Purpose/Background: Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Sixty to seventy percent of patients with AF who present to the emergency department (ED) have rapid ventricular response (RVR), a heart rate (HR) greater than 120 beats per minute (bpm) in response to inappropriate ventricular rate control. The 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation recommends that patients with acute AF with RVR without decompensated heart failure receive an intravenous (IV) bolus dose of diltiazem 0.25 mg/kg actual body weight. However, this is not always applied in practice with some prescribers utilizing lower, non-weight-based doses.
Methodology: A retrospective chart review and analysis was conducted to evaluate the efficacy of utilizing the full, guideline and package insert recommended bolus of diltiazem as compared to a low dose bolus for AF with RVR. All patients included in this study were adults admitted to any CaroMont Health ED. Patients were identified by generating a report of those who have been admitted for AF with RVR and received an IV bolus of diltiazem between January 1, 2022 and January 1, 2025. The primary endpoint was the incidence of achieving a HR of less than 100 bpm within 30 minutes of diltiazem bolus administration. Secondary endpoints included incidence of bradycardia, incidence of hypotension, administration of additional rate-controlling medications, length of stay, mortality and readmission after 30 days. Additional information collected included past medical history of AF, heart failure, hypertension, and hyperthyroidism; home antiarrhythmic prescription(s); and primary diagnosis of admission. All categorical endpoints and demographics were evaluated using a chi-square test. Parametric continuous variables utilized t-tests, while nonparametric continuous variables were analyzed using Mann-Whitney U tests. The reliability of data abstracted was validated through a 10 percent medical record review by a co-investigator. An interrater agreement coefficient was reported using a kappa statistic.
