IV potassium and magnesium acute treatment for AF?

A brand new registry examine discovered that the probability of spontaneous conversion to sinus rhythm (SVC) was elevated by intravenous magnesium and potassium in sufferers with nonsustained atrial fibrillation who introduced to the ER.

Compared with no treatment, administration of potassium and magnesium was related to a ten% greater fee of SVC.

The findings recommend that intravenous potassium and magnesium could scale back the necessity for antiarrhythmic remedy and scale back potential unwanted effects in sufferers with nonsustained atrial fibrillation, the examine authors famous.

However, they add, “The outcomes of our examine would not have direct implications for medical observe within the administration of care for sufferers with AF or AFL. [atrial flutter] In the ED. The findings are merely exploratory and speculation producing, however could present the premise for a potential acceptable trial.”

The examine was revealed on-line on October 19 JAMA Network Open.

“Atrial fibrillation (AF) is an growing problem for well being care methods on account of an growing older inhabitants worldwide,” write Filippo Cacioppo, MD, and colleagues on the Medical University of Vienna, Vienna, Austria.

“Pharmacologic and electrical conversion are widespread therapies in emergency departments (EDs), particularly for symptomatic sufferers. Each intervention has particular dangers and is just not thought of cost-effective due to the frequent recurrence of AF. In addition, AF usually resolves spontaneously.” , Cacioppo and colleagues write.

They add that proof means that hypokalemia and hypomagnesemia contribute to the event of AF, so potassium and magnesium administration could also be an affordable technique to enhance the course of SCV.

To check their speculation, Cacioppo et al performed a registry-based cohort examine of all sufferers with AF or AFL who introduced to the middle’s ED between February 6, 2009, and February 16, 2020.

During this time, they noticed 2,546 episodes of nonsustained AF. The median age of sufferers was 68 years (interquartile vary). [IQR], 58 – 75 years previous). The majority had been males (n = 1411 sufferers, 55.4%).

In addition, there are 573 episodes of non-permanent AFL. The median age of the sufferers was 68 years (IQR, 58 – 75 years), and 332 sufferers (57.9%) had been male.

Intravenous potassium and magnesium had been administered in barely greater than half of the episodes (n = 1763, 56.5%).

Average quantities of potassium and magnesium had been delivered through a 250 mL infusion bag containing 500 mL of balanced crystalloid fluid containing 24 mEq potassium and 145.8 mg magnesium and 2.5 mEq potassium and 18.2 mg mini magnesium. authors write.

If sufferers skilled ache on the injection web site, the speed of infusion was lowered till the ache subsided.

Conversion to sinus rhythm is taken into account spontaneous if pharmacological rhythm management is just not tried earlier than conversion happens; if SVC happens after a failed try at electrical cardioversion; or fee management with beta-blockers, nondihydropyridine calcium channel blockers, or digitalis glycosides, in line with the authors.

IV treatment elevated the probability of SVC

Median size of keep in AD was 6.4 hours (IQR, 3.9 to 11.6 hours) for sufferers with AF and 6.1 hours (IQR, 3.9 to 11.8 hours) for sufferers with AFL.

During the ED keep, SCV occurred in 15.4% (n = 393) of AF episodes and 12.7% (n = 73) of AFL episodes.

Intravenous potassium and magnesium elevated SVC probability however not IV potassium and magnesium in AF however not AFL.

During episodes of AF, intravenous potassium and magnesium was related to a 19.2% improve in SVC, in contrast with 10.4% for no administration. [OR], 1.98; (95% CI, 1.53 to 2.57).

In distinction, for AFL, no affiliation was noticed for the likelihood of SCV with potassium and magnesium administration in comparison with no administration (13.0% vs 12.5%; OR, 1.05; 95% CI, 0.65 – 1.69).

Not within the handbook

“To date, it’s unclear whether or not the administration of potassium and magnesium within the acute treatment of AF and AFL could also be affordable, and this intervention could also be widespread observe in some EDs, however it isn’t a part of the treatment suggestions in present tips,” Cacioppo and colleagues write.

“Our findings present that intravenous potassium and magnesium administration or hypokalemia or plasma potassium ranges within the vary of three.50 to three.99 mEq/L can improve the potential for SCV. In sufferers with AFL, nonetheless, potassium and magnesium administration. With the potential for SCV can’t be linked,” they write.

Cacioppo et al. However, they warning that “as a restricted variety of SCV sufferers had symptom onset better than or equal to 48 hours, this discovering warrants additional investigation.”

Installation technique

“I’m a bit skeptical about this examine,” mentioned Georgios Syros, MD, director of Arrhythmia Services at Sinai Queens and Mount Sinai Brooklyn, New York. theheart.org | Medscape Cardiology.



Dr. Georgios Syros

“Atrial fibrillation is a continual illness. The pure historical past of this illness is paroxysmal at first, and typically the episodes turn out to be extra frequent and last more. For some individuals, sooner or later, it turns into everlasting,” Syros mentioned.

“Let’s say I reduce my finger whereas chopping bread. I put a Band-Aid on the reduce. That doesn’t suggest I fastened it, it means I briefly helped. It’s similar to atrial fibrillation on paper,” he says. mentioned. “The affected person could have an episode, go to the emergency room, you give them drugs and briefly relieve the situation in order that the affected person doesn’t should admit. It’s easy, low cost, you restore the center fee, moderately regular. With just a few unwanted effects, perhaps on the injection web site. besides for a bit little bit of ache, however that does not imply you have fastened your AFib for good. Because it is the weekend, sure, you need to use that as a band-aid,” he mentioned. .

The intravenous potassium and magnesium really helpful within the present examine is much like a drug at present utilized in Europe, referred to as vernakalant, Syros mentioned.

“Vernakalant is just not FDA authorised within the US. It is just not meant to be a everlasting treatment for atrial fibrillation, so we have to educate the general public in regards to the limitations of what we’re doing,” he mentioned. “Vernakalant IV is much like potassium and magnesium, which is given on this examine, however it’s dearer. It briefly permits individuals to return to sinus rhythm, however it’s not there perpetually and you may return to everlasting AFib, so it isn’t magic, sadly. .”

Siros emphasised that the outcomes of the present examine solely apply to instances of paroxysmal atrial fibrillation lasting lower than 48 hours. “It’s an important distinction,” he mentioned.

“For instance, a affected person who drank closely and had AFib the subsequent day, what we name a vacation coronary heart, could be a superb candidate for treatment on this examine. He’s younger, has no coronary heart injury, no diabetes, no hypertension. , no earlier stroke, so he wants potassium.” and assist with magnesium if he can show to us that it began inside 48 hours,” Syros mentioned.

Cacioppo et al and Syros report within the related monetary studies. Corresponding creator of the examine, Jan Niederdoeckl, MD, PhD, acquired funding for the examine.

JAMA Netw Open. 2022;5(10):e2237234. Abstract

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