Intravenous Diltiazem Research Articles

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Introduction: Abstract: Various neurotransmitters and endogenous chemicals such as serotonin and epinephrine are known to cause atrial fibrillation. We report a case of refractory atrial fibrillation with rapid ventricular response in a patient with carcinoid tumor. The atrial fibrillation in this case was secondary to elevated serotonin levels and responded to treatment with octreotide. Case: A 56 year-old woman was admitted for management of superior vena-cava (SVC) syndrome. She had a diagnosis of thyroid cancer with papillary, Hurthle cell and anaplastic histopathology after total thyroidectomy for goiter few years back. Later on, she was diagnosed with bronchial carcinoid based on an endobronchial biopsy. Her chest imaging showed a mediastinal mass and a left lower lobe endobronchial lesion with several metastatic lesions. She was treated with chemoradiation and a bronchial stent was placed. During her current hospitalization, her respiratory status deteriorated necessitating transfer to the intensive care unit and intubation. A bedside bronchoscopy confirmed the diagnosis of pneumonia. The patient was noted to have atrial fibrillation with rapid ventricular response (>160). A 2D echocardiography of the heart was performed and showed a normal left ventricle with an ejection fraction of 55%, normal right ventricle and no valvular abnormalities. The atrial fibrillation was initially attributed to sepsis and the patient was treated accordingly with appropriate resuscitation and antibiotics. However, the patient continued to have recurrent episodes of atrial fibrillation with rapid ventricular rhythm. Rate control was attempted but was unsuccessful. Treatment included beta-blockers (intravenous metoprolol), calcium channel blockers (intravenous diltiazem boluses and drip), intravenous amiodarone (bolus and drip) and intravenous digoxin over a period of several days. Because of the history of bronchial carcinoid cancer and the lack of response to conventional medications, neurotransmitter related atrial fibrillation was suspected. A random 5-HIAA to creatinine ratio was sent and was elevated at 20 ng/mg. octreotide therapy was initiated at 500 microgram subcutaneous every 8 hour. Patient responded within few hours, converting and remaining in normal sinus rhythm. Elevated epinephrine levels, seen in association with metastatic anaplastic thyroid cancer could have contributed to the atrial fibrillation and 24-hour urine collection for 5-HIAA and catecholamines would have been useful to further support the diagnosis but was not obtained. Nevertheless, the clinical response to octreotide therapy was compelling. Similar case reports of treatment of atrial fibrillation by methysergide and cyproheptadine has been described. Conclusions: We present a case of refractory atrial fibrillation due to elevated serotonin levels that responded to octreotide treatment. Atrial fibrillation has been described in association with vasoactive neurotransmitters like serotonin or epinephrine. Management options including agents such as octreotide, which inhibits the secretion of these neurotransmitters should be considered.

Pantoprazole (Proton Pump Inhibitor) Contributing to Torsades de Pointes Storm

Proton pump inhibitors (PPI), commonly used medications for peptic ulcer prophylaxis, have been recently described to cause hypomagnesemia through both urinary and gastrointestinal losses. Very few reports have linked hypomagnesemia with life-threatening ventricular arrhythmias. However, these reports included patients with other complex medical problems that may have also contributed to these arrhythmias. To our knowledge, ventricular arrhythmias associated with hypomagnesemia induced by proton pump inhibitors have never been reported. We present a case of a 53-year-old chronic alcoholic male patient, who was started on a proton pump inhibitor for peptic ulcer prophylaxis, which resulted in resistant hypomagnesemia associated with a storm of life-threatening arrhythmias, namely Torsades de Pointes (TdP). A 53-year-old man with no previous cardiac history was brought by Emergency Medical Services with a chief complaint of palpitations and dizziness for 1 day. His only significant medical history was chronic alcohol abuse and was not taking any medications before his admission. His physical examination was normal, except for an irregularly irregular rapid pulse and a blood pressure of 157/104 mm Hg. The ECG on admission showed atrial fibrillation with rapid ventricular response at an average of 190 beats per minute. Admitting routine labs showed normal complete blood counts. Electrolyte laboratory values revealed 136 mEq/L of sodium, 4.6 mmol/L of potassium, 100 mEq/L of chloride, 16 mEq/L of bicarbonate, 11 mg/dL of blood urea nitrogen, 0.68 mg/dL of creatinine, 9 mg/dL of calcium, and 1.5 mg/dL of magnesium. He was started on intravenous diltiazem for rate control and intravenous heparin for anticoagulation. Routine oral pantoprazole 40 mg once daily was also prescribed for peptic ulcer prophylaxis. Seven hours later, while on telemetry, the patient became unresponsive. The telemetry rhythm …

