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Clinical Outcomes Associated with Diltiazem Use in Heart Failure With Reduced Ejection Fraction After Implementation of a Clinical Decision Support System

May 7, 2024

Experts from the UPMC Heart and Vascular Institute recently published new research regarding clinical outcomes associated with diltiazem use in heart failure in the Annals of Pharmacotherapy journal.

In this study, an institution implemented a clinical decision support system (CDSS)-based tool that advises against the use of diltiazem in patients with an ejection fraction (EF) less than or equal to 40%. The objective of the study was to evaluate the clinical outcomes of patients who adhered to the CDSS-based tool compared to patients who were nonadherent.

This study evaluated patients across 20 UPMC hospitals who triggered a CDSS alert at any point during their hospitalization. The CDSS alert was triggered any time an IV diltiazem order was placed for a patient with an ejection fraction less than or equal to 40% by echocardiogram documented within the past 5 years. Researchers then compared those who did and who did not discontinue diltiazem after receiving the alert.

The study’s primary outcome was the occurrence of clinical deterioration. Measures of clinical deterioration included increased utilization of inotropes and vasopressors, renal replacement therapy, mechanical circulatory support, higher rate of transfer to ICU, and development of acute kidney injury or acute liver injury within 48 hours of the initial CDSS alert.

Conclusion of Findings

The study assessed 246 patients: 146 patients who received diltiazem and 100 patients who did not receive diltiazem. Findings revealed a higher proportion of patients experiencing clinical deterioration in the alert nonadherence group who did receive diltiazem. Clinical deterioration included increased utilization of inotropes, vasopressors, and the need for ICU transfer.

In patients with heart failure with reduced EF, diltiazem has been linked to an increase in mortality when used as a long-term treatment. Overall, the study findings support previous evidence that patients with reduced EF should avoid the use of diltiazem.

Future research is needed to understand the driving factors for alert nonadherence in order to improve the alert design. With improved design, methods can be developed to increase adherence to diltiazem safety alerts.


Elizabeth M. Foster, James C. Coons, Elena A. Puccio, Danine Sullinger, Rachel Ibrahim, Joseph Ibrahim, Gavin W. Hickey, Edward Horn, Vincent Mosesso, Ryan M. Rivosecchi. Clinical Outcomes Associated With Diltiazem Use in Heart Failure With Reduced Ejection Fraction After Implementation of a Clinical Support System. Annals of Pharmacotherapy. 2024;0(0).