IV Magnesium use in the treatment of acute atrial fibrillation with rapid ventricular response in the Emergency Department including cardiovascular compromise
Date First Published:
October 7, 2010
Last Updated:
March 30, 2011
Report by:
Jason Wilson, Chief Resident (University of South Florida College of Medicine)
Search checked by:
David Wein, University of South Florida College of Medicine
Three-Part Question:
In [adult ED patients in atrial fibrillation with rapid ventricular rate refractory to standard medications unable to tolerate standard medications] does the addition of [IV magnesium] lead to [decrease in ventricular rate].
Clinical Scenario:
70 yo male presents to ED with SOB and hypotension 75/40 with HR of 160. Pt found to be in afib. Pt does have h/o afib but usually rate controlled with dig. Pt is unsure how long he has been in afib. Pt is given 10mg of dilt after 1L IV NS bolus and pressure drops to 70/35. No change in HR. Would the addition of IV magnesium help with rate control of this patient?
Search Strategy:
Ovid PubMed
magnesium.mp OR magnesium sulphate.mp OR MGSO4
AND
atrial fibrillation.mp
Then excluded post-op CABG studies, theoretical, lab based, animal models
Included prospective, clinical comparison studies of mag vs. another agent or with another agent for management of atrial fibrillation
13 Studies Included in my review
magnesium.mp OR magnesium sulphate.mp OR MGSO4
AND
atrial fibrillation.mp
Then excluded post-op CABG studies, theoretical, lab based, animal models
Included prospective, clinical comparison studies of mag vs. another agent or with another agent for management of atrial fibrillation
13 Studies Included in my review
Search Details:
Excluded post-op CABG studies, theoretical, lab based, animal models
Included prospective, clinical comparison studies of mag vs. another agent or with another agent for management of atrial fibrillation
Included prospective, clinical comparison studies of mag vs. another agent or with another agent for management of atrial fibrillation
Outcome:
211 total search results, limited to 13 after reviewing for criteria described above
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The effect of magnesium versus verapamil on supraventricular arrhythmias. Gullestad L, Birkeland K, Mølstad P, Høyer MM, Vanberg P, Kjekshus J. 1993 USA | ED pts with SVT with onset < 1w; N = 57 |
mag vs. verapamil; randomized, single-blind |
conversion to sinus rhythm | 58% of Mag group converted to sinus rhythm in 4h; 19% of Verapamil group converted; p < 0.01 | mag alone |
| Effect of magnesium sulfate on ventricular rate control in atrial fibrillation. Hays JV, Gilman JK, Rubal BJ. 1994 USA | ED pts with new afib; N = 15 |
Mag + Digoxin after 30m clinical case series |
rate at 5m, then 30m for 3.5h | Ventricular Rate decrease of 16bpm +/- 7 and improved w/dig to 26% +/- 7 | no comparison group, small, case series |
| Efficacy of intravenous magnesium sulphate in supraventricular tachyarrhythmias. Joshi PP, Deshmukh PK, Salkar RG. 1995 India | ED pts with SVT > 160bpm; N = 154 |
2g MgSO4 IV vs. 5mg Verapamil IV; randomized |
HR < 100 binary | lower rate control with mag (19/74, 25.7%) compared to verapamil (48/80, 60%) p < 0.0001 | mag alone |
| Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation. Eray O, Akça S, Pekdemir M, Eray E, Cete Y, Oktay C. 2000 | ED pts with Afib HR > 120bpm N = 34 |
2g MgSO4 IV then 1g/h over 6h; clinical case series |
rate at 15, 30, 60m; mag level | Stasticially significant decrease in VR at each time period; no correlation between mag level and response | no comparsion group, mag alone |
| Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation. Chiladakis JA, Stathopoulos C, Davlouros P, Manolis AS. 2001 Greece | ED pts with Afib HR > 120bpm; N = 46 |
mag vs. diltiazem; RCT |
rate at 1, 2, 3, 4, 5, 6h; conversion to sinus rhythm at 6h | similar decrease in both groups at each hour; higher conversion to sinus rhythm in mag group at 6h (13/23, 57%, p = 0.03) | not blinded, single agent tx |
| A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Davey MJ, Teubner D. 2005 USA | ED pts with new afib; N = 199 |
standard care + 2.5g Mag or standard + NS; randomized, double-blind, placebo controlled |
HR < 100, Mean HR reduction | Mag more likely to lead to HR < 100bpm (RR 1.89, 95%CI 1.38-2.59); standard tx most often wsa dig | no control of other agents given with mag |
| Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Ho KM, Sheridan DJ, Paterson T. 2007 Australia | new afib, pooled studies; N = 515 |