Diltiazemin Ondansetron ile Birlikte Kullanımının Anestezi Almış Sıçan Elektrokardiyografisi Üzerindeki Etkisinin Değerlendirilmesi

Objective: This study investigated the changes in electrocardiograms in rats after combined use of ondansetron and diltiazem. Material and Methods: Seventeen rats were included in the study but data were collected from 11 rats with available data. After anesthesia, electrocardiogram records of rats for the initial 5 minutes were considered ''Baseline'' record. Following this, rats received intravenous ondansetron injection and their electrocardiograms were recorded for another 5 minutes. The same procedure was repeated with intravenous diltiazem injection. Results: After ondansetron injection QTc from 9 rats were longer and 2 rats were shorter compared to baseline (before the administration of ondansetron). When diltiazem was given after ondansetron, in 10 rats out of 11, the QTc time was correlated negatively with measurements obtained before diltiazem. There was no statistically significant difference between the baseline QTc measurements and the QTc obtained after the administration of diltiazem. Conclusion: The combined use of ondansetron and diltiazem does not lead to any change in rat electrocardiography.

Differences in the Acute Pulmonary Vascular Effects of Oxygen with Nitric Oxide and Diltiazem: Implications for the Long-term Treatment of Pulmonary Arterial Hypertension

Right heart catheterization is performed in patients with pulmonary arterial hypertension to determine the severity of disease and their pulmonary vascular reactivity. This study sought to determine whether the acute pulmonary vasodilatory effects of diltiazem and oxygen with nitric oxide are similar enough to support the practice of using nitric oxide as a surrogate agent to identify patients to treat with an oral calcium channel blocker alone. Retrospective descriptive study. A tertiary medical center for children. Twenty-four individuals (7 months to 17 years of age) with pulmonary arterial hypertension who met criteria for a favorable acute pulmonary vasodilatory response to oxygen with nitric oxide, and were also evaluated with intravenous diltiazem. Right heart catheterization and an evaluation of pulmonary vascular reactivity. The pulmonary vasodilatory effects of oxygen, oxygen with nitric oxide, and intravenous diltiazem; and the need for medications other than amlodipine to decrease long-term pulmonary arterial pressure. Oxygen, oxygen with nitric oxide, and diltiazem acutely decreased pulmonary arterial pressure. Diltiazem also decreased systemic arterial pressure. A lower mean pulmonary arterial pressure was achieved with oxygen and nitric oxide than with diltiazem (30 ± 2 mm Hg vs. 39 ± 3 mm Hg, P< .05). Half of the patients who were treated long term with amlodipine alone failed to develop a long-term 20% decrease in pulmonary arterial pressure and were treated with additional medications. The combination of oxygen and nitric oxide decreased pulmonary arterial pressure more than a dose of intravenous diltiazem that was large enough to decrease systemic arterial pressure. Oxygen and nitric oxide may identify patients who can be treated safely with a calcium channel blocker; however, they should not be used as surrogates to identify patients to treat with a calcium channel blocker alone.

Resolution of sustained narrow complex ventricular tachycardia and tachycardia-induced cardiomyopathy in a Quarter Horse following quinidine therapy

Sustained narrow-QRS tachycardia of three months duration and left ventricular systolic dysfunction were identified in a fifteen-year-old Quarter Horse. No underlying cause for the tachyarrhythmia was found and no predisposing structural cardiac lesions were evident by echocardiography. Intravenous diltiazem and lidocaine were administered without achieving successful conversion of the arrhythmia. Oral quinidine therapy converted the tachyarrhythmia to sinus rhythm. Ventricular systolic dysfunction and chamber dilatation subsequently resolved. As with other species, echocardiographic features of dilated cardiomyopathy can be tachycardia-induced and may resolve following successful control of heart rate and rhythm.

