Elsevier

Resuscitation

Volume 146, 1 January 2020, Pages 118-125
Resuscitation

Review
Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2019.11.019Get rights and content

Abstract

Background

Refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) refers to cases that do not respond to traditional Advanced Cardiac Life Support measures and are associated with significantly lower survival rates. Beta-blockade may improve outcomes by protecting against the deleterious effects associated with epinephrine’s beta-receptor effect.

Objective

This systematic review and meta-analysis aimed to evaluate whether beta-blockade compared with control improved outcomes among patients in cardiac arrest due to refractory VF/VT.

Methods

PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed on September 2nd, 2019 for all studies evaluating beta-blockade versus control groups in patients with cardiac arrest due to refractory VF/VT. PRISMA guidelines were followed. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Cochrane Risk of Bias in Non-randomised Studies of Interventions tool. Data were summarized and a meta-analysis was performed assessing temporary and sustained return of spontaneous circulation (ROSC), survival-to-admission, survival-to-discharge, and survival with a favorable neurologic outcome.

Results

Three studies (n = 115 patients) were selected for final inclusion. Beta-blockade was associated with an increased rate of temporary ROSC (OR 14.46; 95% CI 3.63–57.57), sustained ROSC (OR 5.76; 95% CI 1.79–18.52), survival-to-admission (OR 5.76; 95% CI 1.79–18.52), survival-to-discharge (OR 7.92; 95% CI 1.85–33.89), and survival with a favorable neurologic outcome (OR 4.42; 95% CI 1.05–18.56). Overall risk of bias ranged from moderate-to-severe, which was primarily influenced by selection of participants and potential confounding. This study was registered with PROSPERO (CRD42019126902).

Conclusions

The data suggest that beta-blockade may be associated with improved outcomes ranging from ROSC to survival with a favorable neurologic outcome. Future randomized controlled trials are needed to further evaluate this intervention in refractory VF/VT.

Introduction

There are approximately 356,000 patients each year that experience out-of-hospital cardiac arrest (OHCA) with over 20% of them presenting in a shockable rhythm.1 Patients presenting in ventricular fibrillation/ventricular tachycardia (VF/VT) have a higher chance of survival to hospital discharge.1 However, there continues to be a subset of these patients who are not successfully resuscitated using standard Advanced Cardiovascular Life Support (ACLS) care and that remain in VF/VT, with an incidence ranging from 2% to 28%.2, 3, 4 This increasingly recognized group of patients with a shockable rhythm that does not respond to traditional ACLS therapies (e.g. defibrillation, epinephrine, antiarrhythmic medications) have been labeled as ‘refractory VF/VT’. While 30% of patients presenting in a shockable rhythm responding to ACLS therapies survive with a favorable neurological outcome, those that are refractory have a survival rate of 3%–15% with only 5% of these patients surviving with good neurologic outcomes.5 The most recent update to the American Heart Association (AHA) ACLS guidelines in 2018 recognized the growing evidence of using novel therapies such as beta-blockade in refractory VF/VT but provided no formal recommendations for their use.6 Prior literature has primarily focused on animal data.7, 8 However, there have been several recent human studies which have evaluated the impact of beta-blockers on refractory VF/VT prompting the need for the current systematic review and meta-analysis.9, 10, 11

The primary aim of this study was to evaluate the effect of beta-blockade compared with control in patients with refractory VF/VT arrest for the primary outcome of return of spontaneous circulation (ROSC). Secondary outcomes included survival-to-admission, survival-to-discharge, survival with a favorable neurologic outcome, and adverse events.

Section snippets

Methods

Our study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and was performed in accordance with best practice guidelines.12 This review was registered with PROSPERO (CRD42019126902). In conjunction with a medical librarian, we conducted a search of PubMed, Scopus, the Cumulative Index of Nursing and Allied Health (CINAHL), the Latin American and Caribbean Health Sciences Literature database (LILACS), Google Scholar,

Results

A total of 3,682 studies were identified with the search strategy. PubMed identified 1972 studies, Scopus yielded 857 studies, CINAHL discovered 317 studies, LILACS found 14, the Cochrane Database of Systematic Reviews identified 323 studies, and the Cochrane Central Register of Controlled Trials yielded 2 studies. In addition, the initial 200 studies from Google Scholar were also included as recommended by Bramer and colleagues.20 After removing duplicates, 2824 original abstracts were

Discussion

In this systematic review and meta-analysis, we investigated the efficacy of beta-blockade compared with control in patients with refractory VF/VT arrest. The data suggests that beta-blockade may lead to improved outcomes, including temporary and sustained ROSC, survival-to-admission, survival-to-discharge, and survival with a favorable neurologic outcome.

To our knowledge, this is the first systematic review and meta-analysis on this topic focusing on human studies. Two prior systematic reviews

Limitations

It is important to consider several limitations with regard to the current study. All studies were observational in nature and there were no randomized controlled trials. As such, it is possible that unidentified confounders may have been present, which may have influenced the findings. Future randomized controlled trials are recommended to further assess this intervention. Additionally, while all studies assessed esmolol, Nademanee and colleagues included LSGB which may have led to some

Conclusion

Beta-blockade may be associated with improved outcomes including ROSC, survival-to-discharge, survival-to-admission, and survival with a favorable neurologic outcome. Future randomized controlled trials are needed to further evaluate this approach to refractory VF/VT.

Author contributions

MG, SPD, and GDP contributed to the study concept and design.

MG, SPD, and GDP contributed to the acquisition of the data.

MG, SPD, and GDP contributed to the analysis and interpretation of the data.

MG, SPD, and GDP contributed to drafting of the manuscript.

MG, SPD, and GDP contributed to critical revision of the manuscript for important intellectual content.

MG and GDP contributed to the statistical expertise.

No funding was obtained for this study.

Prior presentations

None.

Conflicts of interest

None.

Acknowledgement

The authors would like to thank Jennifer C. Westrick, MSLIS for her assistance with the literature search.

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