Abstract
Background
Atrial fibrillation (AF) is a common dysrhythmia associated with significant morbidity
and mortality. Although many patients have stable AF, some patients can present with
a rapid ventricular response (RVR). In these patients, it is important to lower their
heart rate. However, there are several options available for rate control in the emergency
department setting.
Clinical Question
What is the most effective agent for rate control for the patient with AF in RVR?
Evidence Review
Studies retrieved included two prospective, randomized, double-blind studies and six
retrospective cohort studies. These studies provide estimates of the efficacy and
safety of calcium channel blockers and β-blockers for rate control in those with AF
with RVR.
Conclusion
Based upon the available literature, diltiazem likely achieves rate control faster
than metoprolol, though both agents seem safe and effective. Clinicians must consider
the individual patient, clinical situation, and comorbidities when selecting a medication
for rate control.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Emergency department, hospital inpatient, and mortality burden of atrial fibrillation in the United States, 2006 to 2014.Am J Cardiol. 2017; 120: 1966-1973
- Beta-blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review.Eur J Emerg Med. 2015; 22: 150-154
- Diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department.J Emerg Med. 2015; 49: 175-182
- Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation.Emerg Med J. 2005; 22: 411-414
- 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Heart Rhythm. 2019; 16: e66-e93
- A population-based description of atrial fibrillation in the emergency department, 2002 to 2010.Ann Emerg Med. 2013; 62: 570-577
- Epidemiology and natural history of atrial fibrillation: clinical implications.J Am Coll Cardiol. 2001; 37: 371-378
- Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994–1998: analysis of data from the general practice research database.Heart. 2001; 86: 284-288
- Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications.Arch Intern Med. 1995; 155: 469-473
- Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study.Eur Heart J. 2006; 27: 949-953
- Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.JAMA. 2001; 285: 2370-2375
- 2012 focused update of the ESC Guidelines for the management of atrial fibrillation.Eur Heart J. 2012; 33: 2719-2747
- The 2020 ESC Guidelines on the Diagnosis and Management of Atrial Fibrillation.Arrhythm Electrophysiol Rev. 2021; 10: 65-67
- The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation.Can J Cardiol. 2020; 36: 1847-1948
- 2014 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation.Can J Cardiol. 2014; 30: 1114-1130
- Emergency medicine considerations in atrial fibrillation.Am J Emerg Med. 2018; 36: 1070-1078
- Update on atrial fibrillation.Egypt Heart J. 2014; 66: 193-216
- Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm.Ann Emerg Med. 2015; 65: 511-522
- Managing atrial fibrillation.Ann Emerg Med. 2015; 65: 532-539
- Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness.Acad Emerg Med. 2013; 20: 222-230
- Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department.Am J Emerg Med. 2021; 46: 585-590
- Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem.Am J Emerg Med. 2021; 40: 15-19
- Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department.Am J Health Syst Pharm. 2016; 73: 2068-2076
- Hemodynamic comparison of intravenous push diltiazem versus metoprolol for atrial fibrillation rate control.Am J Emerg Med. 2020; 38: 1879-1883
- Rate control with intravenous diltiazem, verapamil, and metoprolol in acute atrial fibrillation with rapid ventricular rate.SAGE Open Med. 2021; 9 (20503121211017756)
- Lenient versus strict rate control in patients with atrial fibrillation.N Engl J Med. 2010; 362: 1363-1373
- Diltiazem hydrochloride [package insert].Boehringer-Ingelheim, Schaumburg, IL2007
- Metoprolol tartrate [package insert].Novartis Pharmaceuticals, East Hanover, NJ2008
- Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II).Am J Cardiol. 1990; 66: 779-785
- Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).Lancet. 1999; 353: 2001-2007
- The effect of diltiazem on mortality and reinfarction after myocardial infarction.N Engl J Med. 1988; 319: 385-392
- 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 62: e147-e239
- Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction.Am J Emerg Med. 2019; 37: 80-84
- The use of beta-blockers after myocardial infarction.JAMA. 1983; 249: 2512-2516
- Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study.BMJ. 2011; 342: d2549
- Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease.Arch Intern Med. 2010; 170: 880-887
- 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.CJEM. 2021; 23: 604-610
- Electrical vs. pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.Lancet. 2020; 395: 339-349
- Just the facts: atrial fibrillation or flutter in patients who are candidates for rate control.CJEM. 2021; 23: 437-440
Article Info
Publication History
Published online: July 29, 2022
Accepted:
July 10,
2022
Received in revised form:
June 10,
2022
Received:
March 6,
2022
Footnotes
This review does not reflect the views or opinions of the U.S. government, Department of Defense, U.S. Army, U.S. Air Force, or SAUSHEC EM Residency Program.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
