Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR
Release Date: 08/25/2025
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Podcast 1006: Cannabinoid Pharmacology
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Podcast 1005: Balanced Fluid vs Normal Saline in Pediatric Patients
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Contributor: Aaron Lessen, MD Educational Pearls: There has long been many questions about which IV fluid is best for ED resuscitation Multiple adult studies have shown no clear benefit of balanced fluid vs normal saline A large pediatric randomized clinical trial published in April compared balanced fluid vs normal saline in children with septic shock The study included about 9,000 patients from 47 emergency departments in five countries Patients with septic shock were randomized to receive either balanced fluid or normal saline The primary outcome was adverse kidney event...
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Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Podcast 1003: Nasal Intubation
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Podcast 1001: Acute Intermediate Risk Pulmonary Embolism
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Contributor: Aaron Lessen, MD Educational Pearls: Patients with pulmonary embolism (PE) are divided into three risk categories Low risk (non-massive PE): patients are stable Treatment: prescribe anticoagulants and discharge home Intermediate risk (submassive PE): patients are stable but display evidence of clot burden such as elevated troponin, elevated BNP, and/or right heart strain Treatment is controversial High risk (massive PE): patients are unstable with hypotension, hypoxia, and/or respiratory distress Treatment: IV thrombolysis to prevent decompensation A recent randomized...
info_outlineContributor: Taylor Lynch, MD
Educational Pearls:
What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)?
- AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction.
- Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals.
- AFib with RVR is distinguished from AFib when the patient’s ventricular rate is greater than 100-110 beats per minute in AFib with RVR.
What is the treatment for AFib with RVR?
- Diltiazem is considered one of the first line therapeutic agents in the treatment of AFib with RVR.
- Diltiazem inhibits L-Type calcium channels in the AV Node, reducing the amount of signals conducted to the ventricles, thus reducing the ventricular rate.
Why pretreat patients receiving Diltiazem for AFib with RVR with calcium?
- While diltiazem inhibits cardiac calcium channels, it may also cause peripheral vasodilation, resulting in diltiazem-induced hypotension.
- A recent study found that this hypotension can be blunted by pretreating with 1-2g IV Calcium Chloride (IV Calcium Gluconate can be used in the ED).
- Calcium is thought to peripherally stabilize the vascular smooth muscle, preventing vasodilation without impacting the desired calcium channel blocker action at the AV node.
Key takeaways?
- In combination with slower pushes of diltiazem for patients in AFib with RVR (AFib with ventricular rate >100-110 bpm) with borderline low blood pressures, 1-2 g of IV Calcium Gluconate can combat diltiazem induced hypotension peripherally without negating the cardiac effect of diltiazem to reduce the heart rate.
References
- 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193
- Az A, Sogut O, Dogan Y, et al. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025;88:23-28. doi:10.1016/j.ajem.2024.11.033
Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4
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