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A comparison of isoproterenol and epinephrine for the ...
1
Your life is our life’s work. A comparison of isoproterenol and epinephrine for the induction of arrhythmia during cardiac ablation procedures Taylor Mize, PharmD Candidate; Kevin Howk, PharmD Candidate; Amanda Troup, PharmD, BCPS Mercy Hospital, Springfield, MO Taylor Mize, PharmD Candidate Mercy Hospital, Springfield, MO Email: [email protected] Contact Background • The electronic medical record system was used to retrospectively identify patients 18 years or older who underwent cardiac ablation with arrhythmia induction using isoproterenol or epinephrine at Mercy Health System between June 2017 and May 2019. • Initially, the study team targeted SVT specifically. However, this revealed insufficient data, so the IRB protocol was amended to include all arrhythmias within the stated time frame. The amended protocol was approved by the Mercy IRB on May 31, 2020. • Exclusion criteria included: • Patient age less than 18 years old • Patients in whom drug infusion was used only to test after ablation (i.e., patients who didn’t need an induction agent) • The following data were collected: arrhythmia induction (yes/no), which induction agent was used and at what total dose, cost of induction agent per procedure, procedure length, atropine use, arrhythmia induction following atropine administration, procedure length, procedure complications, and patient demographics such as age, sex, presence of comorbid conditions, and home use of a beta blocker, calcium channel blocker, or an antiarrhythmic medication. • Power was set at 80% and alpha was set at 0.05. 247 patients in each group were required to meet power. • Statistical analysis of the primary outcome measure was conducted using the Pearson chi-square test. Methods and Materials • While both agents were effective for the induction of arrhythmias, isoproterenol was more effective with fewer adverse events. • Of note, data analysis revealed no instances of atropine use to induce an arrhythmia after a single induction agent was failed. • It is also notable that the epinephrine group included patients of older age and with more comorbid conditions, which could confound results. • If epinephrine is used rather than isoproterenol, cost savings could be significant. • More patients in the epinephrine group were admitted to the hospital following their procedure. Therefore, further studies are needed to assess the safety of epinephrine when used as an induction agent. • While power was not met, the primary outcome was statistically significant. Therefore, it can be concluded that isoproterenol is more effective than epinephrine for arrhythmia induction during cardiac ablation procedures. • Study limitations: • Retrospective design • Did not meet power • Confounding variables such as distribution of age and comorbid conditions between groups • Does not assess long-term patient outcomes after procedure completion Discussion Despite lack of power, this study is statistically significant for the primary outcome. While isoproterenol appears to be more effective for arrhythmia induction, epinephrine also led to successful induction in more than 60% of cases. This suggests that epinephrine may be appropriate for induction of arrhythmias during cardiac ablation procedures if isoproterenol is unavailable. Conclusions Secondary Objectives • Compare the cost of epinephrine and isoproterenol for use as an induction agent during cardiac ablation procedures • Assess the need for atropine usage to further induce arrhythmias and outcomes of atropine use among patients who received epinephrine or isoproterenol for arrhythmia induction during cardiac ablation procedures • Compare the baseline characteristics of patients who received epinephrine or isoproterenol for arrhythmia induction during cardiac ablation • Compare the incidence of hospital admission or death between epinephrine and isoproterenol when used as an induction agent for cardiac ablation procedures • 172 patient charts were included in this retrospective chart review. • Of the 172 patient charts included, 106 received isoproterenol as an induction agent and 66 received epinephrine. • 92.5% of the patients receiving isoproterenol and 63.6% of the patients receiving epinephrine underwent successful arrhythmia induction. • Statistical analysis revealed a chi squared value of 10.57 for this study, which is statistically significant. However, this study did not meet power. • Isoproterenol was estimated to cost $116.48 more per dose than epinephrine. Results • To compare the effectiveness of epinephrine and isoproterenol for the induction of arrhythmias during cardiac ablation procedures Primary Objective None of the authors have any financial or professional conflicts to disclose. Disclosure Statement • Historically, isoproterenol, a β1-specific agonist, has been the induction agent of choice during cardiac ablation procedures. 1-5 • However, the price of isoproterenol has risen drastically in recent years and currently costs between $540 and $1,098 per mL. 6 • Some institutions have estimated the cost of isoproterenol per procedure to approach $1,800. 7,8 • Literature shows that some cardiologists have used epinephrine, a nonspecific β1, β2, and 1-agonist as an induction agent. 