Virginia Commonwealth University Health, Virginia Commonwealth University Medical Center, United States of America.
Virginia Commonwealth University Health, Department of Pharmacy, 401 North 12th Street, PO Box 980042, Richmond, VA 23298-0042, United States of America.
Am J Emerg Med. 2022 Aug;58:39-42. doi: 10.1016/j.ajem.2022.03.058. Epub 2022 Apr 6.
Acute heart rate control for atrial fibrillation (AF) with rapid ventricular response (RVR) in the emergency department (ED) is often achieved utilizing intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB). For patients with concomitant heart failure with a reduced ejection fraction (HFrEF), the American Heart Association and other clinical groups note that CCB should be avoided due to their potential negative inotropic effects. However, minimal evidence exists to guide this current recommendation. The primary objective of this study was to compare the incidence of adverse effects in the HFrEF patient population whose AF with RVR was treated with IV diltiazem or metoprolol in the ED.
This single center, retrospective review included patients ≥18 years old with HFrEF who presented in AF with RVR and received IV diltiazem or metoprolol in the ED. The primary outcome was adverse effects of therapy defined as: 1) hypotension (systolic blood pressure < 90 mmHg requiring fluid bolus or vasopressors) or bradycardia (heart rate < 60 beats/min) within 60 min of medication administration 2) worsening heart failure symptoms defined as increased oxygen requirements within four hours or inotropic support within 48 h. Secondary outcomes included the incidence of rate control failure, patient disposition, ED length of stay, hospital length of stay, and in-hospital mortality.
One hundred and twenty-five patients met inclusion criteria, with 57 receiving diltiazem and 68 receiving metoprolol. Overall adverse effects for diltiazem and metoprolol were similar (32% vs. 21%, P = 0.217). However, there was a significantly higher incidence of worsening heart failure symptoms within the diltiazem group (33% vs 15%, P = 0.019). Rate control failure at 60 min did not differ significantly between diltiazem and metoprolol (51% vs 62%, P = 0.277).
In HFrEF patients with AF, there was no difference in total adverse events in patients treated with IV diltiazem compared to metoprolol. However, the diltiazem group had a higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.
在急诊科（ED）中，对于快速性心室反应（RVR）的心房颤动（AF），通常采用静脉（IV）非二氢吡啶类钙通道阻滞剂（CCB）或β受体阻滞剂（BB）来控制急性心率。对于射血分数降低的心力衰竭（HFrEF）合并症患者，美国心脏协会和其他临床组织指出，由于 CCB 可能具有负性肌力作用，应避免使用。然而，目前的建议缺乏足够的证据支持。本研究的主要目的是比较在 ED 中接受 IV 地尔硫卓或美托洛尔治疗 RVR 的 HFrEF 患者中，治疗相关不良反应的发生率。
这是一项单中心回顾性研究，纳入了年龄≥18 岁、HFrEF 合并 RVR 并在 ED 接受 IV 地尔硫卓或美托洛尔治疗的患者。主要结局为治疗相关不良反应，定义为：1）药物治疗后 60 分钟内出现低血压（收缩压＜90mmHg，需补液或升压治疗）或心动过缓（心率＜60 次/分钟）；2）在 4 小时内需要增加氧需求或在 48 小时内需要使用正性肌力支持药物的心力衰竭恶化症状。次要结局包括：转复失败发生率、患者处置情况、ED 住院时间、住院时间和院内死亡率。
共纳入 125 例患者，其中 57 例接受地尔硫卓治疗，68 例接受美托洛尔治疗。地尔硫卓和美托洛尔的总体不良反应发生率相似（32% vs. 21%，P = 0.217）。然而，地尔硫卓组心力衰竭恶化症状的发生率明显更高（33% vs. 15%，P = 0.019）。60 分钟时的转复失败率在地尔硫卓组和美托洛尔组之间无显著差异（51% vs. 62%，P = 0.277）。
在 HFrEF 合并 AF 的患者中，IV 地尔硫卓与美托洛尔治疗的患者在总不良反应发生率方面无差异。然而，地尔硫卓组的心力衰竭恶化症状发生率更高，定义为在 4 小时内需要增加氧需求或在 48 小时内需要使用正性肌力支持药物。
