search
Back to results

Rate, Rhythm or Risk Control for New-onset Supraventricular Arrhythmia During Septic Shock: a Randomized Controlled Trial (CAFS)

Primary Purpose

Supraventricular Arrhythmia, Septic Shock

Status
Recruiting
Phase
Not Applicable
Locations
France
Study Type
Interventional
Intervention
Risk control strategy
Rate control strategy:
Rhythm control strategy:
Sponsored by
Assistance Publique - Hôpitaux de Paris
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Supraventricular Arrhythmia focused on measuring New-onset supraventricular arrhythmia, Atrial fibrillation, Septic shock, Critically ill patient, Strategies, Antiarrhythmic drugs

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. Age >= 18 years

  2. Septic shock, defined by the association of the following criteria:

    • Documented or suspected infection, with initiation of antibiotic therapy
    • Initiation of vasopressors (norepinephrine, epinephrine) for at least 1 hour to maintain the MAP > 65 mmHg
  3. NOSVA with heart rate ≥ 110 bpm lasting 5 minutes or more
  4. Written informed consent (patient, next of skin or emergency situation)
  5. Affiliation to a social security system

Exclusion Criteria :

  1. Refractory shock defined by a dose of noradrenaline BASE or adrenaline BASE > 1.2 µg/kg/min
  2. Cardiac surgery or cardiac transplant in the previous month
  3. Aortic or mitral mechanical prosthesis, significant mitral stenosis (mitral surface < 1.5 cm2)
  4. Congenital heart disease other than bicuspid aortic valve, atrial defect or patent foramen ovale.
  5. History of supraventricular arrhythmia before septic shock
  6. NOSVA lasting at most 36 hrs (or 24 hrs with vasopressors)
  7. Electrical cardioversion or use of amiodarone, other antiarrhythmic, or drug inducing bradycardia (beta-blockers, bradycardic calcium channel blocker, digitalis, flécaïnamide) in the previous 6 hours before inclusion
  8. Contraindication to amiodarone: history of serious adverse event related to amiodarone, history of lung disease related to amiodarone, history of hyperthyroidism related to amiodarone, PR interval > 240 ms, severe sinus node dysfunction with no pacemaker, 2°/ 3° atrioventricular block with no pacemaker, QTc>480 ms, known or treated hyperthyroidism, hypersensitivity to iodine, amiodarone or to any of the excipients, severe hepatocellular insufficiency (prothrombin rate <20%), diffuse Interstitial Lung Disease.
  9. Kalemia < 3 mmol/L
  10. Pregnant or breast feeding women
  11. Moribund patient or death expected from underlying disease during the current admission; Patient deprived of liberty and persons subject to institutional psychiatric care
  12. Participation to another interventional trial on septic shock and/or arrhythmic disease

Sites / Locations

  • Service de Médecine Intensive Réanimation-Hôpital TenonRecruiting

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm Type

Active Comparator

Active Comparator

Active Comparator

Arm Label

Risk control strategy

Rate control strategy

Rhythm control strategy

Arm Description

Magnesium sulfate + control of the modifiable NOSVA risk factors

Risk-control + "low-dose" amiodarone

Risk-control + "high-dose" amiodarone +/- electrical cardioversion

Outcomes

Primary Outcome Measures

all-cause mortality (a hierarchical criterion)
The duration of septic shock is defined as the time (number of days) from randomization to successful weaning of vasopressors The Finkelstein-Schoenfeld method is based on the principle that each patient in the clinical trial is compared with every other patient within each stratum in a pairwise manner. The pairwise comparison proceeds in hierarchical fashion, using all-cause mortality, followed by the duration of septic shock when patients cannot be differentiated on the basis of mortality. This method gives a higher importance to all-cause mortality.
the duration of septic shock according to the Finkelstein-Schoenfeld method (a hierarchical criterion).
The duration of septic shock is defined as the time (number of days) from randomization to successful weaning of vasopressors The Finkelstein-Schoenfeld method is based on the principle that each patient in the clinical trial is compared with every other patient within each stratum in a pairwise manner. The pairwise comparison proceeds in hierarchical fashion, using all-cause mortality, followed by the duration of septic shock when patients cannot be differentiated on the basis of mortality. This method gives a higher importance to all-cause mortality.

