The Safety and Efficacy of Verapamil Versus Diltiazem Continuous Infusion for Acute Rate Control of Atrial Fibrillation at an Academic Medical Center

Abstract

Purpose: Due to critical shortages of intravenous diltiazem in 2018, the Ohio State University Wexner Medical Center (OSUWMC) adopted intravenous verapamil as an alternative. However, there is a paucity of data supporting the use of intravenous verapamil infusions for rate control in the acute treatment of atrial arrhythmias. The purpose of this study was to determine the safety and efficacy of intravenous verapamil as compared with diltiazem for the acute treatment of atrial arrhythmias. Methods: This retrospective, case-control study compared patients who received verapamil infusions between June 1 and September 30, 2018, with patients who received diltiazem infusions between June 1 and September 30, 2017, at OSUWMC. Patients were matched 1:1 based on age, sex, and the presence of comorbid heart failure with reduced ejection fraction (≤40%). Results: A total of 73 patients who received at least 1 verapamil infusion and 73 patients who received at least 1 diltiazem infusion met inclusion criteria. The composite need for inotrope or vasopressor was similar for both groups (5% with verapamil versus 4% with diltiazem, P = .999). The rate of hypotension was similar between groups (37% versus 33% experiencing a systolic blood pressure <90 mm Hg, P = .603, and 27% versus 23% experiencing a mean arterial pressure <65 mm Hg, P = .704), as was the rate of bradycardia (19% versus 18%, P = .831). The efficacy outcomes of this study were similar for both groups, with 89% of patients in the verapamil group and 90% of patients in the diltiazem group achieving a heart rate less than 110 beats per minute ( P = .785). Conclusion: Intravenous verapamil and diltiazem infusions had similar safety and efficacy outcomes when used for acute treatment of atrial arrhythmias in the institutional setting.

Keeping It “Current”: A Review of Treatment Options for the Management of Supraventricular Tachycardia

“…Specifically, diltiazem is associated with less interactions with cardiac glycosides and beta-blockers, has less negative inotropic effects, and has less conduction disturbances. 35,36 Verapamil has also been shown to decrease gut motility and cause constipation due to its increased effect on smooth muscle relative to diltiazem. 37 In addition, in data for atrial fibrillation, verapamil was shown to increase the risk of symptomatic hypotension including cases of life-threatening hypotension.…”

“…37 In addition, in data for atrial fibrillation, verapamil was shown to increase the risk of symptomatic hypotension including cases of life-threatening hypotension. 36 For these reasons, it may be reasonable to choose diltiazem over verapamil in patients presenting in SVT despite the limited amount of comparative data. If institutions choose to routinely use non-DHP CCB for the treatment of PSVT, these agents should be added to automated dispensing cabinets in the ED to facilitate rapid delivery to the patient.…”

The Optimal Management of Patients with Atrial Fibrillation and Acute Heart Failure in the Emergency Department

“…Only 4% in the diltiazem group and 1.4% in the verapamil group required the addition of amiodarone infusion on top of non-dihydropyridine CCBs in order to achieve a heart rate less than 100 bpm. There was no significant difference between the two treatment groups regarding the need for inotropes/vasopressors and the incidence of hypotension (defined as systolic blood pressure < 90 mmHg) or bradycardia [49]. Likewise, a study of 182 patients with AF or atrial flutter, 10% of whom had LVEF < 50%, demonstrated that the safety and efficacy outcomes were similar for verapamil and diltiazem when used for acute rate control [50].…”

Intra-arterial verapamil improves functional outcomes of thrombectomy in a preclinical model of extended hyperglycemic stroke

“…Intra-arterial (i.a.) verapamil is a safe and routine practice to treat cerebral vasospasm, and is less likely to lower perfusion pressure (Forshay et al, 2021) which is detrimental for the ischemic tissue in a stroke brain. The study by Bix and others (2017) has recently shown that the selective i.a.…”