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Amiodarone is not recommended as a first-line therapy for out-of-hospital cardiac arrest. While it may improve survival to the emergency department when combined with other drugs, evidence for long-term benefits is insufficient.
Area of Science:
- Emergency Medicine
- Cardiology
- Pharmacology
Background:
- William Osler's advice on adopting new therapies remains relevant.
- Amiodarone is being considered for use in cardiac arrest scenarios.
- Current guidelines require robust evidence before adopting new treatments.
Purpose of the Study:
- To evaluate the efficacy of amiodarone in out-of-hospital cardiac arrest.
- To compare amiodarone with existing therapies for cardiac arrest.
- To determine the appropriate classification for amiodarone in cardiac arrest treatment.
Main Methods:
- Review of available cardiac arrest studies involving amiodarone.
- Comparison of amiodarone's effectiveness against placebo and other drugs.
- Analysis of effects on survival, long-term survival, and neurologic status.
Main Results:
- One study showed improved survival to the emergency department when amiodarone was added to other drugs compared to placebo.
- No significant effect on long-term survival or neurologic function was observed.
- Amiodarone showed comparability to bretylium in treating recurrent ventricular tachycardia/ventricular fibrillation (VT/VF).
Conclusions:
- Amiodarone is not sufficiently supported as a first-line therapy for out-of-hospital cardiac arrest.
- It may be classified as indeterminate when used alone or Class IIb when used with other therapies.
- Further research is imperative to clarify amiodarone's role and efficacy in advanced cardiac life support (ACLS).
Abstract:
Years ago, William Osler taught physicians, "Be not the first nor the last to adopt a therapy." This continues to be sage advice. Clinicians should be cautious in considering the use of amiodarone in a field setting for cardiac arrest until studies clearly show a benefit over drugs currently in use. The endpoint of the only cardiac arrest study available shows improved survival when amiodarone is combined with other drugs over placebo until the patient gets to the emergency department, but is not a comparison with other current drugs nor had any effect on long-term survival or functioning neurologic status. As previously cited, amiodarone was comparable with bretylium in treating recurrent VT/VF in one controlled study. Further study of this and other ACLS drugs is imperative. In summary, amiodarone should be reclassified as either a class indeterminate agent when used alone ("no harm but no benefit ... evidence insufficient to support final class decision") or a class IIb agent ("acceptable and useful ... supported by fair to good evidence") when used in addition to other therapies in the treatment of ventricular fibrillation and pulseless ventricular tachycardia. There is not sufficient evidence to move amiodarone to first-line therapy in the "out-of-hospital" cardiac arrest. This evidence may be available in the future and would then change this recommendation.