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
-
Published:2023-09-01
Issue:
Volume:
Page:
-
ISSN:1861-0684
-
Container-title:Clinical Research in Cardiology
-
language:en
-
Short-container-title:Clin Res Cardiol
Author:
Perrett Madeleine, Gohil Nisha, Tica Otilia, Bunting Karina V., Kotecha DipakORCID
Abstract
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.
Graphical abstract
Funder
Amomed British Heart Foundation Medical Research Council Horizon 2020 Framework Programme National Institute for Health and Care Research UK National Health Service -Data for R&D-
Publisher
Springer Science and Business Media LLC
Subject
Cardiology and Cardiovascular Medicine,General Medicine
Reference28 articles.
1. Lane DA, Skjoth F, Lip GYH, Larsen TB, Kotecha D (2017) Temporal trends in incidence, prevalence, and mortality of atrial fibrillation in primary care. J Am Heart Assoc 6:e005155. https://doi.org/10.1161/JAHA.116.005155 2. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstrom-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL, ESCSD Group (2021) 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS). Eur Heart J 42:373–498. https://doi.org/10.1093/eurheartj/ehaa612 3. Ziff OJ, Samra M, Howard JP, Bromage DI, Ruschitzka F, Francis DP, Kotecha D (2020) Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment. BMC Med 18:103. https://doi.org/10.1186/s12916-020-01564-3 4. Kotecha D, Bunting KV, Gill SK, Mehta S, Stanbury M, Jones JC, Haynes S, Calvert MJ, Deeks JJ, Steeds RP, Strauss VY, Rahimi K, Camm AJ, Griffith M, Lip GYH, Townend JN, Kirchhof P, T Rate Control Therapy Evaluation in Permanent Atrial Fibrillation (2020) Effect of digoxin vs bisoprolol for heart rate control in atrial fibrillation on patient-reported quality of life: the RATE-AF randomized clinical trial. JAMA 324:2497–2508. https://doi.org/10.1001/jama.2020.23138 5. Karwath A, Bunting KV, Gill SK, Tica O, Pendleton S, Aziz F, Barsky AD, Chernbumroong S, Duan J, Mobley AR, Cardoso VR, Slater L, Williams JA, Bruce EJ, Wang X, Flather MD, Coats AJS, Gkoutos GV, Kotecha D (2021) Redefining beta-blocker response in heart failure patients with sinus rhythm and atrial fibrillation: a machine learning cluster analysis. Lancet 398:1427–1435. https://doi.org/10.1016/S0140-6736(21)01638-X
|
|