Intravenous Diltiazem or Metoprolol Administration in the Emergency Department for Acute Rate Control of Atrial Fibrillation Patients with Rapid Ventricular Response with Unknown Ejection Fraction
Abstract
Aim: Atrial fibrillation (AF) is the most widespread persistent cardiac arrhythmia in adults. There is no standard procedure applied in AF patients with rapid ventricular response with unknown ejection fraction (EF) in the emergency department. This study aimed to compare the effectiveness and side effects of diltiazem and metoprolol treatments without knowing the EF in AF patients with rapid ventricular response in the emergency department.
Material and Methods: Patients with a ventricular response ≥110/min were selected as having AF with rapid ventricular response. The patients first received 25 mg intravenous diltiazem as a rate control drug were compared with those first received 5 mg metoprolol. A total of 50 patients whose EF were not registered before the admission date and was measured after being consulted for cardiology following acute rate control in emergency department were included in this study.
Results: For the first drug treatment, diltiazem was given to 56% (n=28) of the patients and metoprolol to 44% (n=22). Moreover, 44% (n=22) of the patients needed a second drug infusion. The proportion of patients received diltiazem in those with preserved EF was significantly higher than those with reduced EF (p=0.032). No statistically significant difference was found between the rates of needing a second administration based on the EF (p=0.157).
Conclusion: Diltiazem was found to reduce heart rate earlier than metoprolol. While updating the guidelines for drug selection in acute rate control of AF with rapid ventricular response, rural emergency departments, where EF measurement cannot be achieved, should also be considered.
Keywords
atrial fibrillation diltiazem ejection fraction emergency department metoprolol rapid ventricular response
References
- Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498.
- Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: A report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
- Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-47.
- Vandermolen JL, Sadaf MI, Gehi AK. Management and disposition of atrial fibrillation in the emergency department: A systematic review. J Atr Fibrillation. 2018;11(1):1810.
- Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, et al. Rate-and rhythm-control therapies in patients with atrial fibrillation: a systematic review. Ann Intern Med. 2014;160(11):760-73.
- Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-33.
- Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol. 2020;36(12):1847-948.
- January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-76.
- Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-2200.
- Masip J, Gayà M, Páez J, Betbesé A, Vecilla F, Manresa R, et al. Pulse oximetry in the diagnosis of acute heart failure. Rev Esp Cardiol (Engl Ed). 2012;65(10):879-84.
- Valk MJ, Mosterd A, Broekhuizen BD, Zuithoff NP, Landman MA, Hoes AW, et al. Overdiagnosis of heart failure in primary care: a cross-sectional study. Br J Gen Pract. 2016;66(649):e587-92.
- Hines MC, Reed BN, Ivaturi V, Bontempo LJ, Bond MC, Hayes BD. Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department. Am J Health Syst Pharm. 2016;73(24):2068-76.
- Demircan C, Cikriklar HI, Engindeniz Z, Cebicci H, Atar N, Guler V, et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J. 2005;22(6):411-4.
- Memiş MB, Rohat A, Öztürk TC, Özge O, Özgür O. Which one is the first choice for rapid ventricular rate atrial fibrillation in emergency department: Metoprolol or Diltiazem? A randomized clinical trial. J Surg Med. 2019;3(1):13-7.
- Martindale JL, deSouza IS, Silverberg M, Freedman J, Sinert R. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med. 2015;22(3):150-4.
- Liu F, Chen Y, Feng X, Teng Z, Yuan Y, Bin J. Effects of beta-blockers on heart failure with preserved ejection fraction: a meta-analysis. PloS One. 2014;9(3):e90555.
- Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, et al. Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet. 2014;384(9961):2235-43.
- Atzema CL, Austin PC. Rate control with beta‐blockers versus calcium channel blockers in the emergency setting: Predictors of medication class choice and associated hospitalization. Acad Emerg Med. 2017;24(11):1334-48.
Acil Serviste Ejeksiyon Fraksiyonu Bilinmeyen Hızlı Ventriküler Yanıtlı Atriyal Fibrilasyon Hastalarının Akut Hız Kontrolünde İntravenöz Diltiazem veya Metoprolol Uygulaması
Abstract
Amaç: Atriyal fibrilasyon (AF) erişkinlerdeki en yaygın inatçı kardiyak aritmidir. Acil serviste, ejeksiyon fraksiyonu (EF) bilinmeyen hızlı ventrikül yanıtlı AF hastalarında uygulanan standart bir tedavi prosedürü yoktur. Bu çalışmanın amacı acil serviste EF'si bilinmeyen hızlı ventrikül yanıtlı AF hastalarında diltiazem ve metoprolol tedavilerinin etkinliğinin ve yan etkilerinin karşılaştırılmasıdır.
