REVIEW

CURRENT
OPINION Antiarrhythmic drug therapy during
cardiopulmonary resuscitation: should we use it?
Jasmeet Soar

Purpose of review
The optimal antiarrhythmic drug therapy (amiodarone or lidocaine) in the treatment of ventricular
fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest that is refractory to defibrillation is
uncertain. This article reviews the evidence for and against these drugs, alternatives treatments for
refractory VF/pVT and aims to define the role of antiarrhythmic drugs during cardiopulmonary
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resuscitation (CPR).
Recent findings
A large randomized controlled trial that compared amiodarone, lidocaine and saline 0.9% sodium
chloride for the treatment of refractory VF/pVT out-of-hospital cardiac arrest reported no difference in
survival to hospital discharge or neurological outcome. In patients with witnessed arrest, survival was
improved with antiarrhythmic drugs compared to saline.
Summary
The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and
defibrillation attempts fail and the antiarrhythmic drug is given early. There does not appear to be any
clear survival benefit for any one particular drug and other factors such as availability and cost should be
considered when deciding which drug to use. Furthermore, other interventions (e.g. percutaneous coronary
intervention and extra-corporeal CPR) may provide additional survival benefit when defibrillation attempts
and antiarrhythmic drugs are not effective.
Keywords
amiodarone, cardiac arrest, lidocaine, nifekalant

INTRODUCTION Heart Association Get With The Guidelines Registry

Antiarrhythmic drugs are currently recommended
for the treatment of cardiac arrest with a shockable
rhythm [ventricular fibrillation or pulseless ventric-
ular tachycardia (VF/pVT)] that is refractory to car-
of in-hospital cardiac arrest (IHCA) show that about
25% of patients receive an antiarrhythmic drug dur-
ing CPR [7]. A large recent randomized controlled
trial (RCT) has provided us with further information
&&

diopulmonary resuscitation (CPR) and defibrillation
attempts. This is based on evidence for improved
short-term outcomes and an unproven benefit in
survival to hospital discharge [1–4]. An initial cardiac
arrest rhythm of VF/pVT is a strong predictor of
survival after cardiac arrest as long as there is early
defibrillation and the chances of survival decrease
with each additional defibrillation attempt as well as
&&
over time [5 ]. A drug intervention that can help
improve survival after initial shock attempts have
failed is therefore of potential value. The most com-
monly used drugs are amiodarone and lidocaine,
with nifekalant also being used in Japan. Only a small
proportion of all cardiac arrests are given an antiar-
rhythmic drug during CPR. In a large study of out-of-
hospital (OHCA), about 6% of all cases received an
antiarrhythmic drug [6], and data from the American
on the role of antiarrhythmic drugs during CPR [8 ].
THE RESUSCITATION OUTCOMES
CONSORTIUM AMIODARONE, LIDOCAINE,
PLACEBO STUDY
The North American Resuscitation Outcomes Consor-
tium (ROC) Amiodarone, Lidocaine, Placebo Study
(ALPS) compared amiodarone 300 mg, lidocaine
120 mg and saline placebo in adults with nontraumatic
Southmead Hospital, North Bristol NHS Trust, Bristol, UK
Correspondence to Jasmeet Soar, Consultant in Intensive Care Medi-
cine, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB,
UK. Tel: +44 117 414 5114; e-mail: Jasmeet.soar@nbt.nhs.uk
Curr Opin Crit Care 2018, 24:138–142
DOI:10.1097/MCC.0000000000000498