9,10 • While both isoproterenol and epinephrine have been well-studied and accepted as appropriate induction agents, there is minimal literature comparing isoproterenol outcomes versus epinephrine outcomes. References 1) American Heart Association. (2016, September 30). Ablation for Arrhythmias . Retrieved from American Heart Association : https://www.heart.org/en/health-topics/arrhythmia/prevention-- treatmentof-arrhythmia/ablation-for-arrhythmias 2) American Heart Association. (2016, September 30). Electrophysiology Studies (EPS). Retrieved from American Heart Association: https://www.heart.org/en/health- topics/arrhythmia/symptomsdiagnosis--monitoring-of-arrhythmia/electrophysiology-studies-eps 3) Cedars-Sinai. (n.d.). Catheter Ablation for Arrhythmias. Retrieved from Cedars-Sinai : https://www.cedars- sinai.org/programs/heart/clinical/electrophysiology/conditionstreatments/catheter-ablation.html 4) Mayo Clinic . (2019, September 28). Cardiac Ablation. Retrieved from Mayo Clinic : https://www.mayoclinic.org/tests-procedures/cardiac-ablation/about/pac-20384993 5) Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; November 19, 2019. 6) Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; November 7, 2019. 7) D'Ambrosi, J. A. (2018). Hyperinflation of Isoproterenol. Journal of Pharmacy Practice, 390-394. 8) Parkin, S. R. (2019). Cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures . American Journal of Health-System Pharmacists , 551-553. 9) Cismaru, G. R. (2014). The value of adrenaline in the induction of supraventricular tachycardia in the electrophysiological laboratory . Europace, 1634-1638. 10) Patel PJ, Segar R, Patel JK, Padanilam BJ, Prystowsky EN. Arrhythmia induction using isoproterenol or epinephrine during electrophysiology study for supraventricular tachycardia. J Cardiovasc Electrophysiol. 2018;29:1635 1640. https://doi.org/10.1111/jce.13732 Baseline Characteristics Characteristic Isoproterenol Epinephrine Number of Patients 106 66 Average Age (years) 63.1 69.3 Male (%) 58.4 60.6 Average Procedure Length (min.) 230.5 271.3 Heart Failure (%) 20.8 31.8 Diabetes (%) 20.8 39.4 Hypertension (%) 34.0 42.4 Coronary Artery Disease (%) 16.0 24.2 Obesity (%) 66.0 42.4 0% 20% 40% 60% 80% 100% Isoproterenol Epinephrine Percent of Patients Successfully Induced $0.00 $20.00 $40.00 $60.00 $80.00 $100.00 $120.00 $140.00 Isoproterenol Epinephrine Cost per Dose 0% 10% 20% 30% 40% 50% 60% 70% 80% Beta Blocker Calcium Channel Blocker Antiarrhythmic Home Medications Prior to Procedure Isoproterenol Group Epinephrine Group Figure 1: Percent of patients in which an arrhythmia was successfully induced Figure 2: Baseline characteristics of patient charts included in review Figure 3: Estimated cost per dose of each induction agent Figure 4: Home medication use compared between the two groups
Transcript of A comparison of isoproterenol and epinephrine for the ...
Your life is our life’s work.
A comparison of isoproterenol and epinephrine for the induction of arrhythmia during cardiac ablation procedures
Taylor Mize, PharmD Candidate; Kevin Howk, PharmD Candidate; Amanda Troup, PharmD, BCPS Mercy Hospital, Springfield, MO
Taylor Mize, PharmD CandidateMercy Hospital, Springfield, MOEmail: [email protected]
Contact
Background
• The electronic medical record system was used to retrospectively identify patients 18 years or older who underwent cardiac ablation with arrhythmia induction using isoproterenol or epinephrine at Mercy Health System between June 2017 and May 2019.• Initially, the study team targeted SVT specifically. However, this
revealed insufficient data, so the IRB protocol was amended to include all arrhythmias within the stated time frame. The amended protocol was approved by the Mercy IRB on May 31, 2020.
• Exclusion criteria included:• Patient age less than 18 years old • Patients in whom drug infusion was used only to test after ablation
(i.e., patients who didn’t need an induction agent)• The following data were collected: arrhythmia induction (yes/no), which
induction agent was used and at what total dose, cost of induction agent per procedure, procedure length, atropine use, arrhythmia induction following atropine administration, procedure length, procedure complications, and patient demographics such as age, sex, presence of comorbid conditions, and home use of a beta blocker, calcium channel blocker, or an antiarrhythmic medication.
• Power was set at 80% and alpha was set at 0.05. 247 patients in each group were required to meet power.
• Statistical analysis of the primary outcome measure was conducted using the Pearson chi-square test.
Methods and Materials
• While both agents were effective for the induction of arrhythmias, isoproterenol was more effective with fewer adverse events.
• Of note, data analysis revealed no instances of atropine use to induce an arrhythmia after a single induction agent was failed.
• It is also notable that the epinephrine group included patients of older age and with more comorbid conditions, which could confound results.
• If epinephrine is used rather than isoproterenol, cost savings could be significant.
• More patients in the epinephrine group were admitted to the hospital following their procedure. Therefore, further studies are needed to assess the safety of epinephrine when used as an induction agent.
• While power was not met, the primary outcome was statistically significant. Therefore, it can be concluded that isoproterenol is more effective than epinephrine for arrhythmia induction during cardiac ablation procedures.
• Study limitations: • Retrospective design• Did not meet power• Confounding variables such as distribution of age and comorbid
conditions between groups• Does not assess long-term patient outcomes after procedure
completion
Discussion
Despite lack of power, this study is statistically significant for the primary outcome. While isoproterenol appears to be more effective for arrhythmia induction, epinephrine also led to successful induction in more than 60% of cases. This suggests that epinephrine may be appropriate for induction of arrhythmias during cardiac ablation procedures if isoproterenol is unavailable.
