From the Guidelines
For a patient who developed hypertension after being administered Cardizem (Diltiazem) for atrial fibrillation with rapid ventricular response (AFib RVR), the first step is to stop the Cardizem infusion if it's still running and consider alternative rate control strategies. The development of hypertension in this context may be due to the body's compensatory response to the initial heart rate reduction caused by diltiazem, or it could be unrelated to the medication.
- According to the 2024 ESC guidelines for the management of atrial fibrillation 1, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms.
- However, given the patient's development of hypertension, switching to a beta-blocker (if blood pressure permits) or considering other rate control strategies such as amiodarone may be necessary.
- It's essential to monitor the patient's blood pressure, heart rate, and cardiac rhythm continuously to adjust the treatment plan as needed.
- The 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1 also provides recommendations for ongoing management of AVNRT, but the primary concern in this case is the patient's hypertension and the need to adjust the rate control strategy accordingly.
- The patient's hypertension should be managed according to standard hypertension treatment guidelines, and the underlying cause of the hypertension should be investigated and addressed.
- In terms of specific medication adjustments, the decision to continue, stop, or change the rate control medication should be based on the patient's individual response and the clinical context, taking into account the potential benefits and risks of each medication.
From the Research
Hypertension Development after Cardizem Administration
- If a patient develops hypertension after being administered Cardizem (Diltiazem) for atrial fibrillation with rapid ventricular response (AFib RVR), the following points should be considered:
Diltiazem Dosing Strategies
- A study published in 2021 2 investigated diltiazem administration in a community ED and determined the effect of varying doses on heart rate control, systolic blood pressure, and diastolic blood pressure.
- The study found that diltiazem bolus dosing ≥ 0.13 mg/kg was associated with significantly improved times to achieve heart rate control compared to < 0.13 mg/kg.
Adverse Events Associated with Diltiazem
- A systematic review and meta-analysis published in 2024 3 compared the incidence of adverse events (AEs) associated with IV diltiazem and metoprolol for AFib with RVR.
- The study found that metoprolol was associated with a 26% lower risk of AE compared to diltiazem.
Alternative Rate Control Agents
- A study published in 2022 4 compared the efficacy and safety of calcium channel blockers and β-blockers for rate control in patients with AFib with RVR.
- The study found that diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective.
Route of Diltiazem Administration
- A study published in 2018 5 compared the incidence of treatment failure between oral immediate-release and IV continuous infusion diltiazem after an initial IV diltiazem loading dose.
- The study found that oral immediate-release diltiazem was associated with a lower rate of treatment failure at four hours than IV continuous infusion.
Safety of Diltiazem in Patients with Heart Failure
- A study published in 2024 6 described the incidence of worsening heart failure in patients who receive intravenous diltiazem for acute atrial fibrillation management.
- The study found that the development of worsening heart failure is multifactorial and may include the use of diltiazem in critically ill patients requiring hospital admission.