Secondary Outcome Measures

Rhythm efficacy at day-7 (or at discharge or death if before day-7)
Number of patients with sinus rhythm Number of days alive with sinus rhythm Number of days alive with NOSVA and heart rate < 110 bpm Proportion of patients receiving therapeutic anticoagulation after randomisation
Morbimortality
Duration of septic shock and Length of stay in intensive care unit and in hospital at day-28 Proportion of patients alive free from vasopressors at day-7 (or at discharge or death if before day-7) Arterial lactate clearance at day-3 defined as the percentage of arterial lactate decrease between lactate at randomisation (day-1) and at day-3. Proportion of patients alive free from organ dysfunction at day-7 (or at discharge or death if before day-7) All-cause deaths at day-28.
Tolerance at day-7 and day-28
Proportion of patients with at least one arterial thrombotic event including ischemic stroke and non-cerebrovascular arterial thrombotic event Proportion of patients with at least one major bleeding event according to the International Society of Thrombosis and Haemostasis definition at Day-28; Proportion of patients with at least one serious adverse event related to amiodarone or to magnesium sulfate; and proportion of each type of event Proportion of patients presenting at least one serious adverse event associated with electrical cardioversion (for patients receiving electrical cardioversion).

Full Information

First Posted
February 26, 2021
Last Updated
August 22, 2022
Sponsor
Assistance Publique - Hôpitaux de Paris
search

1. Study Identification

Unique Protocol Identification Number
NCT04844801
Brief Title
Rate, Rhythm or Risk Control for New-onset Supraventricular Arrhythmia During Septic Shock: a Randomized Controlled Trial
Acronym
CAFS
Official Title
Comparison of Three Care Strategies in Cases of New-onset Supraventricular Arrhythmia During Septic Shock : a Randomized Controlled Trial
Study Type
Interventional

2. Study Status

Record Verification Date
August 2022
Overall Recruitment Status
Recruiting
Study Start Date
November 9, 2021 (Actual)
Primary Completion Date
December 2023 (Anticipated)
Study Completion Date
December 2023 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Assistance Publique - Hôpitaux de Paris

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
New-onset supraventricular arrhythmia (NOSVA) is reported in 40 % of patients with septic shock and is associated with hemodynamic alterations and mortality. The lack of consensus regarding best practices for the management of NOSVA in this setting has led to major variations in practice patterns. Observational studies reported three usual strategies: (i) heart rate control (hereafter rate control) with the use of antiarrhythmic drugs, essentially based on low dose of amiodarone, (ii) rhythm control with the use of antiarrhythmic drugs, essentially based on high dose of amiodarone, and electrical cardioversionand (iii) modifiable NOSVA risk factors control (hereafter risk control) without using antiarrhythmic drugs. Risk control would minimize adverse events of antiarrhythmic drugs. Rhythm control would rapidly improve haemodynamics via restoring diastole and decreasing cardiac metabolic demand, while minimizing exposure to anticoagulation. Rate control, would limit potential adverse events of high dose of amiodarone and of electrical cardioversion (only in patients intubated on mechanical ventilation), while controlling haemodynamics. Therefore, it seems important to compare these three strategies. Our hypothesis is dual: first, that rate control and rhythm control each improve hemodynamics with in fine a decreased mortality, as compared to a risk control; second, that rhythm control outperforms rate control in this setting. This is a multicenter, parallel-group, open-label, randomized controlled superiority trial to compare the effectiveness and safety of these three strategies (risk control, rate control and rhythm control) for NOSVA during septic shock.
Detailed Description
All consecutive adult patients admitted to the intensive care unit with NOSVA during septic shock will be included in the presence of inclusion criteria and in the absence of exclusion criteria. Randomization, performed immediately after the inclusion (Day-1), in 1:1:1 ratio will be stratified on center. Then the patient will receive the randomized strategy: risk control, rate control or rhythm control. Before inclusion, the informed consent will be proposed to the patient. If the patient is unable to give his/her consent, the informed consent of the next-of-kin will be sought by study investigator. In the case the next-of-kins are unidentified and/or unreachable, an emergency procedure will be applied. Patient consent will be sought as soon as their state of health allows it. According to clinical guidelines, patients in all groups will receive therapeutic anticoagulation if NOSVA > 48 hours and in the absence of contraindication. In all groups, recommendations for the management of septic shock will be followed. After day-7 (or hospital discharge if before J7), NOSVA treatment will be left at the discretion of attending physicians. Evaluation criteria will be collected at day-2, day-3, day-7 (or at hospital discharge if before day-7), at the day of ICU discharge and at Day-28. If the patient has been discharged before Day-28, the vital status may be obtained by phone call at Day-28.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Supraventricular Arrhythmia, Septic Shock
Keywords
New-onset supraventricular arrhythmia, Atrial fibrillation, Septic shock, Critically ill patient, Strategies, Antiarrhythmic drugs

