![]() ![]() New York in which 54 patients were randomized, with 24 receiving IV diltiazem andĢ8 receiving IV metoprolol ( Fromm 2015). Of a more recent randomized controlled trial from Maimonides Medical Center in SigniBicant difference in blood pressure change. No patient converted to sinus rhythm during this time period and there was no Medication administration, success rates were similar at 5, 10, 15, and 20 minutes. More likely to have “successful treatment” (reduction in ventricular rate to < 100īpm or by 20% as long as the resulting rate was < 120 bpm) 2 minutes following While patients assigned to IV diltiazem were Small study comprised of 40 patients, randomized in a 1:1 fashion to the two Although there is no clear consensus on which agent is preferable in the ED population, there have been several studies addressing this question.Įarly research comparing IV metoprolol with IV diltiazem in AF with RVR included a Or diltiazem recommended when urgent rate control is desired. With beta-blocking agents or calcium-channel blocking agents, with IV metoprolol Rate control is most commonly accomplished Modalities ( Wyse 2002, Chatterjee 2013), practice patterns in the US tend to favor Have demonstrated similar outcomes among patients treated with these two (via electrical or chemical cardioversion) and rate control. Management options for patients with new-onsetĪF with a rapid ventricular rate (RVR) in the ED typically include rhythm control Answer Key.Ītrial Bibrillation (AF) is the most common dysrhythmia encountered in theĮmergency department (ED) and is responsible for over 500,000 visits in the United Ventricular rate in atrial Bibrillation. Comparison of theĮffectiveness of intravenous diltiazem and metoprolol in the management of rapid Answer Key.Īrticle 4: Demircan C, Cikriklar HI, Engindeniz Z, et al. HemodynamicĬomparison of intravenous push diltiazem versus metoprolol for atrial Bibrillation Answer Key.Īrticle 3: Nicholson J, Czosnowski Q, Flack T, Pang PS, Billups K. Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in theĮmergency Department. 2013 20(3):Īrticle 2:Fromm C, Suau SJ, Cohen V, et al. Safety and efBiciency ofĬalcium channel blockers versus beta-blockers for rate control in patients with atrialīibrillation and no acute underlying medical illness. ![]() The four most relevant articles from theĪrticle 1: Scheuermeyer FX, Grafstein E, Stenstrom R, et al. An additional search of the Cochrane Database of Systematic Reviews revealed no additional evidence. Outcome: Frequency and time to rate control, ED length of stay, need for hospital admission, hypotension, bradycardia requiring urgent treatmentĪ PubMed search was performed using the terms “(atrial Bibrillation) OR (atrialīlutter)) AND (metoprolol AND diltiazem)” resulting in 38 citations ( /y6smse9t). Intervention: Bolused intravenous diltiazemĬomparison: Bolused intravenous metoprolol Population: Adult patients presenting to the emergency department in atrial fibrillation or atrial flutter with a rapid ventricular response without signs of hemodynamic compromise Wondering if there is a benefit to one agent over the other, you decide to do some digging and find a few relevant articles in the literature… But which agent to use for rate control? You know from prior rotations that some seem to prefer metoprolol, but in your ED you have noticed that most attending use diltiazem almost exclusively. After discussing with your attending, your plan is for anticoagulation and rate control. Z has been having symptoms for more than 48 hours, she is not a candidate for urgent cardioversion, as previously discussed in journal club. She reports that other than feeling her heart racing and noting shortness of breath on exertion she has no symptoms, including chest pain, syncope, and lightheadedness. Lower extremity exam reveals no edema or calf tenderness. Cardiac exam reveals an irregularly irregular rhythm. She is well-appearing and in no distress. Her doctor did an ECG in the office and found her to be in new-onset atrial fibrillation with a rate in the 140s, so sent her to the ED for evaluation and treatment. Her symptoms began on Friday, but she decided to wait out the weekend and see her primary care doctor today (Monday). Z, a sixty-five-year old woman with a history of mitral valve stenosis who presents with three days of palpitations and shortness of breath. During your first shift you encounter Mrs. Having recently returned from an extended (and entirely unexpected) six-week-long “staycation,” you return to work full of pep and vigor. Washington University Emergency Medicine Journal Club- September 2020 ![]()
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