Rate control with intravenous diltiazem, verapamil, and metoprolol in acute atrial fibrillation with rapid ventricular rate

Abstract

Introduction: Diltiazem is a preferred agent for rate control in atrial fibrillation due to its quick onset, minimal side effects, and low cost. Due to its intermittent national shortage since February 2018, the utilization of intravenous metoprolol and verapamil has increased. This study investigated the effect of intravenous diltiazem, metoprolol, and verapamil on rate control in patients with atrial fibrillation with rapid ventricular rate. Methods: This study was a retrospective, single-center, cohort study conducted in patients with acute atrial fibrillation receiving intravenous diltiazem, metoprolol, or verapamil for rapid ventricular rate between 1 January 2012 and 31 August 2018. The primary outcome was the incidence of patients who achieved a rate less than 100 bpm within 1 h of treatment. Secondary outcomes included time to achieve rate control, heart rate at 30 min and 1 h after administration, bradycardia and hypotension incidence, the requirement of other rate control agent(s), inpatient admission, length of stay, and mortality. Results: A total of 73 patients were included in the study. At 1 h after receiving the initial rate control drug, there was no statistically significant difference between diltiazem, metoprolol, and verapamil in achieving rate control. Median time to ventricular rate control was 166 min in the diltiazem group, 297 min in the metoprolol group, and 100.5 min in the verapamil group. Conclusion: There was no difference in achieving rate control when using intravenous diltiazem, metoprolol, or verapamil. Any of the three rate control agents may be used for rate control. However, further studies are needed to determine which agent is superior for rate control.

Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis

“…2 ). 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 These studies enrolled 1732 patients in emergency departments (thirteen studies) and intensive care unit settings (one study). These fourteen studies were pooled, as they each reported achievement of rate control target with diltiazem (n = 773) compared to metoprolol (n = 959) in patients with atrial fibrillation with rapid ventricular rate.…”

“…3 ). 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 18 , 20 Meta-analysis of outcomes of these twelve studies showed no significant difference in the occurrence of hypotension as an adverse event with diltiazem (n = 647) vs. metoprolol (n = 830) in patients with atrial fibrillation with rapid ventricular rate (odds ratio: 0.96; 95% CI: 0.61 to 1.52; p = 0.87); without significant heterogeneity (I 2 = 35%). Nine studies, including 1203 patients, reported the rate of bradycardia as an adverse event with diltiazem versus metoprolol ( Fig.…”

“…4 ). 7 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 Meta-analysis of outcomes of these nine studies did not show a significant difference in the occurrence of bradycardia as an adverse event with intravenous diltiazem (n = 505) vs. metoprolol (n = 698) in patients with atrial fibrillation with rapid ventricular rate (odds ratio: 2.44; 95% CI: 0.82 to 7.31; p = 0.11); without significant heterogeneity (I 2 = 48%). A summary of the risk of bias assessments is provided in Fig.…”

Pharmacokinetics and Pharmacodynamics of Etripamil, an Intranasally Administered, Fast‐Acting, Nondihydropyridine Calcium Channel Blocker

“…Nondihydropyridine calcium channel blockers (eg, verapamil, diltiazem), beta blockers, and adenosine are indicated to terminate AV node‐dependent PSVT when vagal maneuvers are ineffective 2,3 . Likewise, calcium channel blockers and beta blockers are often used to establish ventricular rate control during atrial‐based tachyarrhythmias by slowing conduction over the AV node 4,5 …”

“…2,3 Likewise, calcium channel blockers and beta blockers are often used to establish ventricular rate control during atrial-based tachyarrhythmias by slowing conduction over the AV node. 4,5 Etripamil, a fast-acting nondihydropyridine L-type calcium channel blocker, is a close structural analog of verapamil, modified by the addition of an ester group (Figure 1A). [6][7][8][9][10] According to an unpublished in vitro study of the incubation of etripamil in human whole blood, etripamil is rapidly and completely transformed to the stable and pharmacologically inactive metabolite MSP-2030 by blood esterases, indicating that hepatic metabolism is not a significant factor in the biotransformation of etripamil (Figure 1B, Figure S1).…”