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Use of Sympathomimetic Drugs Leads to Increased Risk of Hospitalization for Arrhythmias in Patients with Congestive Heart Failure

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Use of Sympathomimetic Drugs Leads to Increased Risk of Hospitalization for Arrhythmias in Patients with Congestive Heart Failure ORIGINAL INVESTIGATION Use of Sympathomimetic Drugs Leads to Increased Risk of Hospitalization for Arrhythmias in Patients With Congestive Heart Failure Marcel L. Bouvy, PharmD; Eibert R. Heerdink, PhD; Marie L. De Bruin, PharmD; Ron M. C. Herings, PhD; Hubert G. M. Leufkens, PhD; Arno W. Hoes, PhD Background: Sympathomimetic agents have a direct exposure to sympathomimetic agents, expressed as positive chronotropic effect on heart rate and may cause odds ratios. hypokalemia, even when administered by inhalation. In selected patients (eg, patients with congestive heart fail- Results: Of 149 case patients, a total of 33 (22.1%) were ure [CHF]) this can lead to arrhythmias. Despite the po- treated with any sympathomimetic agent, and 6 pa- tential adverse effects of these agents, they are used fre- tients (4.0%) were treated with systemic sympathomi- quently in patients with CHF, due to a high incidence of metics. The use of any sympathomimetic drug was as- respiratory comorbidity. This study investigates the ef- sociated with an increased risk of admission for arrhythmia fects of sympathomimetics on the incidence of hospital- (odds ratio, 4.0; 95% confidence interval, 1.0-15.1). For izations for arrhythmias in patients with CHF. systemic sympathomimetic drugs, the corresponding odds ratio was 15.7 (95% confidence interval, 1.1-228.0). Methods: In a cohort of 1208 patients with a validated hospital discharge diagnosis of CHF, we identified 149 Conclusions: The results of this study strongly suggest cases with a readmission for arrhythmias, and com- an increased risk of hospitalization for arrhythmias in pa- pared these in a nested matched case-control design tients with CHF treated with sympathomimetic drugs. with 149 controls from the remainder of the cohort Sympathomimetics should be given under close surveil- with no hospital readmission for any cardiac cause. lance to patients with CHF. Conditional logistic regression was used to calculate the risk for hospitalization for arrhythmias associated with Arch Intern Med. 2000;160:2477-2480 RRHYTHMIAS can be in- that these drugs could be safely used in duced or aggravated by a patients with chronic obstructive pulmo- variety of drugs, which in- nary disease (COPD).6 By now, however, clude cardiotonic drugs evidence accumulates that arrhythmias (digoxin, sympathomimet- due to systemic use of sympathomimet- Aics, and antiarrhythmics), and by drugs ics do occur occasionally.7,8 Even the that lower plasma potassium levels, occurrence of arrhythmias after inhala- such as diuretics and corticosteroids. tion of sympathomimetics has inciden- A special group comprises drugs that tely been reported.9 lengthen QT interval and can lead to in- Elderly patients and patients with duction of torsade de pointes (eg, antihis- congestive heart failure (CHF), renal or tamines, antidepressants, macrolide anti- hepatic dysfunction, electrolyte dis- biotics, cisapride, and antipsychotics).1 turbance (hypokalemia, hypomagnese- Sympathomimetic drugs have a mia), or a history of arrhythmias are direct positive chronotropic effect that probably more prone to the proarrhyth- From the Department of can promote arrhythmia. Moreover, sym- mic effect of sympathomimetics.10 More- Pharmacoepidemiology and pathomimetics can induce hypokalemia over, patients with CHF often use diuret- Pharmacotherapy, Utrecht and further worsen arrhythmias.2,3 Stud- ics. The hypokalemic response to University, Utrecht (Drs Bouvy, ies on chronotropic and hypokalemic diuretics could be additive to that of sym- Heerdink, De Bruin, Herings, effects of sympathomimetics have shown pathomimetics.11,12 and Leufkens), Stevenshof Institute for Research, Leiden small but significant effects, which can Cardiac arrest and arrhythmia are (Dr Bouvy), and Julius Centre even be induced by inhalation of sympa- the major causes of death in patients 4,5 13 for Patient-Oriented Research, thomimetics. At the introduction of with CHF. Despite the potential nega- Utrecht (Dr Hoes), selective b2-sympathomimetics, a limited tive effects of sympathomimetics in the Netherlands. number of small-scale studies suggested patients with CHF, they often receive (REPRINTED) ARCH INTERN MED/ VOL 160, SEP 11, 2000 WWW.ARCHINTERNMED.COM 2477 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 PATIENTS AND METHODS DATA ANALYSIS We performed a nested case-control analysis comparing ex- SETTING posure in cases vs controls. Odds ratios (ORs) were calcu- lated for exposure to sympathomimetic agents, at the time Data were used from the PHARMO record linkage system, of the hospitalization