So this tends to focus on HR in the ED and not what happens after leaving. What do you use for discharge? Makes sense to continue diltiazem if you used it. However, my understanding is, Diltiazem as primary agent has very little effect on exercise induced acceleration of AFib which is sympathetically mediated. Accordingly poor in younger, active patients. Also, metoprolol is poor in some people because of high first pass metabolism. Bisoprolol and Nadolol often better drugs. So should you use metoprolol IV in the ED if you are going to use a b-blocker on discharge. And don't say we just leave that to Cardiology because not everyone is going to have access to them and really we need to know that one step beyond.
Hi Bruce, Thanks for your message! You're right -- this is really a review article and meta-analysis of available trials on the topic of diltiazem vs metoprolol for rate control (and does focus more on the ED than going home). You bring up some good points about contraindications for these drugs as well. It's a complex topic and no formal strong recommendations from any guidelines favor one drug over the other. We do have a nice deep-dive into the topic -- what drugs to use, cautions, dosages, home regimens, etc. in the CorePendium chapter on Atrial Fibrillation: https://www.emrap.org/corependium/chapter/recdIAvPWi4VYLwc2/Atrial-Fibrillation
Here is a little quote from the chapter: "Oral rate control in stable patients prevents unnecessary hospital admissions, and is favored over the previous tendency towards reflexive IV administration. IV rate control is appropriate in situations where the patient clearly requires admission to the hospital or adequate rate control cannot be achieved."
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Bruce M. - July 18, 2022 9:17 AM
So this tends to focus on HR in the ED and not what happens after leaving. What do you use for discharge? Makes sense to continue diltiazem if you used it. However, my understanding is, Diltiazem as primary agent has very little effect on exercise induced acceleration of AFib which is sympathetically mediated. Accordingly poor in younger, active patients. Also, metoprolol is poor in some people because of high first pass metabolism. Bisoprolol and Nadolol often better drugs. So should you use metoprolol IV in the ED if you are going to use a b-blocker on discharge. And don't say we just leave that to Cardiology because not everyone is going to have access to them and really we need to know that one step beyond.
Jessie W. - July 19, 2022 11:39 AM
Hi Bruce,
Thanks for your message! You're right -- this is really a review article and meta-analysis of available trials on the topic of diltiazem vs metoprolol for rate control (and does focus more on the ED than going home). You bring up some good points about contraindications for these drugs as well. It's a complex topic and no formal strong recommendations from any guidelines favor one drug over the other. We do have a nice deep-dive into the topic -- what drugs to use, cautions, dosages, home regimens, etc. in the CorePendium chapter on Atrial Fibrillation: https://www.emrap.org/corependium/chapter/recdIAvPWi4VYLwc2/Atrial-Fibrillation
Here is a little quote from the chapter: "Oral rate control in stable patients prevents unnecessary hospital admissions, and is favored over the previous tendency towards reflexive IV administration.
IV rate control is appropriate in situations where the patient clearly requires admission to the hospital or adequate rate control cannot be achieved."