Large Atrial Myxoma Causing Dynamic Obstruction of the Mitral Valve and Atrial Fibrillation

A 42-year-old healthy dairy farmer experienced 2 months of progressive exertional dyspnea and fatigue. Two days before presentation he noted palpitations at rest. Ausculatory cardiac examination revealed an irregular rhythm with an early diastolic plop. Electrocardiographic finding of atrial fibrillation with rapid ventricular response (Figure, A) was poorly responsive to intravenous diltiazem drip. Transthoracic echocardiography showed severe left atrial dilation and a large mobile left atrial mass causing pseudostenosis and mitral valve regurgitation (Video, Figure, B). Within 12 hours, the cardiac surgery team performed a mass excision and a maze procedure. The myxoma measured 5.2 × 4.8 × 3.7 cm and was attached to the left atrial surface by a broad stalk near the posteromedial commissure of the mitral valve, close to the annulus (Figure, B). The postoperative transthoracic echocardiogram showed no marked mitral valve regurgitation and an intact atrial septum. The patient's symptoms and electrocardiographic findings resolved after surgery. Myxomas make up half of the primary cardiac tumors in adults, and 75% are in the left atrium.1 Unlike malignant neoplasms, myxomas arise from the endocardium, vary widely in size, and are pedunculated and gelatinous (Figure, C). Histologic diagnosis is based on hematoxylin and eosin stain showing myxoma cells in a mucopolysaccharide stroma (Figure, D). Auscultatory findings of valvular abnormalities are common (64%), with classic “tumor plop” in 30%.2 Systemic embolization is present in 30% to 40% of patients, and valvular obstruction can cause sudden cardiac death, so high suspicion and prompt resection are required.2

Coronary Artery Spasm After Cryo Maze III Procedure

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines.

Effect of intravenous diltiazem and digoxin on atrial fibrillation after on-pump coronary artery bypass surgery

Atrial fibrillation (AF) occurs in 10–40% of patients undergoing coronary artery bypass surgery (CABG). The purpose of this study is to determine predictors of the time to occurrence of AF after CABG and the impact of intravenous diltiazem and digoxin on acutely (<6 hours) controlling heart rate (≤ 100/minute) and converting AF to normal sinus rhythm (NSR). We performed a retrospective review of 151 consecutive patients who had undergone CABG during a four-month period at our institution. Patients who developed AF postoperatively were treated at the discretion of the attending physician with the combination of IV diltiazem and digoxin, as per an approved protocol by a hospital committee. Univariate analysis using chi-square and Student’s t-test was performed. Cox Proportional Hazards Model was performed to determine variables that predicted the time to occurrence of AF. Time to achieve rate control (≤ 100/minute) was recorded in patients who did not convert to NSR. Arrhythmia control was defined as either conversion to NSR or rate control within six hours of initiation of treatment. AF occurred in 59 patients (39%) at a mean of 2.17 days following surgery, and 29 patients received immediate IV diltiazem (bolus 0.25 mg/kg followed by 5 mg/hr incremental drip) and digoxin (0.75 mg IV load). Acute conversion to NSR occurred in 21/29 (72%) patients. Arrhythmia control was achieved in 24/29 (83%) patients. Patients who developed AF and were on beta-blockers (BB) derived no incremental benefit from the addition of IV diltiazem and digexin in converting to NSR (p = NS). Using Cox Proportional Hazards Model, history of AF (p < 0.0001), age (p < 0.001), and chronic obstructive pulmonary disease (COPD) (p = 0.028) were significant variables in predicting the time to occurrence of AF. AF occurs frequently after CABG, and the combination of IV diltiazem and digoxin appears to be effective in rate control and was associated with a high conversion rate to NSR. History of AF, age, and COPD predicted the time to occurrence of AF.

Late erosion of an Amplatzer septal occluder device 6 years after placement

CLINICAL SUMMARY A 46-year-old man underwent transcatheter closure of a PFO at our institution after a stroke-like event. The stretched diameter of the PFO was 9 to 10 mm. A 14-mm Amplatzer septal occluder device (AGA Medical Corporation, Golden Valley, Minn) was placed. Immediately after placement, a trivial degree of left-to-right shunt was seen through the center of the device by intracardiac echocardiography; agitated saline injection revealed a trivial right-to-left shunt. The procedure was uncomplicated, and the patient was dismissed from the hospital the following day. Predismissal transthoracic echocardiogram (TTE) showed good position and stability of the device with no apparent shunt. Ten days later, the patient returned with intermittent palpitations. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. He was given intravenous diltiazem and promptly returned to sinus rhythm. TTE again documentedgoodposition of the occluder devicewith no recurrent atrial shunt or pericardial effusion. He was observed in the hospital overnight and dismissed on a regimen of oral diltiazem for 1 month. He had no recurrence of atrial fibrillation. Six years later, he came to the emergency department with progressive pleuritic chest pain. He had had similar chest pains 1month prior, which were not extensively investigated, but resolved spontaneously. In the emergency department he was hypotensive with mild jugular venous distention. TTE documented moderate pericardial effusion with tamponade. Pericardiocentesis removed 325 mL of bloody fluid. Transesophageal echocardiography did not show any evidence of shunt around the device. The device was again noted to not straddle the aortic root. Transesophageal echocardiographic

