Safety and Efficiency of Calcium Channel Blockers Versus Beta‐blockers for Rate Control in Patients With Atrial Fibrillation and No Acute Underlying Medical Illness

Abstract

Objectives Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta‐blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30‐day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30‐day safety outcomes including stroke, death, and emergency department (ED) revisits. Methods This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. Results A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty‐seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = −7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7‐ or 30‐day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. Conclusions In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department

“…More recently, Scheuermeyer and colleagues published a retrospective comparison of beta-blocker and calcium channel blocking agents used for atrial fibrillation in 259 patients without underlying medical illness in Canada between 2006 and 2010 (19). They examined admission rate as a surrogate marker for successful rate control and secondarily compared ED length of stay and adverse events.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Lekarze powinni oceniać dodatkowe przyczyny mogące leżeć u podłoża przyspieszenia czynności komór, takie jak zakażenie, zaburzenia endokrynologiczne, niedokrwistość i zatorowość płucna. W celu doraźnej kontroli częstości rytmu komór beta-adrenolityki oraz diltiazem/werapamil są preferowane w stosunku do digoksyny ze względu na ich szybki początek działania oraz skuteczność w stanach zwiększonej aktywności współczulnej [528][529][530][531][532]. Wybór leku (tab.…”

Funny and Late: Targeting Currents Governing Heart Rate in Atrial Fibrillation

“…Patients in this study received both oral and IV agents over the 5 hours, on average, that they spent in the ED. Of note, 4% risk of hypotension was reported . In another short duration study of patients with chronic AF, diltiazem 240 mg daily lowered the baseline heart rate of 96 bpm by an average of 20 bpm (∼21%), while verapamil 360 mg daily, metoprolol 100 mg daily and carvedilol 25 mg twice daily lowered heart rate 12–15 bpm (∼13–16%) .…”

“…Of note, 4% risk of hypotension was reported. 22 In another short duration study of patients with chronic AF, diltiazem 240 mg daily lowered the baseline heart rate of 96 bpm by an average of 20 bpm (ß21%), while verapamil 360 mg daily, metoprolol 100 mg daily and carvedilol 25 mg twice daily lowered heart rate 12-15 bpm (ß13-16%). 23 The acute heart rate reduction reported by Verrier et al in preclinical models was of similar magnitude.…”