Intravenous beta blockers and non-dihydropyridine calcium channel blockers are recommended first-line for atrial fibrillation (AF) with rapid ventricular rate (RVR) . In a previous post, Bryan Hayes (@PharmERToxGuy) provided an overview of the data comparing beta blockers to calcium channel blockers for atrial fibrillation rate control in the ED. Here is part 2 of our two-part AF series.
Thinking Beyond the Emergency Department
Although clinicians are cautioned regarding their use in heart failure or hypotension, minimal guidance is provided on which of the two classes is most appropriate in an individual patient. While acute rate control is certainly an important therapeutic goal for patients in AF with RVR, consideration of the patient’s comorbid conditions may be just as important for determining which drug class represents a more viable long-term solution. As a consequence, judicious selection of initial therapy may therefore avoid unnecessarily prolonging a patient’s hospitalization while therapy is transitioned. The following are several common comorbidities of AF where one agent may be more ideal over another:
1. Heart failure
Both beta blockers and non-dihydropyridine calcium channel blockers exert negative inotropic effects in the acute setting and should therefore be used with caution in patients with heart failure with reduced ejection fraction (HFrEF). However, long-term beta blocker use confers significant improvements in survival whereas non-dihydropyridine calcium channel blockers either exert no beneficial effects or may even worsen outcomes [2-4]. For these reasons, the use of non-dihydropyridine calcium channel blockers should generally be avoided in patients with HFrEF despite minimal differences in their acute risks .
2. Ischemic heart disease
Although both classes are associated with improvements in major adverse cardiovascular events in patients with a history of myocardial infarction (MI), only beta blockers have been associated with reductions in the incidence of ventricular arrhythmias and sudden cardiac death [3, 4, 6]. Notably the benefits of beta blockers in the post-MI setting appear to attenuate over time, though they remain a standard of care and should be favored over non-dihydropyridine calcium channel blockers. The latter remain an option in patients with chronic stable angina or those whose symptoms are refractory to maximally-tolerated doses of beta blockers.
Along with angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and thiazide diuretics, calcium channel blockers are recommended as a first-line option for patients with high blood pressure . Their use as initial therapy is especially advocated in black patients (although thiazides are a viable alternative), given improvements in long-term cardiovascular events compared to inhibitors of the renin-angiotensin-aldosterone system . Beta blockers should be reserved for patients whose blood pressure remains uncontrolled despite use of the four preferred drug classes (ACEi or ARB, thiazide, or calcium channel blocker) given evidence from trials that they are less effective at preventing cardiovascular events . Therefore, in patients with concomitant high blood pressure who may benefit from additional blood pressure lowering, calcium channel blockers may be a more ideal option for rate control. The addition of a nondihydropyridine calcium channel blocker should generally be avoided in patients who are already receiving a dihydropyridine calcium channel blocker (e.g., amlodipine, nifedipine), as only a minimal incremental impact on blood pressure is observed.
4. Pulmonary disease
Calcium channel blockers should be favored over beta blockers in patients with asthma (or other forms of pulmonary disease with a bronchospastic component) given the risk of exacerbating bronchospasm. However, beta blockers need not be avoided in patients with chronic obstructive pulmonary disease (COPD) given lack of evidence to indicate harm and a potential benefit [9, 10].
Clinicians may be cautioned against using beta blockers in a number of other disease states, including diabetes mellitus, peripheral vascular disease, depression, and erectile dysfunction. However, in each case minimal evidence supports the risk of exacerbating disease and in most cases the benefits of therapy outweigh risks. That being said, a calcium channel blocker would be an acceptable choice in any of these conditions in the absence of compelling indications for beta blocker therapy.
Both beta blockers and calcium channel blockers appear safe and effective for acute rate control in AF with RVR. However, given the compelling benefits of one class over the other in several common comorbidities, initial selection should take these factors into consideration so that the medication chosen can represent both a short- and long-term solution.
- Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, et al. Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations) A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 May 7;127(18):1916–26. Pubmed
- Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7. Pubmed
- Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85. Pubmed
- The Multicenter Diltiazem Postinfarction Trial Research Group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med. 1988 Aug 18;319(7):385-92. Pubmed
- Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Oct 15;62(16):e147-239. doi: 10.1016/j.jacc.2013.05.019. Pubmed
- Turi ZG,Braunwald E.The use of beta-blockers after myocardial infarction. JAMA.1983 May 13;249(18):2512-6. Pubmed
- James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA J Am Med Assoc. 2014 Feb 5;311(5):507–20. Pubmed
- Leenen FHH, Nwachuku CE, Black HR, Cushman WC, Davis BR, Simpson LM, et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension. 2006 Sep;48(3):374–84. Pubmed
- Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549. Pubmed
- Rutten FH, Zuithoff NP, Hak E, Grobbee DE, Hoes AW. Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med. 2010 May 24;170(10):880-7. Pubmed
The post Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED appeared first on ALiEM.
IC-HU Project begins the specific activities to call everyone to action, with a measure in which we need your participation and interaction:
We ask you that, in all of Spain and the rest of the world, remove the ICUs mechanical fasteners to your patients, and share a photo in our @HUMANIZALAUCI twitter account or Facebook Group HUMANIZANDO LOS CUIDADOS INTENSIVOS . And of course, that you give diffusion to the Hashtag to all your contacts.
