All Pharmacy Pearls

Introduction

  • Atrial Fibrillation is the most common sustained arrhythmia seen in the emergency department and requires

    • emergent treatment to prevent myocardial ischemia and acute heart failure.

  • Beta-blockers and calcium channel blockers are used for acute rate control in the treatment of atrial

    • fibrillation with rapid ventricular response.

Clinical Detail

    Metoprolol

    Diltiazem

    MOA

    Competitive beta1- adrenergic receptor

    inhibitor (cardio-selective); decreased

    contractility, heart rate, and cardiac

    conduction time, increased relaxation

    Non-dihydropyridine CCB selective to L-type

    calcium channel in cardiac cells; decreased heart

    rate and conduction time, increased vasodilation

    Dose

  • 5-5mg IV

    • Repeat every 5 minutes as needed

    • Max total dose of 15mg

    • Bolus: 0.25mg/kg IV

    • Repeat 0.35mg/kg after 15 minutes if needed

    • After bolus: continuous infusion 5-10mg/hr IV,

    max 15mg/hr or PO IR 30-90 mg

    Administration

    IV bolus over 2 minutes

    IV bolus over 2 minutes

    PK/PD

    • Onset: 1-2 minutes

    • Peak: 20 minutes

    • Metabolism: hepatic CYP2D6

    • Half-life: 3-4 hours

    • Onset: 3 minutes with IV bolus

    • Duration: 1-3 hours with IV bolus, 0.5-10 hours

    after cessation of continuous infusion

Evidence

    Author, year

    Design/ sample

    size

    Intervention & Comparison

    Outcome

    Hargrove, 2021

    Retrospective

    (n=51)

    • Diltiazem

    • Metoprolol

    • No difference regarding sustained rate

    control for 3 hours (diltiazem 87.5% vs

    metoprolol 78.9%)

    • Shorter time to rate control with

    diltiazem (15min vs 30min)

    • No differences in bradycardia or

    hypotension

    Hirschy, 2019

    Retrospective

    cohort (n=48)

    • Diltiazem IV push

    • Metoprolol IV push

    • No difference in successful rate control

    within 30 minutes in patients with HFrEF

    (diltiazem 50% vs metoprolol 62%)

    • No differences in hypotension,

    bradycardia, conversion, or signs of

    worsening heart failure

    Hines, 2016

    Retrospective

    cohort (n=100)

    • Diltiazem

Conclusions

  • Diltiazem has a quicker onset of action and therefore a faster onset to rate control but is not correlated with a

    • significant difference in long-term outcomes.

  • Both medications are appropriate options for treatment of acute rate control, and treatment choice should

    • be based on patient specific factors such as comorbidities, drug interactions, and prior therapy.

References

  • Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved February 17,

    • 2021, from http://www.micromedexsolutions.com/

  • Lexicomp [Electronic version]. Macedonia, OH: Truven Wolters Kluwer Health. Retrieved February 19, 2021.

    • https://online.lexi.com/lco/action/login.

  • Hargrove KL, Robinson EE, Lusk KA, et al. Comparison of sustained rate control in atrial fibrillation with rapid

    • ventricular rate: Metoprolol vs. Diltiazem. Am J Emerg Med. 2021; 40:15-19.

  • Hirschy R, Ackerbauer KA, Peksa GD, O’Donnell EP, 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 Jan;37(1):80-84. PMID: 29731345.

  • 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

    Dec 15;73(24):2068-2076. PMID: 27919874.

  • Kuang P, Mah ND, Barton CA, Miura AJ, Tanas LR, Ran R. Achieving ventricular rate control using metoprolol in

    • β-blocker-naive patients vs patients on chronic β-blocker therapy. Am J Emerg Med. 2016 Mar;34(3):606-8.

    PMID: 26830391.

  • 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 Jun;22(3):150-4. PMID: 25564459.

  • 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.

  • Demircan C, Cikriklar HI, Engindeniz Z, 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; 22:411-414.

  • Scheuermeyer FX, Grafstein E, Stenstrom R, et al. Safety and efficacy 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(3):222-230.

Tags:atrial fibrillation beta blockers calcium channel blockers rate control

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BB vs CCB for Afib. Duco M. JLP2. pharmacy friday Pearls. 2-26-21.pdf