Atrial Fibrillation | Randomized Trial Comparing Diltiazem and Metoprolol For Atrial Fibrillation Rate Control
Atrial Fibrillation research study
What is the primary objective of this study?
Atrial Fibrillation and atrial flutter (AF/FL) is the usually irregular beating of the heart and is a rapidly growing cause of hospitalization. Between 1993 to 2007 AF/FL hospitalizations have increased 203% compared to a 71% increase for all hospitalizations. Changing procedure management such as ablation, transesophageal have had a minimal impact on the trends and there is a need to evaluate Emergency Department (ED) management options of AF/FL that may decrease hospitalizations. The most commonly used medications to control heart rate are metoprolol (MET), a beta blocker, or diltiazem (DT), a calcium channel blocker. Beta blockers are medications that cause the heart to beat more slowly and with less force. DT also helps blood vessels open up to improve blood flow. Both DT and MET are used alone or together with other medicines to treat severe chest pain (angina), high blood pressure (hypertension) or rapid heartbeat. Both are equally acceptable according to recent guidelines for AF/FL. There are limited studies comparing MET to DT for rate control for AF/FL. The initial goal for AF/FL management in the Emergency Department is usually rate control. The most commonly used rate control medications are metoprolol (MET), a beta blocker, or diltiazem (DT) a calcium blocker. Three major guidelines, including the American College of Cardiology (ACC) and the American Heart Association (AHA) indicate beta blockers and DT are equally acceptable medications for rate control in AF (3,4,5) assuming no contraindications. There are limited studies comparing beta blockers (BB) to DT for rate control for AF: 1. Demircan, et. al., compared bolus intravenous BB and DT in 40 patients over a 20 minute period. No follow-up information after 20 minutes was reported. No attempt was made to look at intermediate or long term results. No patients converted to normal sinus rhythm over this short treatment period and there was slightly more rate decrease at 20 minutes, with DT versus BB (6). 2. Time from medication administration to heart rate and rhythm control. Additionally, currently guidelines consider BB or DT medications to slow AF/FL; however, there are some suggestions that BB may not only slow heart rate in AF/FL (as does DT) but also increase all AF/FL conversion from AF/FL to normal sinus rhythm(2), and aid in maintaining normal sinus rhythm (NSR) after cardioversion (10). With recent onset AF/FL occurring within 48 hours prior to the arrival to the ED, approximately 50% of AF/FL patients convert to normal rhythm spontaneously within 24 hours after arrival to the ED (6), making evaluation of current limited studies difficult. Thus, the investigators wish to examine the effect of initial medication strategy on time to NSR in a larger sample than has been previously performed. 3. A randomized study of 48 patients in China reported significantly slower heart rate up to 20 minutes with DT 10mg IV versus metoprolol 5mg IV but not after 30 minutes (7). 4. A retrospective study of post-operative coronary bypass patients showed the intravenous administration of the BB, esmolol, to be more effective than DT for rate control and conversion of AF/FL (8). 5. Hassan et al reported no difference in conversion to regular rhythm with esmolol verses DT in a small, under powered, randomized study of fifty ED patients (9). Conversion to sinus rhythm occurred in 10 patients (42%) in the DT group compared with 10 patients (39%) in the esmolol group (P = 1.0). There were no statistically significant differences in heart rate between the two medications at 1, 6, 12, and 24 hours after initiation of esmolol or DT infusion. Examples of such well quoted strategy trials are the COURAGE trial published in the New England Journal of Medicine and the PROMISE Trial, a worldwide multi-centered study that is nearing completion goal of 10,000 patients of which, Charleston Area Medical Center (CAMC) has enrolled approximately 100 patients. In this trial, patients being evaluated for chest pain will be randomized to two treatment strategies and subsequent outcomes will be recorded. Strategy trials do not attempt to manage treatment after an initial management strategy has been determined by randomization, but, whether the initial treatment affects long-term outcomes. This will be a prospective, randomized study comparing the outcomes of a strategy using either MET or DT in patients with AF presenting to the Charleston Area Medical Center (CAMC) ED. After presentation and receiving consent, the patient will be randomized to receive either MET or DT.
Who is eligible to participate?