"... mechanical fasteners are something that violates a fundamental right such as the right to freedom. Used in excess or inappropriately, they can be interpreted as a form of "abuse", "negligence" or "abuse"...". (Defender of the people, Comunidad Autónoma País Vasco 2009)
The use of physical restraints in intensive care units is a common practice although its use has no scientific basis or their benefits are tested. In addition, we have little bibliography on perceive the use of the same patients and their families despite the fact that it is a controversial subject. We argue that they are used to reduce the risk of "disruption of the therapeutic measures" but does it in all cases?.
While it is true that only used fastening system are the wristbands we should do a reflection to establish interventions that reduce their use without losing the safe care to patients and not to forget that this practice can lead to legal implication for the professional.
The use of restraints should not be an alternative to inadequate human or environmental resources and reflect on this issue makes us separate ourselves from matters merely technicians of the critical patient to get closer to the real needs that are well worth our attention and also our effort so that care remains safe rethinking care model with the integration of the family as an example to decrease the use of restraints.
ICU Nurse, Hospital Universitario de Torrejón.
Fariña-López E, Camacho Cáceres AJ, Estevez-Guerra GJ, Bros i Serra M. Accidentes asociados al uso de restricciones físicas en ancianos con transtornos cognitivos: estudio de tres casos. Rev Esp Geriatr Gerontol. 2009; 44: 262-5.
Documento técnico SEGG Nº3. (2003) Hacia una cultura sin restricciones: las restricciones físicas en ancianos institucionalizados. Grupo de trabajo Julio 2003.
Fariña López, E.; Estévez Guerra, G.J. La restricción física de los pacientes siglos XIX Y XX. Revista Rol de Enfermería 2011; 34 (3): 182-189.
A.I. Perez de Ciriza Amatriaina, A. Nicolas Olmedoa, R. Go.ni Viguria a, E. Regaira Martineza, M.A. Margall Coscojuelab y M.C. Asiain Erroa. Restricciones físicas en UCI: su utilización y percepción de pacientes y familiares. Enfermería Intensiva. 2012; 23(2):77-86
Die Tätigkeit in der Notfallmedizin lässt sich nicht auf die Leistung einer einzelnen Person, einem Helden, reduzieren. Fernsehserien wie “Emergency Room” suggerieren dies gerne. Eine qualitativ hochwertige, professionelle Leistung in der Notfallmedizin lässt sich nur im Team erreichen ….
Hierzu ist neben einer exzellenten ärztlichen Qualitfikation auch eine exzellente pflegerische Qualifikation eine conditio sine qua non. Diesem Schritt ist die DGINA nun näher gekommen, wie in einer Pressemitteilung der DGINA publiziert wurde. Eine Gruppe von Pflegeexperten um das Vorstandsmitglied Frau M. Dietz-Wittstock hat das Fachcurriculum Notfallpflege veröffentlicht. Dies sollte Grundlage für die weitere Ausbildung der Fachkrankenpflege in der Notaufnahme/Notfallzentrum sein!
Gratulation! Tolle Leistung!
Thematisch passende Beiträge
Bronchiolitis is a very common presentation to paediatric emergency departments. In the absence of any effective treatments, most of care focuses around supportive measures e.g. oxygen or feeding supplementation.
There is no clear cut-off for the requirement for supplemental oxygen, but this generally varies between 90 and 95% saturation. These cut-offs are often used for deciding about admission to hospital, but in actual fact they are not predictive of progression of the illness.
This randomised, double-blind, parallel-group trial aims to investigate the role of pulse oximetry in making decisions around hospital admissions. It essentially tries to determine whether as doctors, we over-rely on these measurements.
Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
These were infants presenting with bronchiolitis to a tertiary paediatric emergency department over a five year period. They had to have saturations of 88% or higher to be included.
Those with cardiopulmonary, neuromuscular, haematologic, or congenital airway anomalies were excluded. They also excluded those with severe respiratory distress.
There were 108 infants in the control group, and 105 infants in the intervention group.
Recruited infant were randomised to either the true saturation group, or the altered saturation group.
Those in the altered saturation group had their saturations displayed three points higher than the true reading (i.e. if the true reading was 89% the sats monitor displayed 92%).
Doctors in the department knew that 50% of the infants would have their saturations altered in some way, but they didn’t know how much or in which direction.
The primary outcome was admission to hospital within 72 hours – this included either admission to the ward, or active care for respiratory symptoms for at least six hours. Active care was: oxygen, IV fluids, or bronchodilators.
Secondary outcomes included: supplemental oxygen in ED, timing of agreement for discharge home, length of stay, representations within the 72 hours.
In the true saturations group, 41% were admitted. In the altered saturations group, only 25% were admitted (p=0.005)
There were no differences in the the secondary outcomes (p=0.16).
By falsely elevating the oxygen saturations by just three points, there was a significant reduction in hospital admission rates for bronchiolitis in infants.
Oxygen saturations are just one of the factors we should take into account when deciding on the need for admission in bronchiolitis. We must be careful not to over-depend on arbitrary cut-offs.
The post The effect of oximetry on hospital admission for bronchiolitis appeared first on Don't Forget the Bubbles.