心率控制药物治疗脓毒症相关性心房颤动的疗效比较。
Comparative Effectiveness of Heart Rate Control Medications for the Treatment of Sepsis-Associated Atrial Fibrillation.
机构信息
Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston University School of Public Health, Boston, MA.
Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston University School of Public Health, Boston, MA.
出版信息
Chest. 2021 Apr;159(4):1452-1459. doi: 10.1016/j.chest.2020.10.049. Epub 2020 Oct 24.
BACKGROUND
Atrial fibrillation (AF) with rapid ventricular response frequently complicates the management of critically ill patients with sepsis and may necessitate the initiation of medication to avoid hemodynamic compromise. However, the optimal medication to achieve rate control for AF with rapid ventricular response in sepsis is unclear.
RESEARCH QUESTION
What is the comparative effectiveness of frequently used AF medications (β-blockers, calcium channel blockers, amiodarone, and digoxin) on heart rate (HR) reduction among critically ill patients with sepsis and AF with rapid ventricular response?
STUDY DESIGN AND METHODS
We conducted a multicenter retrospective cohort study among patients with sepsis and AF with rapid ventricular response (HR > 110 beats/min). We compared the rate control effectiveness of β-blockers to calcium channel blockers, amiodarone, and digoxin using multivariate-adjusted, time-varying exposures in competing risk models (for death and addition of another AF medication), adjusting for fixed and time-varying confounders.
RESULTS
Among 666 included patients, 50.6% initially received amiodarone, 10.1% received a β-blocker, 33.8% received a calcium channel blocker, and 5.6% received digoxin. The adjusted hazard ratio for HR of < 110 beats/min by 1 h was 0.50 (95% CI, 0.34-0.74) for amiodarone vs β-blocker, 0.37 (95% CI, 0.18-0.77) for digoxin vs β-blocker, and 0.75 (95% CI, 0.51-1.11) for calcium channel blocker vs β-blocker. By 6 h, the adjusted hazard ratio for HR < 110 beats/min was 0.67 (95% CI, 0.47-0.97) for amiodarone vs β-blocker, 0.60 (95% CI, 0.36-1.004) for digoxin vs β-blocker, and 1.03 (95% CI, 0.71-1.49) for calcium channel blocker vs β-blocker.
INTERPRETATION
In a large cohort of patients with sepsis and AF with rapid ventricular response, a β-blocker treatment strategy was associated with improved HR control at 1 h, but generally similar HR control at 6 h compared with amiodarone, calcium channel blocker, or digoxin.
背景
快速性室性心律失常的心房颤动（房颤）常使脓毒症危重症患者的治疗复杂化，可能需要启动药物治疗以避免血流动力学受损。然而，对于脓毒症伴快速性室性心律失常的房颤，哪种药物控制心室率的效果最佳尚不明确。
研究问题
在伴有快速性室性心律失常的脓毒症并发房颤的危重症患者中，β受体阻滞剂、钙通道阻滞剂、胺碘酮和地高辛等常用房颤药物对心率（HR）降低的效果有何差异？
研究设计与方法
我们对伴有快速性室性心律失常的脓毒症并发房颤（HR＞110 次/分）患者进行了一项多中心回顾性队列研究。我们采用竞争风险模型中的多变量调整、时变暴露，比较了β受体阻滞剂与钙通道阻滞剂、胺碘酮和地高辛在控制心率方面的效果，同时调整了固定和时变混杂因素。
研究结果
在纳入的 666 例患者中，50.6%的患者最初接受了胺碘酮治疗，10.1%的患者接受了β受体阻滞剂治疗，33.8%的患者接受了钙通道阻滞剂治疗，5.6%的患者接受了地高辛治疗。与β受体阻滞剂相比，胺碘酮在 1 小时内使 HR＜110 次/分的调整后危险比（HR）为 0.50（95%CI，0.34-0.74），地高辛为 0.37（95%CI，0.18-0.77），而钙通道阻滞剂为 0.75（95%CI，0.51-1.11）。至 6 小时时，胺碘酮使 HR＜110 次/分的调整后 HR 为 0.67（95%CI，0.47-0.97），地高辛为 0.60（95%CI，0.36-1.004），而钙通道阻滞剂为 1.03（95%CI，0.71-1.49）。
结论
在脓毒症伴快速性室性心律失常并发房颤的大型队列中，与胺碘酮、钙通道阻滞剂或地高辛相比，β受体阻滞剂治疗策略在 1 小时时更有助于控制 HR，但在 6 小时时通常与上述药物具有相似的 HR 控制效果。
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