Inclusion Criteria: - Patients presenting to Charleston Area Medical Center (CAMC) General or Memorial Hospital ED with a primary diagnosis of AF/FL - Patients with a mean ventricular rate of 100 beats per minute or more within one hour of presentation Exclusion Criteria: - Under age 18 years - A diagnosis of acute coronary syndrome (ACS) made by the admitting ED physician (ST elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina) (beta blockers are a Class I medications for ACS) - Known history of heart failure with an ejection fraction <50% - Known ejection fraction <45%, regardless of a history of heart failure. Heart failure and a history of heart failure with an ejection fraction of 40-50% may occur with a normal ejection fraction now referred to as Heart Failure With Preserved Ejection Fraction (HFpEF) or \"diastolic dysfunction\". A low ejection fraction is not always associated with heart failure. Our technology of measuring ejection fraction is by no means perfect. It is acceptable to use MET in larger than usual starting doses of MET for rate control or patients with \"diastolic dysfunction\", but not systolic dysfunction. Thus, a patient who has an ejection fraction of 42% may possibly have an ejection fraction of 37%, possible lower. Thus the investigators want to avoid the possibility of a patient with a history of heart failure does not receive MET unless the investigators feel systolic heart failure is not present. - Systolic blood pressure <90 mm Hg or between 90-99 AND patient is experiencing symptoms of dizziness - Known allergy or adverse reactions to diltiazem or metoprolol. This is very rare. Exclusions from ECG readings: - Current Atrioventricular (AV) block (2nd or 3rd degree) - Pre-excitation syndromes - Wolfe Parkinson White (WPW) (Accelerated AV conduction- a rare condition where MET and DT are not advised) - Pulse rate less 100/minute on ED admission (already at rate control) - Cardiogenic shock or heart failure requiring inotropic agents or intubation - Respiratory failure requiring intubation - Pregnancy or lactation (neither pregnancy or lactation are listed as definitely safe for either medication) - Asthma, defined as (asthma is a relative contraindication for MET: - current use of inhaler - use of steroids for dyspnea - history of being treated for asthma - Inability or unwillingness to provide informed consent - Physician decision - If either medication is a relative contraindication, the patient cannot be randomized.
Which medical condition, disease, disorder, syndrome, illness, or injury is researched?
Interventions can include giving participants drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available or noninvasive approaches such as surveys, education, and interviews.
Drug:MetoprololThe attending ED physician may use higher or lower intravenous doses depending on patient response as this is the norm in clinical practice for these two medications used for decades for AF/FL rate control. Conversion of intravenous to oral, chronic management will be left to the discretion of the ED or managing medical team.
Drug:DiltiazemThe attending ED physician may use higher or lower intravenous doses depending on patient response as this is the norm in clinical practice for these two medications used for decades for AF rate control. Conversion of intravenous to oral medication for rate control for chronic management will be left to the discretion of the ED or managing medical team.
Research studies and clinical trials typically have two or more research arms. An arm is a group of people who receive the same treatment in the study.
MetoprololMetoprolol 2.5 to 5.0 mg IV bolus over two minutes Repeat every five minutes up to a total dose of 15 mg as long as tolerated (Blood pressure is over 100 mm /Hg systolic (or BP is 90 to 100 mm\Hg systolic and the patient is not dizzy)) If rate inadequate the physician has option of: Further doses of metoprolol IV or PO Intravenous amiodarone IV diltiazem Observation
DiltiazemBolus 0.25 Mg/Kg over two minutes (average adult dose 20 mg). If after 15 minutes The first dose is tolerated, and Ventricular rate is over 100 beats a minute AND Blood pressure is over 100 mm /Hg systolic (or BP is 90 to 100 mm\Hg systolic and the patient is not dizzy) Give diltiazem 0.35 Mg/Kg over two minutes (average adult dose 25 mg). After initial bolus', start infusion 5 to 15 Mg/hour to maintain rate control as long as: 1. BP over 100 mm/Hg or between 90 and 100 mm/Hg and the patient is not dizzy. If rate inadequate the physician has an option of: Metoprolol PO (by mouth) or IV (intravenous) Digoxin PO or IV Intravenous amiodarone Observation
Start Date: December 2013
Completed Date: December 2018
Phase: Phase 4
Primary Outcome: Conversion to sinus rhythm
Secondary Outcome: Home discharges from Emergency Department (ED)
Study sponsors, principal investigator, and references
Principal Investigator: William H. Carter, MD
Lead Sponsor: CAMC Health System
Wong CX, Brooks AG, Leong DP, Roberts-Thomson KC, Sanders P. The increasing burden of atrial fibrillation compared with heart failure and myocardial infarction: a 15-year study of all hospitalizations in Australia. Arch Intern Med. 2012 May 14;172(9):739-41. doi: 10.1001/archinternmed.2012.878.