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

Pharmacology

MetoprololDiltiazem
MOACompetitive beta1-adrenergic receptor inhibitor (cardio-selective); decreased contractility, heart rate, and cardiac conduction time, increased relaxationNon-dihydropyridine CCB selective to L-type calcium channel in cardiac cells; decreased heart rate and conduction time, increased vasodilation
Dose
  • 2.5-5mg 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
AdministrationIV bolus over 2 minutesIV 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
  • Metabolism: hepatic CYP3A4 and conjugation
  • Half-life: ~3.5 hours with bolus, 4-5 hours with continuous infusion
Adverse Effects
  • Bradycardia
  • Hypotension
  • AV block
  • Bronchospasms at doses >100mg
  • CNS effects- fatigue, depression, sleep disturbance
  • Bradycardia
  • Peripheral edema
  • Hypotension
  • AV block
Drug Interactions and warnings
  • Avoid in decompensated heart failure
  • Masks symptoms of hypoglycemia and hyperthyroidism
  • Symptomatic hypotension
  • Mild AST/ALT elevations
  • Avoid in heart failure
CompatibilityCompatible with NS or D5WCompatible with NS, D5W, or D5-1/2NS
CommentsAbrupt cessation can result in angina and MIContinuous infusions should not be continued beyond 24 hours due to accumulation

Evidence

Overview of Evidence

Author, yearDesign/ sample sizeIntervention & ComparisonOutcome
Hargrove, 2021Retrospective (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, 2019Retrospective 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, 2016Retrospective cohort (n=100)
  • Diltiazem
  • Metoprolol
  • Predictors for initial selection of metoprolol over diltiazem included past history of atrial fibrillation, diabetes, and prescription for BB prior to ED visit
  • Prescription of CCB prior to ED visit was a negative predictor for metoprolol use in the ED
  • No differences in efficacy or safety
Kuang, 2016Retrospective cohort (n=398)
  • BB naïve patients
  • Patients on chronic BB therapy
  • BB naïve patients achieved successful rate control at higher rates than those on chronic BB therapy (56.1% vs 42.4%) and had shorter LOS (1.79 days vs 2.64 days)
Martindale, 2015Systematic review (n=92)
  • Diltiazem
  • Metoprolol
  • In the ED, diltiazem is more effective at rapidly controlling ventricular rates than metoprolol
  • Administration of calcium prior to diltiazem does not prevent hypotension
Fromm, 2015Prospective, randomized, double blind (n=52)
  • Diltiazem 0.25mg/kg (max 30mg)
  • Metoprolol 0.15mg/kg (max 10mg)
  • Diltiazem decreased heart rate more rapidly and substantially within first 30min
  • No differences in hypotension and bradycardia
Scheuermeyer, 2013Retrospective cohort (n=259)
  • CCB: diltiazem or verapamil
  • BB: metoprolol or atenolol
  • No difference in admission rates, length of stay, adverse events, and 7 or 30-day ED revisits between CCB and BB
Demircan, 2005Prospective, randomized (n=40)
  • Diltiazem 0.25mg/kg (max 25mg)
  • Metoprolol 0.15mg/kg (max 10mg)
  • Successful rate control (HR <100bpm, decrease by 20%, or return to sinus rhythm) was higher with diltiazem at 2 minutes
  • Successful rate control was similar at 20 minutes (diltiazem 90% vs metoprolol 80%)
  • No incidences of hypotension

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

Source PDF

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