Gereç ve Yöntemler: Ventriküler yanıtı ≥110/dk olan hastalar, hızlı ventrikül yanıtlı AF olarak kabul edildi. Hız kontrolünde ilk ilaç olarak 25 mg intravenöz diltiazem almış olan hastalar, ilk ilaç olarak 5 mg metoprolol almış olanlar ile karşılaştırıldı. Başvuru tarihinden önce EF değeri kaydedilmemiş olan ve acil serviste akut hız kontrolünü takiben kardiyoloji bölümüne konsülte edildikten sonra ölçülen toplam 50 hasta bu çalışmaya dahil edildi.
Bulgular: İlk ilaç tedavisi olarak hastaların %56 (n=28)'sına diltiazem ve %44 (n=22)'üne metoprolol verilmişti. İkinci bir ilaç tedavisine ihtiyaç duyan hastaların oranı ise %44 (n=22) idi. EF korunmuş olanlarda diltiazem alan hastaların oranı, EF azalmış olanlara göre anlamlı derecede daha yüksek idi (p=0.032). Hastaların EF’sine göre ikinci bir uygulama ihtiyacı olma oranları arasında istatistiksel olarak anlamlı bir fark bulunmadı (p=0.157).
Sonuç: Diltiazemin kalp atım hızını metoprolole göre daha erken düşürdüğü görüldü. Hızlı ventrikül yanıtlı AF’nin akut hız kontrolünde ilaç seçimi için kılavuzlar güncellenirken, EF ölçümünün elde edilemediği kırsal acil servisler de göz önünde bulundurulmalıdır.
Keywords
atriyal fibrilasyon diltiazem ejeksiyon fraksiyonu acil servis metoprolol hızlı ventriküler yanıt
References
- Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498.
- Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: A report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
- Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-47.
- Vandermolen JL, Sadaf MI, Gehi AK. Management and disposition of atrial fibrillation in the emergency department: A systematic review. J Atr Fibrillation. 2018;11(1):1810.
- Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, et al. Rate-and rhythm-control therapies in patients with atrial fibrillation: a systematic review. Ann Intern Med. 2014;160(11):760-73.
- Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-33.
- Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol. 2020;36(12):1847-948.
- January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-76.
- Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-2200.
- Masip J, Gayà M, Páez J, Betbesé A, Vecilla F, Manresa R, et al. Pulse oximetry in the diagnosis of acute heart failure. Rev Esp Cardiol (Engl Ed). 2012;65(10):879-84.
- Valk MJ, Mosterd A, Broekhuizen BD, Zuithoff NP, Landman MA, Hoes AW, et al. Overdiagnosis of heart failure in primary care: a cross-sectional study. Br J Gen Pract. 2016;66(649):e587-92.
- Hines MC, Reed BN, Ivaturi V, Bontempo LJ, Bond MC, Hayes BD. Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department. Am J Health Syst Pharm. 2016;73(24):2068-76.
- Demircan C, Cikriklar HI, Engindeniz Z, Cebicci H, Atar N, Guler V, et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J. 2005;22(6):411-4.
- Memiş MB, Rohat A, Öztürk TC, Özge O, Özgür O. Which one is the first choice for rapid ventricular rate atrial fibrillation in emergency department: Metoprolol or Diltiazem? A randomized clinical trial. J Surg Med. 2019;3(1):13-7.
- Martindale JL, deSouza IS, Silverberg M, Freedman J, Sinert R. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med. 2015;22(3):150-4.
- Liu F, Chen Y, Feng X, Teng Z, Yuan Y, Bin J. Effects of beta-blockers on heart failure with preserved ejection fraction: a meta-analysis. PloS One. 2014;9(3):e90555.
- Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, et al. Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet. 2014;384(9961):2235-43.
- Atzema CL, Austin PC. Rate control with beta‐blockers versus calcium channel blockers in the emergency setting: Predictors of medication class choice and associated hospitalization. Acad Emerg Med. 2017;24(11):1334-48.
Details
| Primary Language | English |
|---|---|
| Subjects | Clinical Sciences |
| Journal Section | Research Article |
| Authors | |
| Publication Date | April 30, 2021 |
| Submission Date | December 12, 2020 |
| Published in Issue | Year 2021 Volume: 23 Issue: 1 |
Cite
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