Usefulness of diltiazem in the acute management of supraventricular tachyarrhythmias in the elderly

Abstract

Acute management of supraventricular tachyarrhythmias is often difficult in elderly patients. Diltiazem was given intravenously (loading dose of 0.25 mg/kg over 2 minutes followed by a 4 mg/kg/24 hr infusion) in 37 elderly patients (mean age 70 years, range 60-91). Fifteen out of the 37 patients (41%) had left ventricular cardiac disease, 12 (32%) had cor pulmonale, and 10 (27%) had no obvious cardiac disease. Hemodynamic tolerance of the supraventricular tachyarrhythmia was poor in 12 patients. A good result was defined as a return to sinus rhythm after bolus or infusion, or as a slowing of the ventricular rate (VR) to less than 100 beats/min. Of the 23 patients in atrial fibrillation, about half reverted to sinus rhythm after diltiazem, and in most of the others the ventricular rate decreased to less than 100 beats/min. Side effects occurred in 10 patients (bradycardia in 6, cutaneous rash in 2, hypotension in 2). They rapidly reversed after cessation of diltiazem. They were responsible for 2 out of the 5 poor results. Thus, diltiazem appeared effective and safe when used carefully in elderly patients with supraventricular tachyarrhythmia.

Treatment of tachyarrhythmias

“…In patients with atrial fibrillation or flutter, preserved LV function, and a heart rate 120 beats/min or greater, evidence published before and since 1992 supports initial efforts at obtaining rate control with diltiazem (6 studies of fair-to-excellent quality, LOE 2, [162][163][164][165][166][167] and 2 studies of fair-to-good quality, LOE 5 168,169 ), β-blockers (6 studies of fair quality, LOE 5, [170][171][172][173][174][175] and 1 study of good quality, LOE 2 176 ), verapamil (6 studies of good-to-excellent quality, LOE 2, 164,177-181 and 3 studies of fair-to-good quality, LOE 5 [182][183][184] ), or digoxin (1 study of good quality, LOE 2 185 ). Available evidence (from both placebocontrolled and comparative studies of β and calcium channel blockers) suggests that digoxin is the least potent agent and has the slowest onset of action of the available pharmacologic options for ventricular rate control.…”

Part 6: Advanced Cardiovascular Life Support : Section 5: Pharmacology I: Agents for Arrhythmias

“…IV verapamil, 135-143 ␤-blockers, 144 -150 and diltiazem [151][152][153][154][155][156][157] are recommended for rate control in patients with AF or atrial flutter, preserved LV function, and a heart rate Ն120 bpm. 136 Available evidence suggests that digitalis, 158 though effective, is the least potent and has the slowest onset of action of the available pharmacological options for ventricular rate control.…”