mag vs. placebo or mag vs. another agent; meta-analysis |
HR < 100, conversion to NSR, reduction of ventricular response | compared to placebo, mag decreased ventricular response more when added to dig; less effective in reducing ventricular response compared to amio, mag was less likely to cause bradycardia | not a study |
| Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation. Onalan O, Crystal E, Daoulah A, Lau C, Crystal A, Lashevsky I. 2007 Canada | new afib, pooled studies; N = 779 |
mag vs. placebo or mag vs. another agent; meta analysis |
HR < 100, conversion to NSR, reduction of ventricular response | mag was effective in achieving rate and rhythm control compared to placebo; shorter response time in mag group compared to placebo | not a study |
| Intravenous magnesium sulfate enhances the ability of intravenous ibutilide to successfully convert atrial fibrillation or flutter. Tercius AJ, Kluger J, Coleman CI, White CM. 2007 | pts with afib who received ibutilide; N =229 |
mag w/ibutilide vs. mag without ibutilide consecutive enrollment |
conversion to NSR | mag increased the odds of NSR conversion by 78%; OR 1.78, 95% CI 1.02-3.09 | |
| Treatment of new-onset atrial fibrillation in noncardiac intensive care unit patients: a systematic review of randomized controlled trials. Kanji S, Stewart R, Fergusson DA, McIntyre L, Turgeon AF, Hébert PC. 2008 | new afib, pooled studies; N = 143 |
mag vs. amio, procainamide, esmolol, verapamil, dilt; systematic review |
conversion to NSR | no difference across groups | not a study |
| Magnesium sulfate versus placebo for paroxysmal atrial fibrillation: a randomized clinical trial. Chu K, Evans R, Emerson G, Greenslade J, Brown A. 2009 | ED pts with new afib HR > 100bpm; N = 48 |
mag vs. placebo; randomized |
HR q15m; conversion to NSR | no difference across groups | mag alone, small sample |
Author Commentary:
More randomized control trials are needed specifically comparing the ADDITION of magnesium to usual care. Furthermore, specific populations of patients need to be targeted - such as hypotensive patients who do not respond to electric cardioversion (or who are not optimal candidates for cardioversion) or who are refractory to tolerable doses of BP lowering anti-arrhythmics
Bottom Line:
The addition of magnesium (between 2g and 5g IV push) likely does not cause any harm to patients presenting in Acute Atrial Fibrillation with Rapid Ventricular Response to the Emergency Department.
The addition of IV Magnesium may provide benefit in hypotensive patients not able to tolerate higher doses of BP lowering anti-arrhythmic agents. It is likely worth "trying" a dose of Mag in a refractory patient whom is not an ideal candidate for electric cardioversion
The addition of IV Magnesium may provide benefit in hypotensive patients not able to tolerate higher doses of BP lowering anti-arrhythmic agents. It is likely worth "trying" a dose of Mag in a refractory patient whom is not an ideal candidate for electric cardioversion
References:
- Gullestad L, Birkeland K, Mølstad P, Høyer MM, Vanberg P, Kjekshus J.. The effect of magnesium versus verapamil on supraventricular arrhythmias.
- Hays JV, Gilman JK, Rubal BJ.. Effect of magnesium sulfate on ventricular rate control in atrial fibrillation.
- Joshi PP, Deshmukh PK, Salkar RG.. Efficacy of intravenous magnesium sulphate in supraventricular tachyarrhythmias.
- Eray O, Akça S, Pekdemir M, Eray E, Cete Y, Oktay C.. Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation.
- Chiladakis JA, Stathopoulos C, Davlouros P, Manolis AS.. Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation.
- Davey MJ, Teubner D.. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation.
- Ho KM, Sheridan DJ, Paterson T.. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis.
- Onalan O, Crystal E, Daoulah A, Lau C, Crystal A, Lashevsky I.. Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation.
- Tercius AJ, Kluger J, Coleman CI, White CM.. Intravenous magnesium sulfate enhances the ability of intravenous ibutilide to successfully convert atrial fibrillation or flutter.
- Kanji S, Stewart R, Fergusson DA, McIntyre L, Turgeon AF, Hébert PC.. Treatment of new-onset atrial fibrillation in noncardiac intensive care unit patients: a systematic review of randomized controlled trials.
- Chu K, Evans R, Emerson G, Greenslade J, Brown A.. Magnesium sulfate versus placebo for paroxysmal atrial fibrillation: a randomized clinical trial.