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Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis
  1. Matt Wilkinson-Stokes1,2,
  2. Jason Betson2,
  3. Simon Sawyer3
  1. 1Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
  2. 2Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
  3. 3Faculty of Health, Griffith University, Southport, Queensland, Australia
  1. Correspondence to Matt Wilkinson-Stokes, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia; matt.wilkinson-stokes{at}outlook.com

Abstract

Background The current guidelines of the American Heart Association (AHA) and European Society of Cardiology (ESC) recommend that when right ventricular myocardial infarction (RVMI) is present patients are not administered nitrates, due to the risk that decreasing preload in the setting of already compromised right ventricular ejection fraction may reduce cardiac output and precipitate hypotension. The cohort study (n=40) underlying this recommendation was recently challenged by new studies suitable for meta-analysis (cumulatively, n=1050), suggesting that this topic merits systematic review.

Methods The protocol was registered on PROSPERO and published in Evidence Synthesis. Six databases were systematically searched in May 2022: PubMed, Embase, MEDLINE Complete, Cochrane CENTRAL Register, CINAHL and Google Scholar. Two investigators independently assessed for quality and bias and extracted data using Joanna Briggs Institute tools and methods. Risk ratios and 95% CIs were calculated, and meta-analysis performed using the random effects inverse variance method.

Results Five studies (n=1113) were suitable. Outcomes included haemodynamics, GCS, syncope, arrest and death. Arrest and death did not occur in the RVMI group. Meta-analysis was possible for sublingual nitroglycerin 400 μg (2 studies, n=1050) and found no statistically significant difference in relative risk to combined inferior and RVMI at 1.31 (95% CI 0.81 to 2.12, p=0.27), with an absolute effect of 3 additional adverse events per 100 treatments. Results remained robust under sensitivity analysis.

Conclusions This review suggests that the AHA and ESC contraindications are not supported by evidence. Key limitations include all studies having concomitant inferior and RVMI, not evaluating beneficial effects and very low certainty of evidence. As adverse events are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence.

PROSPERO registration number CRD42020172839.

  • acute myocardial infarct
  • analgesia
  • safety

Data availability statement

Primary data are available in public, open access repository. Synthesised data are available on reasonable request. All data are publicly available, and able to be produced on request.

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Data availability statement

Primary data are available in public, open access repository. Synthesised data are available on reasonable request. All data are publicly available, and able to be produced on request.

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Footnotes

  • Handling editor Edward Carlton

  • Twitter @JasonBetson

  • Contributors All authors have contributed to the ideas, writing and final review of the manuscript. All authors have read and approve of this version of the manuscript and its submission to the journal. MW-S acts as guarantor.

  • Funding MW-S received a faculty funding grant from Australian Catholic University to support this research. Funding was determined independently of the review process and no individuals in either group were involved with or report to each other.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • 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.