www.co-criticalcare.com Volume 24  Number 3  June 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Antiarrhythmic drugs still have a role in the treatment of
shock refractory VF/pVT.
 The drugs improve survival to hospital discharge when
given early after the onset of cardiac arrest.
 Amiodarone and lidocaine are similar in terms
of outcomes.
 When defibrillation attempts and antiarrhythmic drugs
are not effective during CPR, other interventions such as
PCI and extracorporeal life support should
be considered.
VF/pVT OHCA that was refractory to at least one
defibrillation attempt (ClinicalTrials.gov number
&&
NCT01401647) [8 ].
An important design feature was the choice of
Nexterone as the formulation of amiodarone used,
and the choice of saline (0.9% sodium chloride) for
the placebo group. The Nexterone amiodarone for-
mulation uses the diluent Captisol (a sulfobutyl ether
b-cyclodextrin) which has no effects on the heart. It
does not contain polysorbate 80 which is found in the
most commonly used formulation of amiodarone, is
viscous (making blinding difficult) and causes hypo-
tension [9,10]. The Nexterone formulation helped
avoid the issues of interpreting the two previous large
studies of antiarrhythmic drugs in cardiac arrest. In
the 1999 reported RCT of amiodarone versus placebo
for VF/pVT OHCA refractory to three defibrillation
attempts, amiodarone improved survival to hospital
admission [11]. The placebo group in this study was
polysorbate 80. In the 2002 reported RCT of amio-
darone versus lidocaine for VF/pVT OHCA refractory
to four defibrillation attempts, amiodarone increased
survival to hospital admission compared with lido-
caine [12]. In this study, polysorbate 80 was added to
the lidocaine so that both the amiodarone and lido-
caine preparations had the same viscous properties.
The 1999 and 2002 RCTs led to amiodarone being
recommended as preferable to lidocaine in guide-
lines, despite a strong possibility that the use of
polysorbate 80 had an adverse effect in the compara-
tor groups in both studies [13].
&&
In all the large RCTs [8 ,11,12] to date and as
recommended in current guidelines, patients were
usually given adrenaline (epinephrine) prior to
receiving the antiarrhythmic drug. Animal studies
suggest that amiodarone decreases coronary perfu-
sion pressure and that this effect is prevented when
adrenaline is also given [14]. Adrenaline increases
the rate of return of spontaneous circulation (ROSC)
after cardiac arrest, but whether it is beneficial or
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Antiarrhythmic drug therapy Soar
harmful in terms of longer term outcomes is uncer-
tain. The role of adrenaline is the subject of a large
RCT that has completed recruitment but has not yet
&
reported its findings [15 ]. The interpretation of the
effect of any antiarrhythmic drug during CPR there-
fore needs to factor in whether adrenaline was or
was not given.
The ROC ALPS RCT randomized 3026 patients to
amiodarone (974), lidocaine (993) or placebo (1059)
and 24.4, 23.7 and 21.0%, respectively, survived to
hospital discharge with no statistical difference
between groups. There was also no difference in
neurological outcome defined as a modified Rankin
scale score at discharge of less than three (18.8, 17.5
and 16.6%, respectively). Amiodarone and lidocaine
did significantly improve survival to discharge for
bystander witnessed arrests compared to placebo
(amiodarone 27.7%, lidocaine 27.8% and placebo
22.7%), decreased the number of shocks required to
terminate VF/pVT and increased the rate of ROSC by
hospital arrival. For emergency medical service
(EMS), witnessed arrest survival to discharge was
38.6% (amiodarone) vs. 23.3% (lidocaine) vs.
16.7% (placebo), with a significant difference
between amiodarone and placebo.
A short collapse to drug interval led to increased
survival to hospital discharge and suggests that
these drugs like most CPR interventions have a time
&
dependent effect – earlier is better [16 ]. The likely
reason for no overall benefit for amiodarone and
lidocaine was that they were given far too late – a
mean (SD) of 19.3  7.4 min after the initial EMS
call and after a median of three shocks. This is at a
stage of cardiac arrest when survival is already poor,
and for unwitnessed cardiac arrests the interval
between collapsed and treatment was probably
excessively long. In addition, the study was under-
powered to show any benefit of the study drugs at
this stage. The study had 90% power to detect an
absolute difference of 6.3% in survival to hospital
discharge between the amiodarone and the placebo
groups. The authors state that if amiodarone had a
3% beneficial treatment effect (the size of the differ-
ence for the primary outcome), a study of 9000
patients would be needed to detect this with 90%
power. This size of difference equates to about 1800
extra cardiac arrest survivors in North America
each year.
SYSTEMATIC REVIEWS AND META-
ANALYSES OF ANTIARRHYTHMIC DRUGS
DURING CARDIOPULMONARY
RESUSCITATION
Following the publication of ROC ALPS, there have
been a number of meta-analyses and systematic
