary Treatment of a Neonatal Atrial Flutter

Atrial flutter is an uncommon arrhythmia in newborn patients, but it can be fatal in intractable cases, which require emergent therapy with multiple antiarrhythmic therapies and an electrical cardioversion. Amiodarone is an antiarrhythmic drug commonly used to treat tachyarrhythmias of supraventricular tachycardia and atrial tachyarrhythmia in adults. The efficacy of amiodarone therapy for neonatal tachyarrhythmia including atrial flutter is currently unknown, but its estimated effectiveness is low with small experiences in neonates. We present a case of successful pharmacologic cardioversion, using intravenous amiodarone, of atrial flutter and did not require electrical cardioversion in a newborn. We suggest that intravenous amiodarone administration can be used to treat neonatal atrial flutter as effective pharmacological therapy in patient with hemodynamic stability.

Approach to the wide QRS-complex tachycardia

Introduction. Patients presenting with tachycardia most often complain of palpitation and dizziness, but can also report episodes of chest pain due to increased myocardial oxygen demand. The aim of this case article was to emphasize the importance of differential diagnosis between different types of supraventricular (SVT) or ventricular tachycardia (VT) according to ECG findings, and highlight the treatment algorithm for wide QRS-complex tachycardia. Case Outline. We present a 34-years old female patient which was admitted to our hospital due to palpitations and chest pain that occurred at rest about two hours before hospital admission. Cardiac auscultation showed the presence of irregular heartbeats with tachycardia, whereas arterial blood pressure was 100/60 mmHg. Initial ECG recording demonstrated wide complex tachycardia (WCT) with irregular heart rate of approximately 180 beats per minute with right bundle branch block-like morphology of QRS complexes. After administration of intravenous amiodarone, patient was converted to sinus rhythm, with short PR interval (&lt; 120 ms) and narrow QRS complexes (&lt; 120 ms) with visible delta waves, indicating the presence of Wolff?Parkinson?White syndrome type A as the underlying cause of atrial fibrillation with right bundle branch block-like morphology of QRS complexes. Conclusion. The ability to differentiate between VT and SVT with a wide QRS complex due to aberrant intraventricular conduction or preexcitation is critical because the treatment of each is different, and inadequate therapy may potentially have lethal consequences.