Intravenous diltiazem infusions for rapid atrial fibrillation or flutter in the emergency department: A retrospective, exploratory analysis.
Journal
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
ISSN: 1553-2712
Titre abrégé: Acad Emerg Med
Pays: United States
ID NLM: 9418450
Informations de publication
Date de publication:
27 Jul 2024
27 Jul 2024
Historique:
revised:
02
07
2024
received:
05
04
2024
accepted:
05
07
2024
medline:
29
7
2024
pubmed:
29
7
2024
entrez:
29
7
2024
Statut:
aheadofprint
Résumé
Emergency physicians commonly treat patients with atrial fibrillation (AF) or atrial flutter (AFL) with rapid ventricular response, and intravenous (IV) diltiazem is the most commonly used medication for rate control of such patients. We sought to compare rate control success and safety outcomes for emergency department (ED) patients with AF or AFL who, after a diltiazem bolus, received a diltiazem drip compared to those who did not receive a drip. We performed a retrospective cohort study comparing outcomes of ED patients from a single hospital system with AF and AFL and a heart rate (HR) > 100 beats/min who received a diltiazem drip after an IV diltiazem bolus to those who received no drip. The primary outcome was a HR < 100 beats/min at the time of ED disposition. Secondary outcomes were hospital length of stay and safety (hypotension, electrical cardioversion, vasopressor use, and death). We compared groups using propensity score matching. Between January 1, 2020, and November 8, 2022, there were 746 AF or AFL patients eligible for analysis. Of those, 382 (51.2%) received a diltiazem drip and 364 (48.8%) did not. In the unadjusted analysis, the last recorded ED HR was <100 beats/min in 55.2% of patients in the drip group compared to 65.9% in the no-drip group (difference 10.7%, 95% confidence interval [CI] 3.7 to 17.7). After propensity matching, diltiazem drip use was associated with lower likelihood of rate control in the ED (OR 0.69, 95% CI 0.48-0.99) and 22.5 h (95% CI 12.2-36.8) longer hospital stay. For patients with AF or AFL, the use of a diltiazem drip after an IV diltiazem bolus was associated with less rate control in the ED.
Sections du résumé
BACKGROUND
BACKGROUND
Emergency physicians commonly treat patients with atrial fibrillation (AF) or atrial flutter (AFL) with rapid ventricular response, and intravenous (IV) diltiazem is the most commonly used medication for rate control of such patients. We sought to compare rate control success and safety outcomes for emergency department (ED) patients with AF or AFL who, after a diltiazem bolus, received a diltiazem drip compared to those who did not receive a drip.
METHODS
METHODS
We performed a retrospective cohort study comparing outcomes of ED patients from a single hospital system with AF and AFL and a heart rate (HR) > 100 beats/min who received a diltiazem drip after an IV diltiazem bolus to those who received no drip. The primary outcome was a HR < 100 beats/min at the time of ED disposition. Secondary outcomes were hospital length of stay and safety (hypotension, electrical cardioversion, vasopressor use, and death). We compared groups using propensity score matching.
RESULTS
RESULTS
Between January 1, 2020, and November 8, 2022, there were 746 AF or AFL patients eligible for analysis. Of those, 382 (51.2%) received a diltiazem drip and 364 (48.8%) did not. In the unadjusted analysis, the last recorded ED HR was <100 beats/min in 55.2% of patients in the drip group compared to 65.9% in the no-drip group (difference 10.7%, 95% confidence interval [CI] 3.7 to 17.7). After propensity matching, diltiazem drip use was associated with lower likelihood of rate control in the ED (OR 0.69, 95% CI 0.48-0.99) and 22.5 h (95% CI 12.2-36.8) longer hospital stay.
CONCLUSIONS
CONCLUSIONS
For patients with AF or AFL, the use of a diltiazem drip after an IV diltiazem bolus was associated with less rate control in the ED.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 Society for Academic Emergency Medicine.
Références
Li X, Liu Z, Jiang X, et al. Global, regional, and national burdens of atrial fibrillation/flutter from 1990 to 2019: an age‐period‐cohort analysis using the Global Burden of Disease 2019 study. J Glob Health. 2023;13:04154.
Jackson SL, Tong X, Yin X, George MG, Ritchey MD. Emergency department, hospital inpatient, and mortality burden of atrial fibrillation in the United States, 2006 to 2014. Am J Cardiol. 2017;120:1966‐1973.
Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(1):109‐279.
Scheuermeyer FX, Grafstein E, Stenstrom R, et al. Safety and efficiency of calcium channel blockers versus beta‐blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness. Acad Emerg Med. 2013;20:222‐230.
Martindale JL, deSouza IS, Silverberg M, et al. 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):150‐154.