www.co-criticalcare.com 139
Cardiopulmonary resuscitation
reviews such that the number of these reviews
exceeds the number of large RCTs. Sanfilippo
&&
et al. [17 ] identified the three RCTs referred to
&&
above [8 ,11,12] and concluded that ‘amiodarone
and lidocaine equally improve survival at hospital
admission as compared with placebo. However, nei-
ther amiodarone nor lidocaine improve long-term
outcome’. The systematic review and meta-analysis
by Laina et al. [18] identified an additional small
RCT [19] from Japan that compared amiodarone
with nifekalant. They concluded that ‘amiodarone
significantly improves survival to hospital admis-
sion. However, there is no benefit of amiodarone in
survival to discharge or neurological outcomes com-
pared to placebo or other antiarrhythmics’. Nifeka-
lant is a pure potassium channel blocker that is used
in Japan. A systematic review and meta-analysis of
the effects of nifekalant (based on two small RCTS
and 11 non-RCTs) concluded that it ‘may be effec-
tive for short-term and long-term survival in shock-
& &
resistant VF/pVT patients’ [20 ]. The review by
Chowdhury et al. [21] differed in that it did not
report any improvement in short-term outcomes
stating that ‘there has been no conclusive evidence
that any antiarrhythmic agents improve rates of
ROSC, survival to admission, survival to discharge
or neurological outcomes’. Finally, a systematic
review and network meta-analysis (NMA) compar-
ing amiodarone, lidocaine, magnesium, bretylium,
sotalol and placebo identified eight RCTs with a
&&
combined total of 4464 patients [22 ]. This study
concluded that for ‘OHCA, amiodarone and lido-
caine were both associated with improved survival
to hospital admission in the NMA, although no
antiarrhythmic was convincingly superior to any
other. However, for the outcomes most important
to patients, survival to hospital discharge and neu-
rologically intact survival, no antiarrhythmic was
convincingly superior to any other agent or pla-
cebo’. This review reported the median time from
initial emergency call to first dose of study drug was
23 min – for unwitnessed cardiac arrests, this sug-
gests a greater than 23-min interval between the
cardiac arrest and drug interventions and could
explain the lack of effectiveness.
ROLE OF ANTIARRHYTHMIC DRUGS
WHEN THE INITIAL RHYTHM IS
NONSHOCKABLE
When the initial cardiac arrest rhythm is nonshock-
able (asystole or pulseless electrical activity), the
rhythm changes to a shockable rhythm during
CPR in up to a quarter of cases [23]. When this
occurs, the precise role of antiarrhythmic drugs is
uncertain, although current guidelines recommend
140 www.co-criticalcare.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
an antiarrhythmic is used in this scenario [1,4]. A
separate analysis by the ROC ALPS group random-
ized 1063 patients with an initial nonshockable
rhythm who then developed shock-refractory VF/
&&
pVT during CPR [24 ]. Survival to discharge was not
significant between groups (amiodarone 4.1%, lido-
caine 3.1% and placebo1.9%, P ¼ 0.24) although the
study was underpowered to detect any difference in
outcome between groups.
INTRAVENOUS VERSUS INTRAOSSEOUS
ROUTE FOR ANTIARRHYTHMIC DRUGS
Retrospective observational data comparing 1525
individuals treated intravenously with 275 treated
via the tibial intraosseous route reported that intra-
osseous-treated patients tended to be younger,
female, with an unwitnessed OHCA of noncardiac
cause of cardiac arrest, with nonshockable rhythm
and less likely to survive to hospital discharge (14.9
vs. 22.8%, P ¼ 0.003) [25 ]. After multivariate risk
adjustment, an association remained for lower
ROSC [odds ratio (OR) ¼ 0.67, 95% confidence
intervals (CIs) 0.50, 0.88, P ¼ 0.004] and survival
to hospital admission (OR ¼ 0.68, 95% CI 0.51,
0.91, P ¼ 0.009). This study did not look at alterna-
tive sites for intraosseous access (humerus and ster-
num) but it could be that those with difficult IV
access are also more difficult to resuscitate.
WHAT ABOUT IN-HOSPITAL CARDIAC
ARREST?
There are no RCTs looking at the use of antiarrhyth-
mic drugs for IHCA. Current guidelines are based on
extrapolation of findings from OHCA studies. Inter-
ventions tend to be much earlier after IHCA and
extrapolating from the ROC ALPS finding that early
antiarrhythmic drug use leads to improved survival,
and the continued use of these drugs after shock
refractory VF/pVT IHCA appears reasonable.
AMIODARONE OR LIDOCAINE?
Amiodarone is currently the preferred drug in resus-
citation guidelines based on evidence from older
studies prior to ROC ALPS [1–3]. There are several
reasons for considering lidocaine, however. First,
there is no compelling evidence that amiodarone
is more effective than lidocaine. Second, lidocaine is
less costly and more widely available and easier to
administer than the commonly used viscous amio-
darone formulation that contains polysorbate 80.
Third, the newer polysorbate 80-free formulation
(Nexterone) is relatively expensive and currently
not widely available for use.
Volume 24  Number 3  June 2018

