Jin Le, Liu Fang, Gao Hongmei, Zheng Luyao
The Second Clinical College, Shandong University of Traditional Chinese Medicine, 250014 Jinan, Shandong, China.
Department of Cardiology, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250001 Jinan, Shandong, China.
Rev Cardiovasc Med. 2024 Jan 9;25(1):12. doi: 10.31083/j.rcm2501012. eCollection 2024 Jan.
Atrial fibrillation is the most common tachyarrhythmia, while catheter ablation is an effective therapy for atrial fibrillation. However, pain and nervousness may occur during the procedure. Moreover, a consensus has still not been reached on which is the best kind of analgesic and sedative to use in these procedures. Therefore, we conducted a network meta-analysis to evaluate the efficacy and safety of analgesics and sedatives used in catheter ablation for atrial fibrillation.
We searched PubMed, Cochrane Library, Web of Science, EMBASE, China National Knowledge Infrastructure, and Baidu Wenku document download website for randomized controlled trials from their inception to February 26, 2023. Only studies that made comparisons among analgesics or sedatives and involved patients with atrial fibrillation undergoing radiofrequency catheter ablation were included. The efficacy endpoints were Ramsay sedation scores and visual analog scale scores during the radiofrequency catheter ablation for atrial fibrillation. The safety endpoints were the incidence of respiratory depression, hypotension, nausea, and vomiting. Pairwise comparisons and frequency method analyses were conducted. Results were reported as odds ratio (OR), mean difference (MD), and corresponding 95% confidence intervals (CIs). We assessed the risk bias of the studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions.
Out of the 709 articles initially retrieved, 14 studies, with a total of 1156 participants, were included. In terms of efficacy, patients receiving dexmedetomidine during radiofrequency ablation for atrial fibrillation had higher Ramsay sedation scores than those receiving midazolam plus fentanyl, or its derivatives (MD -0.88, 95% CI [-0.04 to -0.72]). Compared with morphine, dezocine (MD 1.88, 95% CI [1.16 to 2.60]), hydromorphone (MD 4.07, 95% CI [3.56 to 4.58]), butorphanol (MD 3.18, 95% CI [2.38 to 3.96]), and fentanyl or its derivatives (MD 1.57, 95% CI [1.25 to 1.89]) had a better analgesic effect. In terms of safety, propofol (OR 16.46; 95% CI [1.54 to 175.95]) and midazolam plus fentanyl or its derivatives (OR 7.02; 95% CI [1.33 to 36.99]) significantly increased the incidence of respiratory depression compared with dexmedetomidine plus fentanyl or its derivatives. Dexmedetomidine plus fentanyl or its derivatives reduced the incidence of nausea and vomiting compared with fentanyl alone (OR 4.74; 95% CI [1.01 to 22.22]). Propofol was associated with a lower incidence of nausea and vomiting than hydromorphone (OR 0.01; 95% CI [0.00 to 0.59]) and fentanyl or its derivatives (OR 0.01; 95% CI [0.00 to 0.51]). There was no statistically significant difference in the incidence of hypotension between any two strategies.
Hydromorphone and butorphanol had better analgesic effects than fentanyl or its derivates. Dexmedetomidine had better sedative effects. In terms of safety, dexmedetomidine, oxymorphone, and butorphanol were superior. It is necessary to explore the regimen that can consider both the effectiveness and safety during radiofrequency catheter ablation for atrial fibrillation (AF).
This study was registered with PROSPERO, number: CRD42023403661.
心房颤动是最常见的快速性心律失常，而导管消融是治疗心房颤动的有效方法。然而，手术过程中可能会出现疼痛和紧张情绪。此外，对于这些手术中使用哪种最佳镇痛和镇静药物尚未达成共识。因此，我们进行了一项网状Meta分析，以评估用于心房颤动导管消融的镇痛和镇静药物的疗效和安全性。
我们检索了PubMed、Cochrane图书馆、Web of Science、EMBASE、中国知网和百度文库文档下载网站，以获取从创刊到2023年2月26日的随机对照试验。仅纳入了在镇痛药或镇静药之间进行比较且涉及接受射频导管消融的心房颤动患者的研究。疗效终点是心房颤动射频消融期间的Ramsay镇静评分和视觉模拟量表评分。安全终点是呼吸抑制、低血压、恶心和呕吐的发生率。进行了成对比较和频率法分析。结果以优势比（OR）、平均差（MD）和相应的95%置信区间（CIs）报告。我们根据《Cochrane系统评价干预措施手册》评估了研究的风险偏倚。
在最初检索的709篇文章中，纳入了14项研究，共1156名参与者。在疗效方面，心房颤动射频消融期间接受右美托咪定的患者的Ramsay镇静评分高于接受咪达唑仑加芬太尼或其衍生物的患者（MD -0.88，95% CI [-0.04至-0.72]）。与吗啡相比，地佐辛（MD 1.88，95% CI [1.16至2.60]）、氢吗啡酮（MD 4.07，95% CI [3.56至4.58]）、布托啡诺（MD 3.18，95% CI [2.38至3.96]）以及芬太尼或其衍生物（MD 1.57，95% CI [1.25至1.89]）具有更好的镇痛效果。在安全性方面，与右美托咪定加芬太尼或其衍生物相比，丙泊酚（OR 16.46；95% CI [1.54至175.95]）和咪达唑仑加芬太尼或其衍生物（OR 7.02；95% CI [1.33至36.99]）显著增加了呼吸抑制的发生率。与单独使用芬太尼相比，右美托咪定加芬太尼或其衍生物降低了恶心和呕吐的发生率（OR 4.74；95% CI [1.01至22.22]）。丙泊酚与氢吗啡酮（OR 0.01；95% CI [0.00至0.59]）和芬太尼或其衍生物（OR 0.01；95% CI [0.00至0.51]）相比，恶心和呕吐的发生率较低。任何两种策略之间低血压的发生率没有统计学显著差异。
氢吗啡酮和布托啡诺的镇痛效果优于芬太尼或其衍生物。右美托咪定具有更好的镇静效果。在安全性方面，右美托咪定、羟吗啡酮和布托啡诺更具优势。有必要探索在心房颤动射频消融过程中兼顾有效性和安全性的方案。
PROSPERO注册：本研究已在PROSPERO注册，编号：CRD42023403661。
