What should be done for a patient with atrial fibrillation (AFib) who remains in AFib and develops hypotension after two boluses of Cardizem (diltiazem)?

From the Guidelines

For a patient in atrial fibrillation who becomes hypotensive after two boluses of Cardizem (diltiazem), immediate discontinuation of Cardizem and initiation of fluid resuscitation with normal saline or lactated Ringer's solution is crucial. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, the primary goal is to manage comorbidities and risk factors, avoid stroke and thromboembolism, reduce symptoms by rate and rhythm control, and evaluate and dynamically reassess the patient's condition.

In this scenario, the patient's hypotension is likely due to the negative inotropic effects of diltiazem, a calcium channel blocker that can cause vasodilation and decrease cardiac contractility 1. Therefore, it is essential to discontinue the Cardizem and provide fluid resuscitation to stabilize the patient's blood pressure.

Some key considerations for managing this patient include:

• Providing fluid resuscitation with normal saline or lactated Ringer's solution (500-1000 mL bolus) to stabilize blood pressure
• Considering the use of vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) if hypotension persists despite fluid administration
• Switching to a medication with less negative inotropic effects for rate control, such as amiodarone (150 mg IV over 10 minutes, followed by 1 mg/min for 6 hours, then 0.5 mg/min) or digoxin (0.5 mg IV initially, followed by 0.25 mg IV every 6 hours for a total loading dose of 1-1.5 mg)
• Continuous cardiac monitoring and frequent reassessment of the patient's hemodynamic status

The 2016 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1 also supports the use of intravenous or oral beta blockers, diltiazem, or verapamil for acute rate control in patients with atrial flutter who are hemodynamically stable. However, in this case, the patient's hypotension necessitates a different approach.

Overall, the management of this patient requires careful consideration of the underlying pathophysiology and the potential effects of different medications on cardiac function and blood pressure.

From the FDA Drug Label

As with other agents which slow AV nodal conduction and do not prolong the refractoriness of the accessory pathway (e.g., verapamil, digoxin), in rare instances patients in atrial fibrillation or atrial flutter associated with an accessory bypass tract may experience a potentially life-threatening increase in heart rate accompanied by hypotension when treated with injectable forms of diltiazem Hypotension was the most commonly reported adverse event during clinical trials. Asymptomatic hypotension occurred in 4.3% of patients. Symptomatic hypotension occurred in 3. 2% of patients. When treatment for hypotension was required, it generally consisted of administration of saline or placing the patient in the Trendelenburg position.

For a patient with atrial fibrillation (AFib) who remains in AFib and develops hypotension after two boluses of Cardizem (diltiazem), the following steps should be taken:

• Treatment for hypotension is required, which generally consists of:
  • Administration of saline
  • Placing the patient in the Trendelenburg position 2 2

From the Research

Management of Atrial Fibrillation with Hypotension

For a patient with atrial fibrillation (AFib) who remains in AFib and develops hypotension after two boluses of Cardizem (diltiazem), the following steps can be considered:

• Assess the patient's clinical status and adjust the treatment plan accordingly 3
• Consider alternative rate control medications, such as metoprolol, which may have a lower risk of adverse events, including hypotension 4
• Monitor the patient's blood pressure and heart rate closely, and adjust the treatment plan as needed to avoid hypotension and bradycardia 3, 4
• If the patient's hypotension is severe, consider administering fluids or other supportive measures to stabilize their blood pressure 5

Alternative Treatment Options

Some studies suggest that metoprolol may be a suitable alternative to diltiazem for rate control in AFib, with a lower risk of adverse events 4

• Metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem in one study 4
• However, the choice of medication should be individualized based on the patient's clinical status and medical history 6, 7

Important Considerations

When managing AFib with hypotension, it is essential to consider the patient's overall clinical status and adjust the treatment plan accordingly 3

• The patient's blood pressure and heart rate should be monitored closely, and the treatment plan should be adjusted as needed to avoid hypotension and bradycardia 3, 4
• The choice of medication and dosage should be individualized based on the patient's clinical status and medical history 6, 7