Attenuation of the Pressor Response to Laryngoscopy and Tracheal Intubation with Intravenous Diltiazem and Esmolol Intravenous in Controlled Hypertensive Surgical patients

Tachycardia and hypertension are well documented sequels of laryngoscopy and endotracheal intubation which is transient, highly variable and is generally well tolerated in healthy patients. In hypertensive patients, cardiovascular response to laryngoscopy and intubation is exaggerated. The aim of this study intended to find a better alternative by comparision amongst diltiazem and esmolol to attenuate the pressor response to laryngoscopy and intubation in Kasmiri Population. Randomized placebo controlled double blind study. One hundred fifty hypertensive patients of both sexes (ASA II), controlled on antihypertensive drugs, between age range of 40-60 years scheduled for routine surgical procedures were divided into 3 groups Group A (10 ml of 5 % Dextrose), Group B (Diltiazem 0.2 mg/Kg) and Group C (Esmolol 1.5 mg/Kg). Baseline parameters, i.e. heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and rate pressure product were noted at baseline level, at 1 min., 3min. and 5min after tracheal intubation. Both Esmolol and Diltiazem showed statistically significant attenuation of rise in systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and rate pressure product when compared to control. However Diltiazem failed to attenuate rise in heart rate. We conclude that Esmolol is a very effective agent in attenuating the pressor response to laryngoscopy and intubation in controlled hypertensive patients. La taquicardia e hipertensión son efectos bien documentados de la laringoscopia e intubación orotraqueal que son transitorios, muy variables y generalmente bien toleradas en los pacientes sanos. Sin embargo, en los pacientes hipertensos, la respuesta cardíaca a la laringoscopia e intubación es exagerada. El objetivo de este estudio es encontrar la mejor alternativa entre diltiazem y esmolol para atenuar la respuesta presora a la laringoscopia e intubación en una población de Cachemira. Estudio aleatorizado controlado doble ciego. Ciento cincuenta pacientes hipertensos de ambos sexos (ASA II), controlados con drogas antihipertensivas con edades entre los 40 y 60 años programados para cirugías rutinarias fueron divididos en tres grupos, grupo A (10 ml de dextrosa al 5 %), grupo B (diltiazem 0,2 mg por kilo), y grupo C (esmolol 1,5 mg por kilo). Los parámetros de base como frecuencia cardíaca, presión arterial sistólica, presión arterial diastólica, presión arterial media y doble producto, fueron anotados al inicio al minuto 1 al minuto 3 y al minuto 5 después de la intubación traqueal. Tanto el esmolol como el diltiazem demostraron atenuación estadísticamente significativa de la presión arterial sistólica, diastólica y media, y del doble producto, cuando se compararon al control. Sin embargo el diltiazem no pudo evitar un aumento de la frecuencia cardíaca. Concluimos que el esmolol es un agente muy efectivo para atenuar la respuesta presora a la laringoscopia e intubación en pacientes hipertensos controlados.

Clinical observation of infusion of intravenous diltiazem in treatment of refractory unstable angina

Objective To investigate the efficacy and safety of diltiazem to refractory unstable angina pectoris.Methods 42 unstable angina patients,who were failed to conventional anti-angina pectoris treatment,were treated with continuous infusion of intravenous diltiazem for 72 hours.Gradual titration of diltiazem was controlled.Angina attack frequency,ST segment depression and changes in blood rheologic indexes were observed before and after treatment.Results The attack of angina was effectively controlled after diltiazem treatment.The total effective rate was 90.1%.The average attack frequency,average attack duration and depression of ST segment were significantly decreased after diltizaem treatment(P ＜ 0.05).The blood pressure,heart rate ( P ＜ 0.05) and the systolic blood pressure × heart rate significantly decreased(P ＜ 0.01) after diltizaem treatment,without serious adverse reactions.Conclusion It was effective and safe to treat refractory unstable angina pectoris with diltizaem intravenous injection,but the dose titration should be strictly controlled. Key words: Refractory unstable angina; Diltiazem; Efficacy; Security

Pacing Threshold Testing Induced Ventricular Fibrillation Following Acute Rate Control of Atrial Fibrillation