WHEN DEFIBRILLATION AND
ANTIARRHYTHMIC ARE NOT EFFECTIVE:
OTHER INTERVENTIONS FOR SHOCK
REFRACTORY VENTRICULAR
FIBRILLATION OR PULSELESS
VENTRICULAR TACHYCARDIA
Two studies of patients treated with extra-corporeal
CPR (eCPR) suggest that patients with ongoing
refractory VF/pVT tend to have double or triple
vessel coronary artery disease (CAD) with more
proximal lesions, and this may explain why defibril-
lation attempts and antiarrhythmic drugs are not
effective. Addressing the underlying cause (coronary
artery occlusion) may be required before ROSC can
be achieved. In a single-centre French study, 54 out
of 74 patients with refractory OHCA treated with
eCPR had CAD [26]. Both animal and human studies
suggest that patients with CAD, and ongoing refrac-
tory VF/pVT would benefit from an approach that
includes eCPR and percutaneous coronary angiog-
& intubation during adult in-hospital cardiac arrest and survival. JAMA 2017;
raphy (PCI) [27,28,29 ]. In a single-centre observa-
tional study of eCPR and PCI in patients with
refractory VF/pVT, most had significant CAD, and
26 (42%) of 62 patients were discharged from hos-
& when antiarrhythmic drugs were given in witnessed cardiac arrests.
pital with a good neurological outcome [29 ].
CONCLUSION
We should continue to use antiarrhythmic drugs
during CPR for shock refractory VF/pVT. The benefit
of antiarrhythmic drugs appears to be for those
patients in whom initial early CPR and defibrillation
attempts fail and the antiarrhythmic drug is given
early. There does not appear to be any clear survival
benefit for any one particular drug and other factors
such as availability and cost should be considered
when deciding which drug to use. Furthermore,
interventions such as percutaneous coronary inter-
vention and eCPR may provide additional survival
benefit when defibrillation attempts and antiar-
rhythmic drugs are not effective.
Acknowledgements
None.
Financial support and sponsorship
J.S. is paid an honorarium as editor for the journal
Resuscitation.
Conflicts of interest
J.S. is chair of the International Liaison Committee on
Resuscitation Advanced Life Support (ALS) Task Force.
He is co-chair of the European Resuscitation Council ALS
Science and Education Committee. J.S. chairs the Resus-
citation Council (UK) ALS Subcommittee.
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Antiarrhythmic drug therapy Soar
REFERENCES AND RECOMMENDED
READING
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& of special interest
&& of outstanding interest
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This systematic review looks specifically at the role of nifekalant, a drug commonly
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142 www.co-criticalcare.com
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25. Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to
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‘hyperinvasive approach’ is clearly feasible but currently only available in specialist
settings.
Volume 24  Number 3  June 2018