Best of heart failure

59 management of t making. The patie compassionate bas benefits and side e their parents. 2 Methods We evaluated pa institution for who February 2008 to pharmacy databas starting the medi POTS was specifi heart rate increase 120 bpm within t with symptoms significant orthost age at commence up-titration, reaso treatment, medica medications with worsening of sym and at follow-up cardiogram (EKG dine and at follo 2.1 Statistical An Normally distribut and standard devi were described w pendent t test was nificant level was Table 1 Demographi clinician’s stated indi starting ivabradine 60 for POTS were evaluated. Animal studies and articles written in languages other than English were excluded. The titles and abstracts of the search results were first screened for possible inclusion. The full texts of these reports were then reviewed to determine final eligibility for inclusion in the systematic review. Authors (MEG and AKW) indepen- dently performed the literature review and study selection. Any disagreements were resolved by a third author (JNB). 2.3 Data Extraction Authors, publication date, study design, study location, patient demographics, ivabradine treatment dose and dura- tion, prior medication use for treatment of POTS, con- comitant medication treatment regimens, clinical outcomes including subjective (improvement of symptoms) and objective (change in HR) measures, and ivabradine-related adverse drug events were extracted from each included study using a standardized data extraction process. 3 Results 3.1 Study Selection Figure 1 describes the literature search. Initially, 73 articles were identified. After screening titles and abstracts and removing dup reviewed to consisted of t spective cohor use for POTS summary of i studies, and c 3.2 Literatur Barzilai and single-dose, patients with [ 13 ]. Orthosta of at least 30 more than 2 during a hea rences. Patien nancy, uncont history of syst function. Eig recruited wit 31 ± 3 years, duration of P participants taking propra ticipants were MEDLINE (n=19) Records after dup removed (n=6 Titles and abstracts (n=61) Full text articles ass eligibility (n=4 Articles include qualitative analysis Identi�ication Screening Eligibility Included Fig. 1 Flow diagram for reference search and selection of articles for analysis Ivabradine for the Treatment of Postural Orthostatic Tachycardia Syndrome ivabradine use in large, randomized controlled trials of ivabradine for heart failure with reduced ejection fraction and stable coronary artery disease with angina [ 27 , 28 ]. In the studies reviewed, ivabradine was well tolerated and the most common reported side effects were mild in nature, including dizziness, nausea, headache, fatigue, and phos- phenes. Of the 124 patients with POTS treated with mul- tiple doses of ivabradine, only five patients (4%) discontinued ivabradine because of an adverse outcome: three due to side effects (one dizziness, one increased fatigue, one unknown), one due to allergic reaction, and one due to clinical worsening (pediatric patient) [ 11 , 14 , 15 , 18 ]. However, an additional 13 patients (10.5%) did discontinue therapy due to lack of response to treatment [ 11 , 14 , 15 ]. Also, one patient (0.8%) stopped after finding an alternative treatment, one patient (0.8%) stopped due to pregnancy, and two patients (1.6%) stopped because of insurance coverage [ 11 , 14 , 16 ]. Notably, 16 patients (12.9%) discontinued therapy in the setting of clinical improvement [ 11 , 14 – 16 , 18 ]. Fifteen patients (12%) reported visual changes including phosphenes, but none discontinued ivabradine based on this [ 11 , 14 – 16 , 20 ]. Considering its unique mechanism of action, if patients are unable to tolerate alternate therapies for POTS because of adverse reactions such as dizziness or fatigue secondary to hypotension or CNS depression, ivabradine appears to be a viable therapy to consider. This analysis has several limitations to consider, including the review of studies and cases with small sample sizes or that present data only from an individual practice site. Additionally, when examining case reports, there is an inherent selection bias, in which unsuccessful trials with ivabradine may not have been brought forth for publica- tion. In addition, the included case reports were generally heterogeneous and imprecise in the clinical detail provided and the quality of evidence available for critical review. In regards to the open-label trials, one of the two included 16 patients who experienced fluctuation in BP, which is not consistent with the diagnostic criteria for POTS [ 14 ]. Furthermore, the utilization of patients’ self-assessment of symptomatic improvement without consistent measure- ment of objective outcomes limits interpretation and Establi h diagnosis of postural or h static tachycardia syndrome (POTS) Via tilt table te or 10 min stand test Nonpharmacologic Treatment Stop contributing m dications, increase �luids to 2-3L/day and salt to 10-12g/day, compression stockings, aerobic reconditioning and aerobic exercise Asymptomatic tachyc rdia Consider Inappropriate Sinus Tachycardia (IST) Refer to an electrophysiolgist for further management Symptomatic tachycardia Add pharmcologic treatment per 2015 HRS Expert Consensus Statement [3] Insuf�icient response to treatment Add on ivabradine Initial Dosing: 2.5 mg once or twice daily Reasonabe to titrate up to 20 mg per day, but mean maintenance dose studied was 9 mg per day Monitoring: visual effects, dizziness, nausea, headache, fatigue Treatment intolerance Change to ivabradine Fig. 2 Recommendations for the treatment of postural orthostatic tachycardia syndrome. HRS Heart Rhythm Society 202 M. E. 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