Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department.

OBJECTIVE: The purpose of this study was to compare the effectiveness and safety of the metoprolol and diltiazem administration in the Emergency Department (ED) for rate control of supraventricular tachycardia. METHODS: This was a retrospective cohort study of adult patients who presented to the ED with ventricular rates ≥120 beats per minute (bpm) and who received bolus doses of either intravenous metoprolol or intravenous diltiazem. The primary outcome was achievement of rate control, defined as heart rate < 110 bpm, at two hours after administration of the last bolus dose of metoprolol or diltiazem. Safety outcomes included occurrence of hypotension, defined as systolic blood pressure < 90 mmHg or diastolic blood pressure < 60 mmHg, and bradycardia, defined as heart rate < 60 bpm. RESULTS: There were 166 patients receiving metoprolol and 183 patients receiving diltiazem included in the study. The primary outcome, rate control at two hours after the last bolus dose of metoprolol or diltiazem was similar between the two groups (45.8% vs 42.6%, p = 0.590, respectively). The percentage of patients achieving rate control was also similar (47.0% vs 41.6%, p = 0.333) at one hour. At 0.5 h HR had a significantly greater numerical (diltiazem: 29.3 ± 23.1 bpm vs metoprolol: 21.8 ± 18.9 bpm, p = 0.012) and percent decrease (21.1% vs 15.94%, p = 0.014) in the diltiazem group compared to metoprolol. There was no significant difference in occurrence of bradycardia in the two groups (diltiazem: 3.83% vs metoprolol: 1.2%, p = 0.179). More patients in the diltiazem group compared to the metoprolol group experienced hypotension (39.3% vs 23.5%, p = 0.002). The difference in systolic hypotension events was not significantly different (9.29% vs 5.42%, p = 0.221), while the difference in diastolic hypotension events was significantly different (37.7% vs 22.3%, p = 0.002). CONCLUSION: There was no difference in acute rate control effectiveness two hours after the last bolus dose of diltiazem and metoprolol for supraventricular tachycardias. There was a significantly higher occurrence of hypotension in the diltiazem group which was driven by higher rates of diastolic blood pressures less than 60 mmHg.

Incidence of thromboembolic events following administration of four-factor prothrombin complex concentrate (4F-PCC) for oral anticoagulation reversal.

INTRODUCTION: Prothrombin complex concentrates (4F-PCC) for anticoagulation reversal pose a risk of thromboembolism although data are limited. This study aims to quantify thromboembolic events (TE) and describe associations. MATERIALS AND METHODS: Retrospective, two-center, study of patients receiving 4F-PCC between September 2013 and December 2017 for warfarin or direct oral anticoagulant (DOAC) reversal. Primary outcome was in-hospital TE incidence and secondary outcomes were to describe characteristics associated with TE. Data are reported descriptively and analyzed with bivariate and multivariate analyses. RESULTS: 542 patients were included (mean age 73 ± 14 years, 58% male, 76.6% warfarin/23.4% DOAC reversal). Most had intracranial hemorrhage (68.5%) or were undergoing an emergent procedure (13.4%). Fifty patients (9.2%) experienced in-hospital TE and most (62%) occurred within 7 days of 4F-PCC. Younger age (66 vs. 74 years, p < 0.01), presence of a hypercoagulable risk factor (46% vs. 26%, p < 0.01), indication for anticoagulation (p = 0.008), higher 4F-PCC dose (2148 vs. 2000 units, p < 0.01), and longer hospital length of stay (LOS) (21.5 vs. 7 days, p < 0.01) were associated with TE following bivariate analysis. Multivariate analysis identified anticoagulation indication of venous thromboembolism or "other" (e.g., antiphospholipid syndrome, Factor V Leiden) were independently associated with higher incidence of TE compared to receiving anticoagulation for atrial arrhythmia (p = 0.05). Hospital LOS ≥ 7 days was associated with threefold greater odds of TE compared to <7 days (p = 0.003). CONCLUSIONS: In-hospital TE following 4F-PCC was 9.2%, most events occurred within 7 days, and younger age, indication for anticoagulation, and LOS were independently associated with TE which may influence treatment selection.

Evaluation of Fixed-Dose Four-Factor Prothrombin Complex Concentrate for Emergent Warfarin Reversal in Patients with Intracranial Hemorrhage.

BACKGROUND: Different strategies exist for dosing four-factor prothrombin complex concentrate (PCC4) for international normalized ratio (INR) reversal in the setting of life-threatening bleeding. Fixed doses ranging from 1000 IU to 1750 IU have demonstrated efficacy similar to weight-based dosing, however, few studies look exclusively at intracranial hemorrhage (ICH). OBJECTIVE: Our aim was to evaluate whether a fixed dose of 1000 IU of PCC4 achieves INR reversal similar to weight-based dosing in patients with ICH who were anticoagulated with warfarin. METHODS: We compared a weight-based dose vs. 1000 IU PCC4 between January 2014 and January 2017. The primary end point was achieving an INR < 1.5. Secondary end points included in-hospital mortality, patient disposition, and reversal defined by INR < 1.6. RESULTS: A total of 31 patients were included in the weight-based group and 30 were included in the fixed-dose group, with baseline INRs of 2.98 and 2.84, respectively (p = 0.39). Twenty-two patients (71%) achieved an INR < 1.5 in the weight-based group vs. 16 (53%) in the fixed-dose group (p = 0.15), while 25 (81%) achieved an INR < 1.6 in the weight-based group vs. 22 (73%) in the fixed-dose group (p = 0.49). There was no difference in the number of patients discharged to home (19% vs. 20%; p = 0.95) or in-hospital mortality (26% vs. 27%; p = 0.93). CONCLUSIONS: We found a non-statistically significant difference in warfarin reversal to an INR goal of < 1.5 when comparing a fixed dose of 1000 IU PCC4 and a weight-based dose for ICH. Further studies correlating clinical outcomes with INR reversal are needed.