A properly placed stimulus on the T-wave during ventricular repolarization can result in ventricular fibrillation (VF). Initiation of VF with pacing on T-wave is a rare event with a few reported cases in the literature. We present a unique case of induced VF attributed to a pacing stimulus on T-wave during ventricular pacing threshold testing of a permanent pacemaker. A 64-year-old woman with persistent atrial fibrillation (AF) and a permanent pacemaker for tachycardia-bradycardia syndrome presented with symptomatic AF with rapid ventricular response. Acute rate control was achieved with intravenous diltiazem. During ventricular pacing threshold testing, noncapture occurred followed by a pacing spike on T-wave initiating VF. Cardiopulmonary resuscitation and defibrillation converted the rhythm to rate-controlled AF. An acute prolongation of the QT was noted and normalized within 12 hours. No antiarrhythmic medications were used. Postevent laboratory values were within normal limits. She was free of ischemia and an echocardiogram revealed normal left ventricular function. She recovered from the event and was discharged with rate-controlled AF. No further pacing-induced arrhythmias have occurred during follow-up pacemaker interrogation and 12-lead electrocardiograms continued to show normal QT intervals. Pacemaker-induced VF is an extraordinarily rare complication of cardiac pacing. Alterations in ventricular repolarization with rapid slowing of the heart rate demonstrated by acute prolongation of QT intervals may play a role. This report should alert physicians to the possibility of QT prolongation and an increased risk of ventricular arrhythmias following acute rate control of AF.

Comparison of the effectiveness of intravenous diltiazem and metoprolol in controlling the rapid ventricular rate in patients with atrial fibrillation

Objective To compare the effectiveness between dilfiazem and metoprolol administered intra-venously on controlling the ventricular tachy-cardia in patients with atrial fibrillation (AF). Method From Jan-uaxy 2003 to July 2006, 48 AF patients in the Second Hospital, Jilin University, with a ventricular rate > 120 beats per minute and systolic blood pressure > 100 mmHg were enrolled and divided into dihiazem group (10 mg, Ⅳ, n = 24) or metoprolol group (5 mg, Ⅳ, n = 24). Blood pressure and heart rote were re-checked at different inter-vals of 5, 10, 15 and 30 minutes,respectively. Successful treatment was defined as ventricular rate 20% of the pre-treatment level, or restoumtion of sinus rhythm. Results Compared with pre-treatment value, a significant deceleration in ventricular response to AF was observed after treatment in both groups at each interval (P < 0.01). However, the ventricular rate in the diltiazem group was significantly lower than that in the metoprolol group (P <0.05) at all intervals but 30 minutes. A slight decrease in blood pressure was ob-served in both groups. The drop of blood pressure between two groups was comparable. The successful treatment at the interval of 30 minutes was achieved in 91.7% of patients in dihiazem group and 83.3% of patients in metopro-lol group (P < 0.05). Conclusions Both diltiazem (10 mg, Ⅳ) and metoproiol (5 mg, Ⅳ) are effective on con-trolling the accelerated ventricular response to AF, in particular, the effect of diltiazem seems much superior to ahat of metoprolol. Key words: Atrial fibrillation; Diltiazem; Metoprolol ; Intravenous; Effectiveness

Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation*

To compare the clinical efficacy of intravenous diltiazem, digoxin, and amiodarone for acute ventricular rate (VR) control in patients with acute symptomatic atrial fibrillation (AF) necessitating hospitalization. Randomized control trial. Acute emergency medical admission unit in a regional teaching hospital in Hong Kong. One hundred fifty adult patients with acute AF and rapid VR (>120 bpm). Patients were randomly assigned in 1:1:1 ratio to receive intravenous diltiazem, digoxin, or amiodarone for VR control. The primary end point was sustained VR control (<90 bpm) within 24 hours; the secondary end points included AF symptom improvement and length of hospitalization. At 24 hours, VR control was achieved in 119 of 150 patients (79%). The time to VR control was significantly shorter among patients in the diltiazem group (log-rank test, p < 0.0001) with the percentage of patients who achieved VR control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). The median time to VR control was significantly shorter in the diltiazem group (3 hours, 1-21 hours) compared with the digoxin (6 hours, 3-15 hours, p < 0.001) and amiodarone groups (7 hours, 1-18 hours, p = 0.003). Furthermore, patients in the diltiazem group persistently had the lowest mean VR after the first hour of drug administration compared with the other two groups (p < 0.05). The diltiazem group had the largest reduction in AF symptom frequency score and severity score (p < 0.0001). In addition, length of hospital stay was significantly shorter in the diltiazem group (3.9 +/- 1.6 days) compared with digoxin (4.7 +/- 2.1 days, p = 0.023) and amiodarone groups (4.7 +/- 2.2 days, p = 0.038). As compared with digoxin and amiodarone, intravenous diltiazem was safe and effective in achieving VR control to improve symptoms and to reduce hospital stay in patients with acute AF.