Conclusions
Secondary Objectives• Compare the cost of epinephrine and isoproterenol for use as an induction
agent during cardiac ablation procedures • Assess the need for atropine usage to further induce arrhythmias and
outcomes of atropine use among patients who received epinephrine or isoproterenol for arrhythmia induction during cardiac ablation procedures
• Compare the baseline characteristics of patients who received epinephrine or isoproterenol for arrhythmia induction during cardiac ablation
• Compare the incidence of hospital admission or death between epinephrine and isoproterenol when used as an induction agent for cardiac ablation procedures
• 172 patient charts were included in this retrospective chart review. • Of the 172 patient charts included, 106 received isoproterenol as an
induction agent and 66 received epinephrine. • 92.5% of the patients receiving isoproterenol and 63.6% of the patients
receiving epinephrine underwent successful arrhythmia induction. • Statistical analysis revealed a chi squared value of 10.57 for this study,
which is statistically significant. However, this study did not meet power.• Isoproterenol was estimated to cost $116.48 more per dose than
epinephrine.
Results
• To compare the effectiveness of epinephrine and isoproterenol for the induction of arrhythmias during cardiac ablation procedures
Primary Objective
None of the authors have any financial or professional conflicts to disclose.
Disclosure Statement
• Historically, isoproterenol, a β1-specific agonist, has been the induction agent of choice during cardiac ablation procedures.1-5
• However, the price of isoproterenol has risen drastically in recent years and currently costs between $540 and $1,098 per mL.6
• Some institutions have estimated the cost of isoproterenol per procedure to approach $1,800.7,8
• Literature shows that some cardiologists have used epinephrine, a nonspecific β1, β2, and 𝛼1-agonist as an induction agent.9,10
• While both isoproterenol and epinephrine have been well-studied and accepted as appropriate induction agents, there is minimal literature comparing isoproterenol outcomes versus epinephrine outcomes.
References1) American Heart Association. (2016, September 30). Ablation for Arrhythmias . Retrieved from
American Heart Association : https://www.heart.org/en/health-topics/arrhythmia/prevention--treatmentof-arrhythmia/ablation-for-arrhythmias
2) American Heart Association. (2016, September 30). Electrophysiology Studies (EPS). Retrieved from American Heart Association: https://www.heart.org/en/health-topics/arrhythmia/symptomsdiagnosis--monitoring-of-arrhythmia/electrophysiology-studies-eps
3) Cedars-Sinai. (n.d.). Catheter Ablation for Arrhythmias. Retrieved from Cedars-Sinai : https://www.cedars-sinai.org/programs/heart/clinical/electrophysiology/conditionstreatments/catheter-ablation.html
4) Mayo Clinic . (2019, September 28). Cardiac Ablation. Retrieved from Mayo Clinic : https://www.mayoclinic.org/tests-procedures/cardiac-ablation/about/pac-20384993
5) Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; November 19, 2019.
6) Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; November 7, 2019.
7) D'Ambrosi, J. A. (2018). Hyperinflation of Isoproterenol. Journal of Pharmacy Practice, 390-394.8) Parkin, S. R. (2019). Cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation
procedures . American Journal of Health-System Pharmacists , 551-553.9) Cismaru, G. R. (2014). The value of adrenaline in the induction of supraventricular tachycardia in the
electrophysiological laboratory . Europace, 1634-1638. 10) Patel PJ, Segar R, Patel JK, Padanilam BJ, Prystowsky EN. Arrhythmia induction using isoproterenol or
epinephrine during electrophysiology study for supraventricular tachycardia. J Cardiovasc Electrophysiol. 2018;29:1635 1640. https://doi.org/10.1111/jce.13732
Baseline Characteristics Characteristic Isoproterenol Epinephrine
Number of Patients 106 66Average Age (years) 63.1 69.3
Male (%) 58.4 60.6Average Procedure Length (min.) 230.5 271.3
Heart Failure (%) 20.8 31.8Diabetes (%) 20.8 39.4
Hypertension (%) 34.0 42.4Coronary Artery Disease (%) 16.0 24.2
Obesity (%) 66.0 42.4
0%
20%
40%
60%
80%
100%
Isoproterenol Epinephrine
Percent of Patients Successfully Induced
$0.00 $20.00 $40.00 $60.00 $80.00 $100.00 $120.00 $140.00
Isoproterenol
Epinephrine
Cost per Dose
0%
10%
20%
30%
40%
50%
60%
70%
80%
Beta Blocker Calcium Channel Blocker Antiarrhythmic
Home Medications Prior to Procedure
Isoproterenol Group Epinephrine Group
Figure 1: Percent of patients in which an arrhythmia was successfully induced
Figure 2: Baseline characteristics of patient charts included in review
Figure 3: Estimated cost per dose of each induction agent
Figure 4: Home medication use compared between the two groups