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;73:2068‐2076.
Nicholson J, Czosnowski Q, Flack T, Pang PS, Billups K. Hemodynamic comparison of intravenous push diltiazem versus metoprolol for atrial fibrillation rate control. Am J Emerg Med. 2020;38:1879‐1883.
McGrath P, Kersten B, Chilbert MR, Rusch C, Nadler M. Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department. Am J Emerg Med. 2021;46:585‐590.
Hargrove KL, Robinson EE, Lusk KA, Hughes DW, Neff LA, Fowler AL. Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: metoprolol vs. diltiazem. Am J Emerg Med. 2021;40:15‐19.
Medeiros T, Bui V, Almekdash MH, Keesari R, Lee YR. Rate control with intravenous diltiazem, verapamil, and metoprolol in acute atrial fibrillation with rapid ventricular rate. SAGE Open Med. 2021;9:205031212110177.
Nuñez Cruz S, DeMott JM, Peksa GD, et al. Evaluation of the blood pressure effects of diltiazem versus metoprolol in the acute treatment of atrial fibrillation with rapid ventricular rate. Am J Emerg Med. 2021;46:329‐334.
Sharda SC, Bhatia MS. Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: systematic review and meta‐analysis. Indian Heart J. 2022;74(6):494‐499.
Rogenstein C, Kelly AM, Mason S, et al. An international view of how recent‐onset atrial fibrillation is treated in the emergency department. Acad Emerg Med. 2012;19(11):1255‐1260.
Phillips BG, Gandhi AJ, Sanoski CA, Just VL, Bauman JL. Comparison of intravenous diltiazem and verapamil for the acute treatment of atrial fibrillation and atrial flutter. Pharmacotherapy. 1997;17(6):1238‐1245.
Schwinger RH, Bohm M, Erdmann E. Negative inotropic properties of isradipine, nifedipine, diltiazem, and verapamil in diseased human myocardial tissue. J Cardiovasc Pharmacol. 1990;15:892‐899.
Hermann P, Rodger SD, Remones G, Thenot JP, London DR, Morselli PL. Pharmacokinetics of diltiazem after intravenous and oral administration. Eur J Clin Pharmacol. 1983;24(3):349‐352.
Ellenbogen KA, Roark SF, Smith MS, McCarthy EA, Bjornsson TD, Pritchett ELC. Effects of sustained intravenous diltiazem infusion in healthy persons. Am J Cardiol. 1986;58(11):1055‐1060.
Diltiazem Hydrochloride Injection. Hospira, Inc.; 2017.
Means KN, Gentry AE, Nguyen TT. Intravenous continuous infusion vs. oral immediate‐release diltiazem for acute heart rate control. West J Emerg Med. 2018;19(2):417‐422.
Randolph JJ. Free‐Marginal Multirter Kappa (Multirater κfree): an Alternative to Fleiss’ Fixed‐Marginal Multirater Kappa. Oensuu University Learning and Instruction Symposium, Joensuu, 14th‐15th October 2005.
Gilbert EH, Lowenstein SR, Koziol‐McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305‐308.
Long B, Keim SM, Gottlieb M, Stiell IG. What is the best agent for rate control of atrial fibrillation with rapid ventricular response? J Emerg Med. 2022;63(3):467‐476.
Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity‐score matched samples. Stat Med. 2009;28:3083‐3107.
Konig S, Ueberham L, Schuler E, et al. In‐hospital mortality of patients with atrial arrhythmias: insights from the German‐wide Helios Hospital Network of 161 502 patients and 34 025 arrhythmia‐related procedures. Eur Heart J. 2018;39(44):3947‐3957.
Turagam MK, Velagapudi P, Visotcky A, Szabo A, Kocheril AG. African Americans have the highest risk of in‐hospital mortality with atrial fibrillation related hospitalizations among all racial/ethnic groups: a nationwide analysis. Int J Cardiol. 2012;158(1):165‐166.
Scheuermeyer FX, Pourvali R, Rowe BH, et al. Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm. Ann Emerg Med. 2015;65:511‐522.
Gasbarro NM, DiDomenico RJ. Frequency of “on‐label” use of intravenous diltiazem for rate control in patients with acute‐onset atrial fibrillation or atrial flutter. Am J Health Syst Pharm. 2019;76(4):214‐220.
Bishop J Jr, Akram G. Diltiazem Dosing strategies in the Management of Atrial Fibrillation with Rapid Ventricular Rate. Cureus. 2021;13(10):e18829.
Posen A, Bursua A, Petzel R. Dosing strategy effectiveness of diltiazem in atrial fibrillation with rapid ventricular response. Ann Emerg Med. 2023;81(3):288‐296.