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Arrhythmias and sudden death
Original research
Bayesian analysis of amiodarone or lidocaine versus placebo for out-of-hospital cardiac arrest
  1. Daniel J Lane1,
  2. Brian Grunau1,2,
  3. Peter Kudenchuk3,
  4. Paul Dorian4,
  5. Henry E Wang5,
  6. Mohamud R Daya6,
  7. Joshua Lupton6,
  8. Christian Vaillancourt7,8,
  9. Masashi Okubo9,
  10. Daniel Davis10,
  11. Thomas Rea11,
  12. Demetris Yannopoulos12,
  13. Jim Christenson1,2,
  14. Frank Scheuermeyer1,2
  1. 1 Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
  2. 2 Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
  3. 3 Department of Medicine, Division of Cardiology, Arrhythmia Services, University of Washington, Seattle, Washington, USA
  4. 4 Department of Medicine, Division of Cardiology, Unity Health Toronto, Toronto, Ontario, Canada
  5. 5 Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
  6. 6 Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
  7. 7 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
  8. 8 Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  9. 9 Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  10. 10 Department of Emergency Medicine, University of California San Diego, La Jolla, California, USA
  11. 11 Department of General Internal Medicine, University of Washington, Seattle, Washington, USA
  12. 12 Center for Resuscitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Daniel J Lane, Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, Canada; djlane{at}ucalgary.ca

Abstract

Objective Clinical trials for patients with shock-refractory out-of-hospital cardiac arrest (OHCA), including the Amiodarone, Lidocaine or Placebo (ALPS) trial, have been unable to demonstrate definitive benefit after treatment with antiarrhythmic drugs. A Bayesian approach, combining the available evidence, may yield additional insights.

Methods We conducted a reanalysis of the ALPS trial comparing treatment with amiodarone or lidocaine with placebo in patients with OHCA following shock-refractory ventricular fibrillation or ventricular tachycardia (VF/VT). We used Bayesian regression to assess the probability of improved survival or improved neurological outcome on the 7-point modified Rankin Scale. We derived weak, moderate and strong priors from a previous clinical trial.

Results The original ALPS trial randomised 3026 adult patients with OHCA to amiodarone (n=974, survival to hospital discharge 24.4%), lidocaine, (n=993, survival 23.7%) or placebo (n=1059, survival 21.0%). In our reanalysis the probability of improved survival from amiodarone ranged from 83% (strong prior) to 95% (weak prior) compared with placebo and from 78% (strong) to 90% (weak) for lidocaine—an estimated improvement in survival of 2.9% (IQR 1.4%–3.8%) for amiodarone and 1.7% (IQR 0.84%–3.2%) for lidocaine over placebo (moderate prior). The probability of improved neurological outcome from amiodarone ranged from 96% (weak) to 99% (strong) compared with placebo and from 88% (weak) to 96% (strong) for lidocaine.

Conclusions In a Bayesian reanalysis of patients with shock-resistant VF/VT OHCA, treatment with amiodarone had high probabilities of improved survival and neurological outcome, while treatment with lidocaine had a more modest benefit.

  • cardiac arrest
  • arrhythmias, cardiac
  • ventricular fibrillation
  • tachycardia, ventricular
  • epidemiology

Data availability statement

Data are available upon reasonable request. Data may be requested from the Resuscitation Outcomes Consortium (ROC) investigators.

https://doi.org/10.1136/heartjnl-2021-320513

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    Data availability statement

    Data are available upon reasonable request. Data may be requested from the Resuscitation Outcomes Consortium (ROC) investigators.

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    Footnotes

    • Contributors FS and BG conceived the study. BG obtained data from the original trial, while all coauthors contributed individual site data. DJL designed and conducted the analysis and is the guarantor of the work. DJL and FS wrote the initial manuscript. All coauthors contributed to the review of the results and extensive revision of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.