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Amiodarone for arrhythmia in patients with Chagas disease: A systematic review and individual patient data
Cinara Stein1, Celina Borges Migliavaca1,2, Verônica Colpani1,3,4
1Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil.
Insights
Amiodarone effectively reduces ventricular arrhythmias in Chagas cardiomyopathy patients. However, evidence for improved hard outcomes like sudden death is lacking, necessitating careful benefit-risk assessment.
Area of Science:
- Cardiology
- Infectious Diseases
- Pharmacology
Background:
- Chagas disease, caused by Trypanosoma cruzi, is a prevalent neglected chronic condition in Latin America.
- Ventricular arrhythmias are a common complication of Chagas cardiomyopathy.
- Amiodarone is frequently prescribed for managing these arrhythmias.
Purpose of the Study:
- To evaluate the efficacy and safety of amiodarone in patients diagnosed with Chagas cardiomyopathy.
- To synthesize evidence from existing studies on amiodarone's impact on ventricular arrhythmias.
Main Methods:
- A systematic literature search was conducted across MEDLINE, Embase, and LILACS up to January 2018.
- Included randomized and observational studies were reviewed by two independent researchers.
- Evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
Main Results:
- Nine studies (including 1 RCT) were analyzed, with 2 studies providing individual patient data.
- Amiodarone significantly reduced ventricular tachycardia episodes (99.9%), ventricular premature beats (93.1%), and ventricular couplets (79%).
- Common adverse effects included corneal microdeposits (61.1%), gastrointestinal events (16.1%), sinus bradycardia (12.7%), and dermatological issues (10.6%).
Conclusions:
- Amiodarone demonstrates effectiveness in decreasing ventricular arrhythmias in Chagas cardiomyopathy.
- Current evidence does not support amiodarone's impact on hard clinical endpoints such as mortality or hospitalization.
- Clinical decisions regarding amiodarone use should weigh individual benefits against potential harms.
Background:
Chagas disease is a neglected chronic condition caused by Trypanosoma cruzi, with high prevalence and burden in Latin America. Ventricular arrhythmias are common in patients with Chagas cardiomyopathy, and amiodarone has been widely used for this purpose. The aim of our study was to assess the effect of amiodarone in patients with Chagas cardiomyopathy.
Methodology:
We searched MEDLINE, Embase and LILACS up to January 2018. Data from randomized and observational studies evaluating amiodarone use in Chagas cardiomyopathy were included. Two reviewers selected the studies, extracted data and assessed risk of bias. Overall quality of evidence was accessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Principal Findings:
We included 9 studies (3 before-after studies, 5 case series and 1 randomized controlled trial). Two studies with a total of 38 patients had the full dataset, allowing individual patient data (IPD) analysis. In 24-hour Holter, amiodarone reduced the number of ventricular tachycardia episodes in 99.9% (95%CI 99.8%-100%), ventricular premature beats in 93.1% (95%CI 82%-97.4%) and the incidence of ventricular couplets in 79% (RR 0.21, 95%CI 0.11-0.39). Studies not included in the IPD analysis showed a reduction of ventricular premature beats (5 studies), ventricular tachycardia (6 studies) and ventricular couplets (1 study). We pooled the incidence of adverse side effects with random effects meta-analysis; amiodarone was associated with corneal microdeposits (61.1%, 95%CI 19.0-91.3, 5 studies), gastrointestinal events (16.1%, 95%CI 6.61-34.2, 3 studies), sinus bradycardia (12.7%, 95%CI 3.71-35.5, 6 studies), dermatological events (10.6%, 95%CI 4.77-21.9, 3 studies) and drug discontinuation (7.68%, 95%CI 4.17-13.7, 5 studies). Quality of evidence ranged from moderate to very low.
Conclusions:
Amiodarone is effective in reducing ventricular arrhythmias, but there is no evidence for hard endpoints (sudden death, hospitalization). Although our findings support the use of amiodarone, it is important to balance the potential benefits and harms at the individual level for decision-making.
