roja

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So, I have had several patients with afib and tachycardia (one with a pacer one with out) and the overall preference for slowing rate seems to be Dilt.

Everyone seems to like beta blockers in theory but the general feeling seems to be: 'they just don't work as well'. What's everyone elses experiences?
 

Kalel

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Don't know if you were just looking for anecdotal experience, but the American College of Cardiology has a website with a lot of different "practice guidelines" that I like.
http://www.acc.org/clinical/guidelines/atrial_fib/VIII_management.htm#VIII_F1
A lot of the recent studies examining rate control have been using the non-dihydropyridine calcium channel blockers in addition to digoxin, but there also seems to be some benefit to using beta blockers in the non-acute/chronic management stage since they may decrease morbidity and mortality in heart failure patients (whereas the calcium channel blockers may worsen morbidity and mortality if used chronically).
 

EMIMG

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Depends on the patient population. I am always concerned about the use of cocaine in my patient population therefore, I tend to go with the CCB.
 
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DocWagner

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I use cardizem with greater frequency, but I have used Lopressor also (usually if they are on the PO dose at home). When I have a patient refractory to Cardizem boluses, and they still have a rate of 120 or so I will bolus Lanoxin then redose q 6. There are great articles at www.empractice.net and at www.emrap.us (the writers of EMRAP/USC-LAC)
 

beyond all hope

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Sorry, I don't even really remember how to treat chronic a-fib anymore. I seem to remember I used amiodarone a lot. For rate control I always use a Dilt and Dig, just habit I guess, plus I work with a mostly African-American population with a lot of Asthma, DM and PVD.

If you look at the ACLS protocols and texts you see Verapamil as first line, but I never use Verapamil, even for SVT.
 

dr.smurf

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but remember that CCB are neg inotropes so you have to be careful in pts with CHF as it may put them in failure. the cardiologist i worked with used BB as first line if not contraindicated (severe COPD, etc.). Dig loading is effective and cheap but can take up to an hour so if you have a pt with symptomatic RVR you should go with something that will slow the rate down fast like BB or CCB. but an EF< 40% you should stay away from CCB!
 

southerndoc

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We have a policy at my hospital (where I'm a student, not where I'll be a resident at) whereby any patient who receives diltiazem IV must go to the unit (usually CCU, occasionally MICU) for the first 24-48 hours.

So that brought up a discussion with the cardiologist who I am currently precepting with. He said that a-fib patients with RVR who appear stable should receive ORAL diltiazem instead of IV. He said IV is too expensive and that studies show that oral works just as well, although it takes about an hour longer than IV.

Is anyone currently doing this? Is he just taking a cowboy stance, or is this actually true? The man really knows his stuff, but I wonder whether he was just dissing EM physicians or whether he actually thinks EM docs use IV diltiazem too often. I tend to believe that he's an EM physician supporter because he's pushing for them to do treadmill testing in the ED (instead of admitting for obs and having medicine do it the following morning).
 

trauma_junky

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Well, if you're dealing with a symptomatic acute RVR, I think it would be wise to go IV. Or Versed and "Clear!"
 

DocWagner

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Put it to ya this way...if you come into the ED with symptomatic A fib with RVR 1. you get an IV 2. I plan on using it with IV Cardizem rather than PO...if the rate is initially controlled with IV and they are placed on a drip, they then get po meds.
You guys will get used to managment when you do your ICU months and it is only you! I have used literally everything at some point...from Magnesium, to Ibutilide (sp?) to electricity. I have also noted that the Digoxin IV taking an hour, really hasn't stood up (for me anyway), I find that it works much faster, perhaps because i am using it in conjunction with a CCB.
The point is you should know 3 ways of controlling A fib RVR for just about any situation.
 
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