Hostname: page-component-78c5997874-fbnjt Total loading time: 0 Render date: 2024-11-11T07:45:59.538Z Has data issue: false hasContentIssue false
  • English
  • Français

Safety and Efficacy of Prehospital Diltiazem for Atrial Fibrillation with Rapid Ventricular Response

Published online by Cambridge University Press:  02 May 2019

Alexa Rodriguez ,
Christopher L. Hunter ,
Caitlin Premuroso ,
Salvatore Silvestri ,
Amanda Stone ,
Stacie Miller ,
Christian Zuver  and
Linda Papa
Alexa Rodriguez*
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA Orange County EMS System Office of the Medical Director, Orange County, FloridaUSA
Christopher L. Hunter
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA Orange County EMS System Office of the Medical Director, Orange County, FloridaUSA
Caitlin Premuroso
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA
Salvatore Silvestri
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA Orange County EMS System Office of the Medical Director, Orange County, FloridaUSA
Amanda Stone
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA
Stacie Miller
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA
Christian Zuver
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA Orange County EMS System Office of the Medical Director, Orange County, FloridaUSA
Linda Papa
Affiliation:
Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FloridaUSA
*
Correspondence: Alexa Rodriguez, MD Associate Medical Director Orange County EMS System 2002-A E Michigan Street Orlando, Florida 32806 USA E-mail: alexa.rodriguez@ocfl.net
Get access Rights & Permissions [Opens in a new window]

Abstract

Introduction:

Atrial fibrillation (AFIB) with rapid ventricular response (RVR) is a common tachydysrhythmia encountered by Emergency Medical Services (EMS). Current guidelines suggest rate control in stable, symptomatic patients.

Problem:

Little is known about the safety or efficacy of rate-controlling medications given by prehospital providers. This study assessed a protocol for prehospital administration of diltiazem in the setting of AFIB with RVR for provider protocol compliance, patient clinical improvement, and associated adverse events.

Methods:

This was a retrospective, cohort study of patients who were administered diltiazem by providers in the Orange County EMS System (Florida USA) over a two-year period. The protocol directed a 0.25mg/kg dose of diltiazem (maximum of 20mg) for stable, symptomatic patients in AFIB with RVR at a rate of >150 beats per minute (bpm) with a narrow complex. Data collected included patient characteristics, vital signs, electrocardiogram (ECG) rhythm before and after diltiazem, and need for rescue or additional medications. Adverse events were defined as systolic blood pressure <90mmHg or administration of intravenous fluid after diltiazem administration. Clinical improvement was defined as a heart rate decreased by 20% or less than 100bmp. Original prehospital ECG rhythm interpretations were compared to physician interpretations performed retrospectively.

Results:

Over the study period, 197 patients received diltiazem, with 131 adhering to the protocol. The initial rhythm was AFIB with RVR in 93% of the patients (five percent atrial flutter, two percent supraventricular tachycardia, and one percent sinus tachycardia). The agreement between prehospital and physician rhythm interpretation was 92%, with a Kappa value of 0.454 (P <.001). Overall, there were 22 (11%) adverse events, and 112 (57%) patients showed clinical improvement. When diltiazem was given outside of the existing protocol, the patients had higher rates of adverse events (18% versus eight percent; P = .033). Patients who received diltiazem in adherence with protocols were more likely to show clinical improvement (63% versus 46%; P = .031).

Conclusion:

This study suggests that prehospital diltiazem administration for AFIB with RVR is safe and effective when strict protocols are followed.

Rodriguez A, Hunter CL, Premuroso C, Silvestri S, Stone A, Miller S, Zuver C, Papa L. Safety and efficacy of prehospital diltiazem for atrial fibrillation with rapid ventricular response. Prehosp Disaster Med. 2019;34(3):297–302.

Keywords

atrial fibrillationdiltiazemprehospital
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 34 , Issue 3 , June 2019 , pp. 297 - 302
Copyright
© World Association for Disaster and Emergency Medicine 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

January, CT, Wann, LS, Alpert, JS, et al. 2014 AHAH/ACC/HRS guideline for 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.CrossRefGoogle Scholar
Mozaffarian, D, Benjamin, EJ, Go, AS, et al. Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation. 2015;131(4): e29–322.Google ScholarPubMed
Balderson, J, Aurora, T, Zhang, R, Kontos, M, Gertz, Z. Diltiazem versus esmolol for acute rate control in the emergency department. Am J Emerg Med. 2017;35(11):1759–1783.Google Scholar
Fromm, C, Suau, SJ, Cohen, V, et al. Diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department. J Emerg Med. 2015;49(2):175–182.10.1016/j.jemermed.2015.01.014CrossRefGoogle ScholarPubMed
Karth, DG, Geppert, A, Neunteufi, T, et al. Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias. Crit Care Med. 2001;29(6):1149–1153.10.1097/00003246-200106000-00011CrossRefGoogle Scholar
Siu, CW, Lau, CP, Lee, WL, Lam, KF, Tse, HF. Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation. Crit Care Med. 2009;37(7):2174–2179.10.1097/CCM.0b013e3181a02f56CrossRefGoogle ScholarPubMed
Hirschy, R, Ackerbauer, K, Peksa, GD, O’Donnell, P, DeMott, JM. Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction. Am J Emerg Med. 2019;37(1):80–84.CrossRefGoogle ScholarPubMed
Schreck, DM, Rivera, AR, Tricarico, VJ. Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin. Ann Emerg Med. 1997;29(1):135–140.10.1016/S0196-0644(97)70319-6CrossRefGoogle ScholarPubMed
Wang, HE, O’Connor, RE, Megarel, RE, et al. The use of diltiazem for treating rapid atrial fibrillation in out-of-hospital setting. Ann Emerg Med. 2001;37(1):38–45.10.1067/mem.2001.111518CrossRefGoogle ScholarPubMed
Luk, JH, Walsh, B, Yasbin, P. Safety and efficacy of prehospital diltiazem. West J Emerg Med. 2013;14(3):296–300.10.5811/westjem.2011.8.6692CrossRefGoogle ScholarPubMed
Lim, SH, Anantharaman, V, Teo, WS, Chan, YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523–528.10.1016/j.resuscitation.2009.01.017CrossRefGoogle ScholarPubMed
Jacob, AS, Nielsen, DH, Gianelly, RE. Fatal ventricular fibrillation following verapamil in Wolff-Parkinson-White syndrome with atrial fibrillation. Ann Emerg Med. 1985;14(2):159–160.10.1016/S0196-0644(85)81080-5CrossRefGoogle ScholarPubMed