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Three Part Question

In [adults with haemodinamically stable narrow complex tachycardia] is [esmolol safe and efficient] at [restoring and maintaining sinus rhythm]?

Clinical Scenario

a 54 year old lady with a history of palpitations is refered to A & E by her GP, complaining of palpitations and lightheadedness. The attending registrar performs a 12 lead ECG revealing revealing a regular rhythm, an absent P wave and a narrow complex QRS with a ventricular response of >150 beats/min on the bedside monitor strip on leads II and V5. She is diagnosed with atriventricular nodal reentrant tachycardia and the valsava manoeuvre is attempted unsuccessfully. IV Adenosine is given which restores sinus rhythm but fails to maintain it as the lady relapses into the arrhthmia. A beta-blocker is then considered and the attending clinician debates which beta-blocker is more efficient at restoring and maintaining sinus rhythm.

Search Strategy

Medline using the OVID interface 1966 to June Week 4 2005
EMBASE using the OVID interface 1980 to 2005 Week 27
CINAHL using the OVID interface 1982 to June Week 4 2005
[(exp Tachycardia, Supraventricular/ ) OR (exp Anti-Arrhythmia Agents/) OR (narrow complex tachycardia.mp) OR (exp Tachycardia, Atrioventricular Nodal Reentry/)] OR[(Tachycardia, Supraventricular/dt, th) (Drug Therapy, Therapy)] AND [(esmolol.mp.)] AND [(exp Tachycardia, Supraventricular/ ) OR (exp Anti-Arrhythmia Agents/) OR (narrow complex tachycardia.mp) OR (exp Tachycardia, Atrioventricular Nodal Reentry/)] OR [(Tachycardia, Supraventricular/dt, th) (Drug Therapy, Therapy)] AND [(propanolol.mp. or exp Propranolol/)]

Search Outcome

25 papers were found of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Abrams et al 1985 USA	127 men and non-pregant women over the age of 18 who had rapid ventricular rate (<120 bpm) of supraventricular origin requiring therapy.	Multicentre randomized double-blind parallel clinical trial	>20% heart rate reduction, heart rate <100 bpm, conversion to simus rhythm	72% esmolol vs 69% propanolol; p=NS	outcomes not assessed blind sample size not justified possible patient bias randomisation not explained
			Maintenance of normal of normal sinus rhythm	67% esmolol vs 58% propanolol; p<0.05
			asymptomatic hypotension	45% esmolol vs 18% propanolol; p<0.05

Comment(s)

The use of ultra-short acting beta-blocking agents in the acute management of supraventricular tachycardias in the haemodinamically stable patient allows rapid titration of the drug effect and rapid dissipation of adverse effects when treatment terminates. Esmolol proved to be as potent as propanolol in restoring and maintaining sinus rhythm. It has a greater effect on decreasing blood pressure but it is usually asymptomatic and short-lived.

Clinical Bottom Line

Esmolol is an agent to consider when treating haemodinamically stable supraventricular tachycardias amenable to beta-blockade and without limiting hypotension.

References

1. Abrams J, Allen John, Allin D, Anderson J, Anderson S, Blanski L, Chadda K, DiBianco R, Favrot L, Gonzalez J, Horowitz L, Laddu A, Lee R, MacCosbe P, Morganroth, Narula O, Singh B. Efficacy and Safety of Esmolol vs Propanolol in the Treatment of Supraventricular Tachyarrhythmias: a Multicenter double-blind clinical trial American Heart Journal November 1985; volume 10 number 5