Can Cardizem (Diltiazem) be given to a patient with atrial fibrillation (AFib) with rapid ventricular response (RVR), undergoing hemodialysis, and having congestive heart failure (CHF)?

From the Guidelines

Cardizem (diltiazem) should be used with caution in patients with atrial fibrillation with rapid ventricular response (RVR) who have congestive heart failure (CHF) and are on hemodialysis, as it may worsen heart failure due to its negative inotropic effects. For these patients, beta-blockers like metoprolol are generally preferred as first-line rate control agents, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. If diltiazem is used, it should be at reduced doses (starting at 5-10 mg/hr IV or 120 mg daily oral dose) with careful monitoring of blood pressure, heart rate, and signs of worsening heart failure. Diltiazem requires dose adjustment in renal impairment as it is partially cleared by the kidneys, and hemodialysis does not significantly remove the drug, as noted in the 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation 1. The medication can worsen heart failure due to its negative inotropic effects, potentially decreasing cardiac output. Additionally, the combination of diltiazem with fluid shifts during dialysis may cause hypotension. Alternative rate control strategies include amiodarone or digoxin, particularly if the patient has severely reduced ejection fraction, as suggested by the 2019 ACC/AHA versus ESC guidelines on heart failure: JACC guideline comparison 1. Regardless of the agent chosen, close cardiac monitoring is essential during initiation of therapy. Some key points to consider when managing these patients include:

• The importance of correcting underlying causes of AF and HF, as well as optimizing HF management, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
• The need to assess thromboembolic risk and anticoagulation need, as noted in the 2019 ACC/AHA versus ESC guidelines on heart failure: JACC guideline comparison 1.
• The potential benefits and risks of rhythm control versus rate control strategies, as discussed in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

From the FDA Drug Label

Diltiazem slows the ventricular rate in patients with a rapid ventricular response during atrial fibrillation or atrial flutter The use of diltiazem hydrochloride injection or diltiazem hydrochloride for injection should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium In patients with cardiovascular disease, diltiazem hydrochloride injection administered intravenously in single bolus doses, followed in some cases by a continuous infusion, reduced blood pressure, systemic vascular resistance, the rate-pressure product, and coronary vascular resistance and increased coronary blood flow In a limited number of studies of patients with compromised myocardium (severe congestive heart failure, acute myocardial infarction, hypertrophic cardiomyopathy), administration of intravenous diltiazem produced no significant effect on contractility, left ventricular end diastolic pressure, or pulmonary capillary wedge pressure

Key Considerations:

• Atrial Fibrillation with RVR: Diltiazem can be used to slow the ventricular rate in patients with atrial fibrillation or atrial flutter.
• Hemodialysis: There is no direct information in the provided drug labels regarding the use of diltiazem in patients undergoing hemodialysis.
• CHF: Diltiazem should be used with caution in patients with compromised hemodynamics, including those with congestive heart failure (CHF).
• Clinical Decision: Given the presence of CHF, caution should be exercised when administering diltiazem to a patient with atrial fibrillation and rapid ventricular response (RVR) who is also undergoing hemodialysis. The patient's hemodynamic status should be closely monitored. 2 2

From the Research

Patient Considerations

• The patient has atrial fibrillation (AFib) with rapid ventricular response (RVR) and is undergoing hemodialysis with congestive heart failure (CHF).
• The use of cardizem (diltiazem) in this patient population is a concern due to its potential negative inotropic effects, particularly in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4.

Safety and Efficacy of Diltiazem

• Studies have shown that diltiazem can be effective in controlling heart rate in patients with AFib and RVR, including those with CHF 3, 5, 6.
• However, one study found a higher incidence of worsening heart failure symptoms in patients treated with diltiazem compared to metoprolol 4.
• Another study found that diltiazem was as safe and effective as metoprolol in the acute management of HFrEF patients with AFib RVR 5.

Treatment Options

• The choice of rate control agent for acute management of AFib with RVR does not significantly influence sustained rate control success 6.
• Beta blockers or calcium channel blockers, such as diltiazem, can be used for rate control in patients with AFib and RVR who do not undergo cardioversion 7.
• The decision to use diltiazem in a patient with AFib, RVR, and CHF should be made on a case-by-case basis, taking into account the patient's individual characteristics and medical history 3, 4, 5.