Atrial Fibrillation: The New Epidemic of the Ageing World.

The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases. AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily.

Effects of intravenous diltiazem on a porcine model of endotoxin-induced pulmonary hypertension

Pulmonary hypertension (PAH) is a life-threatening disease commonly seen in ICU septic patients. PAH is characterized by alterations in the pulmonary circulation leading to right ventricular failure and is associated with poor outcome in such patients. Various agents such as nitric oxide, prostaglandins and phosphodiesterase inhibitors have been used for its treatment. Drugs that induce pulmonary vasodilatation, increase contractility and maintain a stable haemodynamic profile seem an attractive treatment option in acute PAH patients. However, there is lack of evidence-based guidelines in the current medical literature. Although oral diltiazem has been shown to improve haemodynamics in chronic PAH patients, it has not been used for the treatment of acute PAH. The aim of the present study was to evaluate the effects of intravenous diltiazem on a porcine model of acute PAH during sepsis.

Precipitation of Ventricular Fibrillation by Intravenous Diltiazem and Metoprolol in a Young Patient with Occult Wolff‐Parkinson‐White Syndrome

We report the case of a young man who presented with a rapid, narrow-complex atrial fibrillation. A few hours after being administered intravenous metoprolol and diltiazem for rate control, he developed intermittent ventricular preexcitation on the electrocardiogram (ECG) and experienced ventricular fibrillation, from which he was successfully defibrillated. A subsequent electrocardiogram in sinus rhythm demonstrated previously unknown Wolff-Parkinson-White pattern. A left lateral accessory pathway was successfully ablated. Wolff-Parkinson-White syndrome should be included in the differential diagnosis when a young patient presents with atrial fibrillation, even if the ventricular complexes on the ECG are not preexcited.

Incessant right ventricular outflow tract ventricular tachycardia due to subacute postpartum thyroiditis

A previously healthy 26-year-old, 4-month postpartum primipara presented with palpitations and pre-syncope and Holter monitoring shows frequent monomorphic ventricular tachycardia (VT). She denies any other symptoms. On admission she was haemodynamically stable and ECG in emergency room showed sustained monomorphic VT (cycle length, 240 ms; left bundle branch abnormality-inferior axis morphology, and right axis deviation) consistent with a right ventricular outflow tract (RVOT) origin. The VT responded initially to intravenous esmolol and diltiazem only to recur. Physical examination, echocardiography, and cardiac MRI were within normal limits. No other arrhythmia was recorded. The patient underwent an electrophysiology (EP) study and attempted ablation on the next day. The mapping/ablation catheter was positioned in the RVOT and mechanical pressure of the catheter on the endocardium led to immediate suppression of the tachycardia and …

Multivessel Coronary Artery Spasm Refractory to Intensive Medical Treatment

This case report describes multivessel coronary artery spasm refractory to oral nifedipine, intravenous isosorbide dinitrate, diltiazem and nicorandil, and intracoronary nitroglycerin. Intracoronary administration of nicorandil only transiently relieved coronary artery spasm. Prednisolone was effective in preventing coronary artery spasm.

Conversion of Atrial Fibrillation to Sinus Rhythm During Treatment With Intravenous Esmolol or Diltiazem: A Prospective, Randomized Comparison

Prior studies have suggested that intravenous diltiazem reduces the probability of spontaneous conversion of atrial fibrillation (AF) to sinus rhythm in the electrophysiology laboratory and in patients with postoperative AF. Whether diltiazem exerts the same effect in patients presenting to the emergency department (ED) with spontaneous AF is unclear. Fifty patients presenting to the ED with new-onset or paroxysmal AF and a rapid ventricular rate (>100 beats per minute) were randomly assigned to receive intravenous diltiazem or esmolol during the first 24 hours of presentation. Conversion to sinus rhythm occurred in 10 patients (42%) in the diltiazem group compared with 10 patients (39%) in the esmolol group (P = 1.0). Diltiazem does not decrease the likelihood of spontaneous conversion of AF to sinus rhythm in the ED setting.