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Supraventricular tachycardia
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| bet | 516/654 | | Sana | 03.01.2022 | | Hajmi | 1,5 Mb. | | #14803 |
Supraventricular tachycardia: A single RCT and 2 cohort studies have reported the effects of pharmacological treatment of SVT in infants and children. Sanatini et al 2012 [11] in a RCT of 61 infants <4 months with SVT (atrioventricular reciprocating tachycardia or atrioventricular nodal re-entrant tachycardia excluding Wolff-Parkinson-White) compared digoxin (loading dose 30 micrograms/kg/day, maintenance 10.5 micrograms/kg/day) versus propranolol 0.5 mg/kg as a single dose then 1.0 mg/kg/dose 8 hourly. SVT recurred in 19% of patients on digoxin and 31% of patients on propranolol (P = 0.25). No first recurrence occurred after 110 days of treatment. The 6-month recurrence-free status was 79% for patients on digoxin and 67% for patients on propranolol (P = 0.34), and there were no first recurrences in either group between 6 and 12 months. There were no deaths and no serious adverse events related to study medication. Hornik et al 2014 [12] in a retrospective cohort of infants with SVT from the Pediatrix Medical Group neonatal ICU database compared 342 infants exposed to digoxin versus 142 infants exposed to propranolol. The incidence rate of treatment failure was 6.7/1,000 infant-days of exposure to digoxin and 15.4/1,000 infant-days of exposure to propranolol. Treatment failure was higher on propranolol when compared with that on digoxin (adjusted hazard ratio, 1.97; 95%CI 1.05–3.71). Hypotension was more frequent during exposure to digoxin versus propranolol (39.4 vs 11.1/1,000 infant-days; p <0.001). There was no difference in frequency of other clinical adverse events. Bolin et al 2017 [13] reported a retrospective cohort of infants with SVT from the Pediatric Health Information System database admitted at ≤2 days of age with structurally normal hearts and treated with an antiarrhythmic medication. 2,657 neonates were identified with a median gestational age of 37 weeks (interquartile range 34 to 39). Digoxin and propranolol were most commonly prescribed; digoxin use steadily decreased to 23% of antiarrhythmic medication administrations over the study period, whereas propranolol increased to 77%. Multivariable comparisons revealed that the odds of mortality for neonates on propranolol were 0.32 times those on digoxin (95% CI 0.17 to 0.59; p <0.001). Propranolol for the neonate with SVT is associated with lower in-hospital mortality and hospital costs compared with digoxin. Recommendation: ANZCOR recommendation for pharmacological management of specific dysrhythmias in the paediatric advanced life support guideline recommend adenosine as the drug of choice for SVT. Amiodarone may be used to treat haemodynamically stable or unstable SVT. Alternative drugs are procainamide, digoxin, a beta blocker or a calcium channel blocker. Calcium channel blockers should not be used to treat SVT in infants and should be avoided or used cautiously in children because they may induce hypotension and cardiac depression.[14] EHRA-AEPC Pediatric Cardiac Arrhythmias Consensus suggested dose for oral prophylactic propranolol for SVT and VT in infants: Propranolol 1–3 mg/kg in 3 divided doses daily.[15] [LOE II GOR C]
Hypertension: There are no clinical trials of antihypertensive use in newborn infants. In a retrospective survey of antihypertensive use in infants ≤32 weeks and ≤1500 g birth weight discharged from one of 348 neonatal intensive care units managed by the Pediatrix Medical Group, hydralazine was the most commonly prescribed antihypertensive drug (1280/2504, 51%), followed by the angiotensin converting enzyme inhibitors captopril (734/2504, 29%) and enalapril (457/2504, 18%) (Table 3). Propranolol was the most commonly used adrenergic receptor blocker (380/2504, 15%) while amlodipine was the most commonly used calcium channel blocker (193/2504, 8%). [16] In adults with hypertension, a systematic review found 13 RCTs that compared beta-blockers to placebo (4 RCTs, 23,613 participants), diuretics (5 RCTs, 18,241 participants), calcium-channel blockers (CCBs: 4 RCTs, 44,825 participants), and renin-angiotensin system (RAS) inhibitors (3 RCTs, 10,828 participants). The most common beta-blocker reported was atenolol. Initiating treatment of hypertension with beta-blockers leads to modest CVD reductions and little or no effects on mortality. These beta-blocker effects are inferior to those of other antihypertensive drugs. Recommendation: In a review of treatment of hypertension in paediatric patients, beta-blockers are not considered first-line management. If used, dosage recommendations were: Propranolol: Initial: 1–2 mg/kg/day up to 80 mg/day; Maximum: 4 mg/kg/day up to 640 mg/day; given in 2 to 3 divided doses.[17] (LOE IV GOR B]
Safety: -adrenoceptor blockers are considered to be quite safe in recommended doses mainly because of their large therapeutic indices. One of their indications is chronic heart failure with reduced ejection fraction. However, their introduction may cause transient worsening of heart failure symptoms (e.g. too fast up-titration) due to their negative inotropic action. The initiation of treatment is recommended after stabilisation of heart failure symptoms. An increased risk of toxicity can be also the result of interactions with other drugs (see drug interactions). The manifestations of -blocker overdose include bradycardia, atrioventricular (AV) blockade, hypotension, left ventricular failure and cardiogenic shock.[18]
Reported adverse effects of oral propranolol include hypoglycaemia, bradycardia, hypotension, bronchospasm, sleep disturbance and gastrointestinal disorders. [1, 4] In clinical trials of propranolol versus placebo for prevention of ROP in preterm infants, there was no significant difference in arterial hypotension, bradycardia or bronchospasm requiring treatment or hypoglycaemia (glucose level <2.5 mmol/L). However, the only infants with these adverse events in the included trials received propranolol. Propranolol dosage in one trial (Filippi at al 2013 [5]) was reduced by 50% in infants of less than 26 weeks’ gestation due to severe hypotension, bradycardia and apnoea in several extremely preterm infants. Meta-analysis from two trials did not indicate an effect of prophylactic oral beta-blockers on mortality or complications of preterm birth. [4] Meta-analysis of clinical trials of propranolol versus placebo for infantile haemangiomas found there was no significant difference in these serious adverse effects (5.3% versus 3.6% respectively).[1]
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