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
240 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Risk control strategy
Arm Type
Active Comparator
Arm Description
Magnesium sulfate + control of the modifiable NOSVA risk factors
Arm Title
Rate control strategy
Arm Type
Active Comparator
Arm Description
Risk-control + "low-dose" amiodarone
Arm Title
Rhythm control strategy
Arm Type
Active Comparator
Arm Description
Risk-control + "high-dose" amiodarone +/- electrical cardioversion
Intervention Type
Procedure
Intervention Name(s)
Risk control strategy
Intervention Description
Magnesium sulfate 2g intravenous bolus over 20 mn (if creatinine clearance >30 mL/min) Control of the modifiable NOSVA risk factors: hypovolemia, sepsis, metabolic disorders (e.g., hypokalemia, hyponatremia), acidosis, hypoxia, excess cardiac inotropism of vasopressors, central venous catheter malposition, hyperthermia.
Intervention Type
Procedure
Intervention Name(s)
Rate control strategy:
Intervention Description
Risk-control as described above "Low dose" amiodarone: Intravenous bolus (day-1): 4 mg/kg over 1hr (maximum 300 mg i.e. 2 IVL vials over 1 hour ) Enteral dose maintenance (day-1 to day-7): 200mg once a day (150 mg intravenous over 1hr if enteral route is unavailable)
Intervention Type
Procedure
Intervention Name(s)
Rhythm control strategy:
Intervention Description
Risk control as described above "High dose" amiodarone: Intravenous bolus (day-1): 7 mg/kg over 1hr 1 hour (maximum 600 mg i.e. 4 IVL vials over 1 hour); followed by continuous intravenous maintenance: for a total of 1200 mg over the first 24 hrs (infusion pump) Enteral dose maintenance Day-2 and day-3: 400 mg three times a day (720 mg continuous intravenous over 24 hrs if enteral route is unavailable). Day-4 to day-7: 200 mg once a day (150 mg intravenous over 1hr if enteral route is unavailable) - Electrical cardioversion (only in patients intubated on mechanical ventilation) if: NOSVA persists after initial bolus of amiodarone AND norepinephrine base (or epinephrine base) doses > 0.3 µg/kg/min; NOSVA persists more than 6 hrs after initial amiodarone bolus.
Primary Outcome Measure Information:
Title
all-cause mortality (a hierarchical criterion)
Description
The duration of septic shock is defined as the time (number of days) from randomization to successful weaning of vasopressors The Finkelstein-Schoenfeld method is based on the principle that each patient in the clinical trial is compared with every other patient within each stratum in a pairwise manner. The pairwise comparison proceeds in hierarchical fashion, using all-cause mortality, followed by the duration of septic shock when patients cannot be differentiated on the basis of mortality. This method gives a higher importance to all-cause mortality.
Time Frame
28 days
Title
the duration of septic shock according to the Finkelstein-Schoenfeld method (a hierarchical criterion).
Description
The duration of septic shock is defined as the time (number of days) from randomization to successful weaning of vasopressors The Finkelstein-Schoenfeld method is based on the principle that each patient in the clinical trial is compared with every other patient within each stratum in a pairwise manner. The pairwise comparison proceeds in hierarchical fashion, using all-cause mortality, followed by the duration of septic shock when patients cannot be differentiated on the basis of mortality. This method gives a higher importance to all-cause mortality.
Time Frame
28 days
Secondary Outcome Measure Information:
Title
Rhythm efficacy at day-7 (or at discharge or death if before day-7)
Description
Number of patients with sinus rhythm Number of days alive with sinus rhythm Number of days alive with NOSVA and heart rate < 110 bpm Proportion of patients receiving therapeutic anticoagulation after randomisation
Time Frame
up to 7 days
Title
Morbimortality
Description
Duration of septic shock and Length of stay in intensive care unit and in hospital at day-28 Proportion of patients alive free from vasopressors at day-7 (or at discharge or death if before day-7) Arterial lactate clearance at day-3 defined as the percentage of arterial lactate decrease between lactate at randomisation (day-1) and at day-3. Proportion of patients alive free from organ dysfunction at day-7 (or at discharge or death if before day-7) All-cause deaths at day-28.
Time Frame
Day 28
Title
Tolerance at day-7 and day-28
Description
Proportion of patients with at least one arterial thrombotic event including ischemic stroke and non-cerebrovascular arterial thrombotic event Proportion of patients with at least one major bleeding event according to the International Society of Thrombosis and Haemostasis definition at Day-28; Proportion of patients with at least one serious adverse event related to amiodarone or to magnesium sulfate; and proportion of each type of event Proportion of patients presenting at least one serious adverse event associated with electrical cardioversion (for patients receiving electrical cardioversion).
Time Frame
Day 7 and day 28

