Why is diltiazem given in the Emergency Department (ED)?

From the Guidelines

Diltiazem is given in the Emergency Department (ED) for acute rate control in patients with atrial flutter who are hemodynamically stable.

Key Points

• The initial dose of diltiazem is 0.25 mg/kg IV bolus over 2 minutes, followed by an infusion of 5-10 mg/hour, up to 15 mg/hour, titrated to heart rate 1.
• Diltiazem is a nondihydropyridine calcium channel blocker that acts on the AV node to slow the ventricular response in atrial flutter 1.
• Intravenous diltiazem is the preferred intravenous calcium channel blocker for acute rate control because of its safety and efficacy 1.
• Diltiazem should be avoided in patients with advanced heart failure, heart block, or sinus node dysfunction in the absence of pacemaker therapy, as well as in patients with known pre-excitation 1.
• The use of diltiazem in the ED is supported by guidelines from the American College of Cardiology, American Heart Association, and Heart Rhythm Society 1.

From the FDA Drug Label

Diltiazem Hydrochloride Injection or Diltiazem Hydrochloride for Injection are indicated for the following: Atrial Fibrillation or Atrial Flutter Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter Paroxysmal Supraventricular Tachycardia Rapid conversion of paroxysmal supraventricular tachycardias (PSVT) to sinus rhythm

Diltiazem is given in the Emergency Department (ED) for:

• Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter
• Rapid conversion of paroxysmal supraventricular tachycardias (PSVT) to sinus rhythm 2

From the Research

Diltiazem Administration in the Emergency Department

Diltiazem is commonly administered in the Emergency Department (ED) for the management of atrial fibrillation (AF) with rapid ventricular response (RVR) or atrial flutter with rapid ventricular response. The primary goal of diltiazem administration is to achieve rate control, which is defined as a heart rate (HR) < 100 beats per minute (bpm) [ 3, 4,5 ].

Indications for Diltiazem

The indications for diltiazem administration in the ED include:

• Atrial fibrillation with rapid ventricular response [ 3, 4,5 ]
• Atrial flutter with rapid ventricular response [ 3, 4,5 ]
• Rate control in patients with AF or atrial flutter [ 3, 4,5 ]

Dosing Strategies

Different dosing strategies have been studied, including:

• Weight-based dosing (0.2-0.3 mg/kg) 5
• Standard dosing (10 mg) 5
• Diltiazem bolus dosing ≥ 0.13 mg/kg 4

Safety and Efficacy

The safety and efficacy of diltiazem administration in the ED have been evaluated in several studies. The results suggest that:

• Diltiazem is effective in achieving rate control in patients with AF or atrial flutter [ 3, 4,5 ]
• Weight-based dosing may be more effective than standard dosing in achieving rate control 5
• Diltiazem bolus dosing ≥ 0.13 mg/kg may be associated with improved times to achieve HR control 4
• The use of a diltiazem drip after an IV diltiazem bolus may be associated with less rate control in the ED 6
• Diltiazem may be safe for use in patients with heart failure and reduced ejection fraction, but the development of worsening heart failure is multifactorial and may include the use of diltiazem in critically ill patients 7