Atrial Fibrillation Clinical Trial
Official title:
Gradual Diltiazem Infusion as an Approach to Initial Rate Control in Atrial Fibrillation or Atrial Flutter With Rapid Ventricular Response in the Emergency Setting
Verified date | October 2019 |
Source | Mercy Health Muskegon |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Interventional |
The administration of intravenous non-dihydropyridine calcium channel blockers such as
diltiazem for patients presenting in atrial fibrillation with rapid ventricular response,
without evidence of pre-excitation, are recommended first-line therapies by the American
Heart Association.1 Hypotension warrants careful consideration in the treatment of atrial
fibrillation with a rapid ventricular response. Hemodynamic stability is a continuum,
however, and rate control is often vital, particularly in patients who are refractory to
electrical cardioversion [or who have underlying conditions such that tachycardia is not well
tolerated]. Diltiazem has been utilized in dosing such as 2.5 mg/min in those with decreased
blood pressure and atrial fibrillation with elevated ventricular rate.2 Lim et al. in 2002
demonstrated the effectiveness of a slow infusion of diltiazem 2.5 mg/min to a maximum of 50
mg to control rate in supraventricular tachycardia.
The study of the slow infusion of diltiazem has been limited to supraventricular tachycardia.
No literature exists evaluating the efficacy of such a gradual infusion in atrial
fibrillation or atrial flutter, rhythms affecting 2.7 million to 6.1 million Americans.1,3 It
can be reasoned that a gradual infusion of diltiazem will minimize side effects,
predominantly hypotension, and perhaps even demonstrate efficacy in alleviating hypotension
due to decreased stroke volume from excessive tachycardia. The proposed benefits of an
infusion, as compared to a bolus, would allow for the termination of an infusion as soon as
rate control is achieved thus limiting the potential for hypotension. With current
evidence-based literature validating the superiority of non-dihydropyridine calcium channel
blockers and questions surrounding present recommendations of weight based intravenous
dosing, the authors suggest an inquiry into the utility of a gradual infusion of diltiazem
for initial rate control in patients presenting with atrial fibrillation or flutter with or
without hypotension related to excessive tachycardia.
This is a prospective, randomized, double blind investigation to compare the effectiveness of
standard IV (intravenous) push diltiazem at 0.25 mg/kg (to a maximum of 25 mg) over 2
minutes, with a potential repeat dose of 0.35 mg/kg if the initial dose is not effective
versus a slow infusion of 50 mg of IV diltiazem diluted in 50 mL of 0.9% normal saline (NS)
administered over 20 minutes. The investigators anticipate the data to be collected over the
course of 2-3 years. These methods of diltiazem administration are already accepted practices
at our institution and are consistent with current approved product labeling and professional
judgment based upon clinical experience, and therefore the investigators do not foresee any
additional risk to patients enrolled in our proposed study. In either treatment group, should
hypotension or other clinical evidence of poor systemic perfusion, no additional IV
diltiazem, or additional administration of a diltiazem infusion will be administered. The
primary outcome measured will be the efficacy of treatment as defined by the obtainment of a
heart rate of <110 beats/minute within 30 minutes of drug administration. Secondary outcomes
evaluated will include the need for additional medications to achieve rate control including
the need for repeat diltiazem bolus at 0.35 mg/kg, electrical cardioversion, admission,
allergic reactions, and side effects including, but not limited to, systolic blood pressure
less than 90 mmHg or bradycardia with heart rate less than 60 bpm.
Status | Not yet recruiting |
Enrollment | 300 |
Est. completion date | December 1, 2021 |
Est. primary completion date | December 1, 2021 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years and older |
Eligibility |
Inclusion Criteria: - Be 18 years and older, - Present with atrial fibrillation or atrial flutter with a rapid ventricular response - Have a 12-lead ECG (electrocardiogram) showing atrial fibrillation or atrial flutter with a rapid ventricular rate greater than 120 beats per minute. - Able to provide consent for self, or have a legally authorized representative available to provide consent by proxy. - Have a cardiac history not inclusive of the diagnoses listed under exclusion criteria. Exclusion Criteria: - Altered mental status as a direct result of hemodynamic instability - Heart rate >220 beats per minute - 2nd or 3rd degree atrioventricular block - QRS (time for ventricular repolarization) >110 milliseconds - Temperature >38 Celsius - Acute STEMI (ST-Elevation Myocardial Infarction) - Pulmonary edema - Unstable angina - Allergy to diltiazem - Pregnancy - Breastfeeding - History of pre-excitation syndrome - Decompensated heart failure - Incarcerated persons |
Country | Name | City | State |
---|---|---|---|
n/a |
Lead Sponsor | Collaborator |
---|---|
Mercy Health Muskegon |
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Resolution of arrhythmia | Efficacy of treatment as defined by the achievement of a heart rate of <110 beats/minute | within 30 minutes of drug administration | |
Secondary | Use of additional medications to achieve rate control | Percentage of patients who require medications other than diltiazem to achieve rate control. | within 30 minutes of diltiazem administration | |
Secondary | Frequency of cardioversion | Incidence of electrical cardioversion to achieve rate control | within 30 minutes of diltiazem administration | |
Secondary | Frequency of hospital admission | Percentage of enrolled patients who require hospital admission to achieve and maintain rate control | within 24 hours of study related treatment in the Emergency Department. | |
Secondary | Identification of adverse events. | Characterization and frequency of adverse events | at the time of diltiazem administration and and immediately following the medication | |
Secondary | Occurrence of allergic reactions | Evaluate occurrence of allergic reactions | at the time of diltiazem administration and and immediately following the medication |
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