due to arrhythmias (cases) or matched a database containing drug dispensing records from com- index date (controls). Conditional logistic regression tech- munity pharmacies and linked hospital discharge records niques were applied to adjust for potential confounders. All of a defined population of 300000 residents of 6 medium- statistical analyses were performed with Egret software (Egret sized cities in the Netherlands.14 for Windows, version 2.0, Cytel Software Corporation, Cam- Medication histories and hospital data were bridge, Mass). collected from 1986 to 1992. Drugs were coded accord- ing to the Anatomical Therapeutic Chemical (ATC) clas- POTENTIAL CONFOUNDERS sification. Hospital discharge records were coded accord- ing to the International Classification of Diseases, Ninth This study was done in a group of patients with a high fre- Revision (ICD-9).15 Clinical modification codes were quency of comorbidity. Arrhythmia is a common compli- used. cation in patients with CHF. Left ventricular hypertrophy and local ischemia of heart tissue may contribute to ar- PATIENTS rhythmogenic effects. Arrhythmias frequently occur in patients with COPD. A total of 1208 patients with a validated hospital dis- An important risk factor is the occurrence of hypoxemia charge diagnosis for CHF were included in the study.16 in patients with COPD. An increased risk for hospital ad- These patients were followed up for a total of 5038 missions for arrhythmias could therefore be related to the person-years (mean follow-up, 4.2 years per patient). In underlying disease instead of the use of sympathomimet- this cohort we identified a total of 454 readmissions for ics. On the other hand, sympathomimetics can also aggra- cardiac causes, including myocardial infarction, angina vate the effects of hypoxemia.17 pectoris, arrhythmias, and CHF. We found 149 patients In addition, a broad range of drugs could affect the with a rehospitalization for arrhythmias (cases). For occurrence of arrhythmias by direct effect on heart rate (eg, each case, a control was sampled randomly from the angiotensin-converting enzyme inhibitors, b-blockers, cal- remainder of the cohort who were not readmitted for cium antagonists, digoxin, antiarrhythmics, and ibopa- any cardiac cause and matched according to follow-up min), blood potassium levels (eg, angiotensin-converting time. An index date was assigned to each control match- enzyme inhibitors, corticosteroids, diuretics, and laxa- ing the hospitalization date of the case. tives), or QT interval (eg, antihistaminic drugs, antide- pressants, antipsychotics, macrolides, and cisapride). EXPOSURE DEFINITION We corrected for these potential confounders by in- cluding the presence of hospital admissions for arrhyth- A patient was defined as exposed when there was at least 1 mias, myocardial infarction, angina pectoris, asthma, and prescription filled for a given drug in the 3 months before COPD in the year preceding the hospitalization for CHF hospital admission for the cases or the corresponding in- and the use of aforementioned drugs in the 3 months prior dex date for the controls. to the hospital admission in the multiple regression model. such drugs, due to a high incidence of respiratory albuterol in 74% and terbutaline in 26%. There was comorbidity (in particular COPD). This study investi- only 1 nasal sympaticomimetic used, which was xylo- gates the effects of sympathomimetics on the incidence metazoline hydrochloride. of hospitalizations due to arrhythmias in patients with Of the 149 cases and controls 33 (22%) and 17 CHF. (11%) were treated with any sympathomimetic agent, yielding a crude OR of 2.2 (95% confidence interval RESULTS [CI], 1.2-4.3). We adjusted for a number of possible confounders, notably, sex, age, prior hospitalizations for Table 1 details the general characteristics of the arrhythmia, asthma, COPD, myocardial infarction, and study population. The majority of arrhythmias were angina pectoris. In addition, we adjusted for the use of a classified as atrial fibrillation (n=98, 60%). The other broad range of drugs that may have direct proarrhyth- frequently seen arrhythmias were ventricular tachycar- mic effects, give rise to hyperkalemia or hypokalemia, or dia (n=15, 9%) and fibrillation (n=16, 10%). The are markers for a history of rhythm disturbances, such as characteristics of users of sympathomimetics differed digoxin, calcium channel inhibitors, b-blockers, oral an- in some aspects from patients not using these drugs ticoagulants, antiarrhythmics, angiotensin-converting (eg, sex, use of corticosteroids, and prior hospital enzyme inhibitors, corticosteroids, laxatives, diuretics, ni- admissions for COPD). The following inhalation trates, neuroleptics, H1-antihistamines, antidepressants, and sympaticomimetics were used: albuterol, 94% of all ibopamin. Adjusted ORs were 4.0 (95% CI, 1.0-15.1) for prescriptions;
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