Emergency care for life-threatening arrhythmias
Background. Sepsis is often accompanied by arrhythmias and conduction disorders. It can be assumed that pacemaker cells of the sinoatrial node, strongly sensitized by massive stimulation with β1-adrenergic catecholamines, tend to trigger arrhythmias. The importance of the inflammatory component in the development of new atrial fibrillation (AF) events is also confirmed by the existence of a strong correlation between increased levels of C-reactive protein, interleukin-6 and tumor necrosis factor and the onset of fibrillation. Under the conditions of the new-onset AF, the hospital mortality of patients of general profile in the intensive care unit (ICU) significantly exceeds that for people without AF.
Objective. To describe the features of treatment of life-threatening arrhythmias.
Materials and methods. Analysis of literature data on this issue.
Results and discussion. Amiodarone, diltiazem and lidocaine are the most commonly used treatments for life-threatening arrhythmias. According to a UK-wide study, amiodarone is used to treat new-onset AF in ICU in 80.94 % of cases, β-blockers (BB) – in 11.60 %, other antiarrhythmic drugs (AAD) – in 3.87 %, and digoxin – in 3.31 %. However, this tactic is not in line with the existing guidelines. According to the recommendations for the heart rate (HR) control in emergency care for AF (Bokeria L.A. et al., 2017), in an acute situation in the absence of ventricular pre-excitation syndrome intravenous administration of BB or non-dihydropyridine calcium channel blockers (CCB) is recommended to slow ventricular rhythm in patients with AF. Caution should be taken in patients with hypotension or heart failure. For the last group of patients intravenous administration of cardiac glycosides or amiodarone is recommended. In patients with ventricular pre-excitation syndrome, class I AAD or amiodarone are the drugs of choice. In presence of the pre-excitation syndrome and AF BB, non-dihydropyridine CCB, digoxin and adenosine are contraindicated. The guidelines for the management of AF patients, developed in 2017 by the European Society of Cardiology in collaboration with the European Association of Cardiothoracic Surgery, recommend to use different management tactics depending on the left ventricular ejection fraction (LV EF). In case of LV EF <40 % or signs of heart failure, the lowest effective dose of BB should be prescribed to achieve rhythm control. Amiodarone is prescribed to hemodynamically unstable patients or to individuals with severely reduced LV EF. The primary goal of treatment is to achieve a HR <110 beats/min. In the absence of this result, digoxin should be added. In case of LV EF ≥40 %, BB, or diltiazem, or verapamil should be administered. In the absence of clinical result, digoxin should be added. Practical models of AF treatment in sepsis have demonstrated the superiority of BB over CCB, digoxin and amiodarone (Walkey A.J. et al., 2016). BB weaken the stimulating effect of the sympathetic part of the autonomic nervous system on the myocardium, have a negative chronotropic effect, improve the contractility of ischemized cardiomyocytes, slow atrioventricular conduction, reduce myocardial oxygen demand, and apoptosis. Esmolol (Biblok, “Yuria-Pharm”) is indicated for supraventricular tachycardia (except for ventricular pre-excitation syndrome) and for the rapid control of ventricular rhythm in patients with AF or atrial flutter in the pre- and postoperative periods or in other circumstances when it is necessary to normalize ventricular rhythm with a short-acting drug. Studies show that esmolol inhibits inflammation in sepsis by increasing the expression of the antimicrobial peptide cathelicidin. Kaplan – Mayer analysis shows better survival for experimental animals with sepsis receiving esmolol compared to animals in the 0.9 % NaCl group (Ibrahim-Zada I. et al., 2014).
Conclusions. 1. Sepsis is often accompanied by arrhythmias and conduction disorders. 2. Under the conditions of new-onset AF, the hospital mortality of patients of general somatic profile in ICU significantly exceeds the number for people without AF. 3. In case of AF and LV EF <40 % or signs of heart failure, the lowest effective dose of BB should be prescribed to achieve rhythm control. 4. In case of LV EF ≥40 %, BB, or diltiazem, or verapamil should be administered. 5. Esmolol is indicated for supraventricular tachycardia and for the rapid control of ventricular rhythm in patients with AF or atrial flutter. 6. Esmolol inhibits inflammation in sepsis by increasing the expression of the antimicrobial peptide cathelicidin.
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