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Age >= 18 years Septic shock, defined by the association of the following criteria: Documented or suspected infection, with initiation of antibiotic therapy Initiation of vasopressors (norepinephrine, epinephrine) for at least 1 hour to maintain the MAP > 65 mmHg NOSVA with heart rate ≥ 110 bpm lasting 5 minutes or more Written informed consent (patient, next of skin or emergency situation) Affiliation to a social security system Exclusion Criteria : Refractory shock defined by a dose of noradrenaline BASE or adrenaline BASE > 1.2 µg/kg/min Cardiac surgery or cardiac transplant in the previous month Aortic or mitral mechanical prosthesis, significant mitral stenosis (mitral surface < 1.5 cm2) Congenital heart disease other than bicuspid aortic valve, atrial defect or patent foramen ovale. History of supraventricular arrhythmia before septic shock NOSVA lasting at most 36 hrs (or 24 hrs with vasopressors) Electrical cardioversion or use of amiodarone, other antiarrhythmic, or drug inducing bradycardia (beta-blockers, bradycardic calcium channel blocker, digitalis, flécaïnamide) in the previous 6 hours before inclusion Contraindication to amiodarone: history of serious adverse event related to amiodarone, history of lung disease related to amiodarone, history of hyperthyroidism related to amiodarone, PR interval > 240 ms, severe sinus node dysfunction with no pacemaker, 2°/ 3° atrioventricular block with no pacemaker, QTc>480 ms, known or treated hyperthyroidism, hypersensitivity to iodine, amiodarone or to any of the excipients, severe hepatocellular insufficiency (prothrombin rate <20%), diffuse Interstitial Lung Disease. Kalemia < 3 mmol/L Pregnant or breast feeding women Moribund patient or death expected from underlying disease during the current admission; Patient deprived of liberty and persons subject to institutional psychiatric care Participation to another interventional trial on septic shock and/or arrhythmic disease
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Vincent LABBE, MD
Phone
01 56 01 69 37
Email
vincent.labbe@aphp.fr
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Vincent LABBE, MD
Organizational Affiliation
Assistance Publique - Hôpitaux de Paris
Official's Role
Principal Investigator
Facility Information:
Facility Name
Service de Médecine Intensive Réanimation-Hôpital Tenon
City
Paris
ZIP/Postal Code
75020
Country
France
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Vincent LABEE, MD
Phone
01 56 01 69 37
Email
vincent.labbe@aphp.fr
First Name & Middle Initial & Last Name & Degree
Armand Mekontso-Dessap, Professor
Phone
0149812389
Email
armand.dessap@aphp.fr

12. IPD Sharing Statement

Plan to Share IPD
Undecided

Learn more about this trial

Rate, Rhythm or Risk Control for New-onset Supraventricular Arrhythmia During Septic Shock: a Randomized Controlled Trial

We'll reach out to this number within 24 hrs